A  SYSTEM  OF  TREATMENT 

IN  FOUR  VOLUMES 

Volume      I.  General  Medicine  and  Surgery 

Volume    II.  General  Medicine  and  Surgery 

Volume  III.  Special  Subjects 

Volume  IV.  Obstetrics  and  Gynaecology 


A   SYSTEM    OF 
TREATMENT 

BY    MANY    WRITERS 


EDITED   BY 


ARTHUR   LATHAM 

M.A.,    M.D.    Oxon.;    F.R.C.P.    Lond. 
PHYSICIAN    AND    LECTURER   ON    MEDICINE,    ST.    GEORGE'S   HOSPITAL 

AND 

T.    CRISP    ENGLISH 

M.B.,   B.S.    Lond.;    F.R.C.S.    Eng. 

SENIOR  ASSISTANT  SURGEON  AND  LECTURER  ON  PRACTICAL  SURGERY, 
ST.  GEORGE'S  HOSPITAL 


VOLUME    II. 
GENERAL     MEDICINE     AND     SURGERY 


New  York 
THE      MACMILL  AN     COMPANY 

1914 

All  rights  reserved 


35 -?-s 


Printed  in  Gt-ent  Britain. 


PREFACE. 


DURING  the  last  ten  years  our  knowledge  of  the  measures  available 
for  the  treatment  of  disease  and  the  relief  of  symptoms  has  become 
more  scientific  and  therefore  more  definite  in  its  application.  Not 
only  have  many  of  our  ideas  undergone  profound  modification,  but 
new  fields  of  work,  some  of  great  promise,  have  been  discovered. 
Of  these  we  may  instance  Vaccine  Therapy,  X-ray  Therapy, 
Radium  Therapy,  Ionic  Medication  and  measures  dependent  on 
improved  methods  of  observation  and  diagnosis  such  as  Broncho- 
scopy.  The  subject  of  the  treatment  of  disease  consequently  has 
become  more  specialised  and  makes  greater  demands  upon  all 
branches  of  the  medical  profession  than  formerly. 

The  aim  of  these  volumes  is  to  provide  the  General  Practitioner 
with  a  series  of  practical  articles,  in  as  concise  a  form  as  possible, 
describing  the  modern  methods  of  dealing  with  all  diseases  and 
written  by  those  who  have  had  special  experience  in  the  subjects 
with  which  they  deal. 

There  are  many  difficulties  in  preparing  such  a  work  as  this. 
Our  knowledge  is  not  yet  sufficiently  exact  to  permit  dogmatic 
expression  in  all  instances,  or  to  enable  us  to  differentiate  sharply 
between  the  various  forms  of  disease.  It  is  therefore  inevitable  that 
certain  articles  should  overlap,  and  that  there  should  be  legitimate 
differences  of  opinion  not  only  in  the  subject-matter  itself  but  also 
with  regard  to  the  classification  adopted.  The  Editors  have  always 
been  guided  in  their  final  decision  by  considerations  of  convenience 
rather  than  of  strict  symmetry.  They  recognise  that  their  decisions 
are  therefore  open  to  criticism  and  will  gladly  welcome  suggestions, 
either  for  alterations  or  additions,  to  be  incorporated  in  future 
issues. 

This  "System  of  Treatment"  was  commenced  rather  less  than 
two  years  ago,  and  it  is  hoped  that  no  material  addition  to  our 
knowledge  made  during  that  period  has  been  omitted.  The  attempt 
to  keep  thoroughly  abreast  of  these  additions  has  been  rendered 
rather  more  difficult  than  usual  by  the  decision  to  issue  all  four 
volumes  simultaneously,  and  to  provide  each  with  an  index  which 
is  complete  for  the  whole  work. 

The  Editors  wish  to  express  their  gratitude  to  a  large  number 


vi  Preface. 

of  their  colleagues  who  have  in  one  way  or  another  generously 
come  to  their  assistance.  Sir  Patrick  Manson,  Sir  Havelock  Charles, 
Dr.  St.  Clair  Thompson,  Dr.  Eisien  Eussell,  Dr.  Gordon  Holmes, 
Mr.  Richard  Lake  and  Mr.  Victor  Bonney  have  advised  them 
with  regard  to  those  departments  of  Medicine  and  Surgery  with 
which  their  names  are  associated.  Dr.  Nachbar  has  kindly  given 
his  advice  and  has  also  revised  a  number  of  the  manuscripts. 
Dr.  Torrens  and  Mr.  Frankau,  respectively  Medical  and  Surgical 
Registrar  at  St.  George's  Hospital,  have  acted  as  sub-editors, 
reading  all  the  manuscripts  and  assisting  in  the  passage  of  proofs 
through  the  Press. 

The  Editors  are  also  indebted  to  Mr.  Charles  Hewitt  for  the 
preparation  of  the  complete  index  attached  to  each  volume,  to 
Mr.  A.  L.  Clarke  for  the  correction  of  the  references,  and  to 
Mr.  J.  D.  Marshall,  of  Messrs.  Bell  and  Croyden,  who  is  responsible 
for  the  correctness  of  the  various  prescriptions. 

In  addition  to  the  many  original  illustrations  a  number  of  others 
have  been  kindly  lent  by  different  authors  and  publishers.  These 
are  duly  acknowledged  in  the  text. 


TABLE    OF    CONTENTS. 


DISEASES  OF  THE  BLOOD  AND  BLOOD  FORMING  ORGANS. 


ADDISOX'S  (PERNICIOUS)  AX.KMIA 

AN  JO  MI  A  DUE  TO  SOME  DEFINITE 
MALADY,  BUT  NOT  DUE  TO  OB- 
VIOUS BLOOD  Loss  . 

AN.EMIA  DUE  TO  ACTUAL  Loss 
OF  BLOOD  .... 

CHLOROSIS 

HJ-IMOPHILIA      . 

APLASTIC  A. N.K.MIA 

LEUKAEMIA         . 

PSKI'DO-LEUK/EMIA     . 

PUBPURA     , 


Dr.  Herbert  Fn-nrli. 


Dr.  Herbert  Frenrlt          . 

/>/•.  J/trbrrf  Frem-h  . 
lir.  Herbert  French  . 
Dr.  Herbert  French  . 
Dr.  Herbert  French  . 
Professor  George  R.  Murraij 
Dr.  James  Torrens  .  . 
Professor  George  A'.  Murray 


I'ACK 

1 


13 

18 
20 


4','> 


DISEASES    OF    THE    ADRENAL    GLANDS. 

ADDISON'S  DISEASE    .  Dr.  Otto  Grunbaum 


4G 


DISEASES    OF    THE    THYROID    GLAND. 


THE  ADMINISTRATION  OF  THY- 
ROID EXTRACT 

CONGESTION  AND  INFLAMMATION 
OF  THE  THYROID  GLAND  . 

Sr  i;< ; ICAL TREATMENT  OF  L\ FLAM- 

MATORY   AFFECTIONS  OF    THE 

THYROID  GLAND     . 
EXOPHTHALMIC  GOITRE 
THE   SURGICAL  TREATMENT   OF 

EXOPHTHALMIC  GOITRE  . 

GOITRE 

INFANTILISM       .... 
MYXCEDEMA  AND  CRETINISM 
MALIGNANT     DISEASE    OF    THE 

THYROID  GLAND  . 
NOCTURNAL  ENURES  is 
THYROID  INADEQUACY 


Dr.  Leonard  Williams 
Dr.  Leonard  Williams 


Mr.  T.  P.  Legg      . 
Dr.  W.  Hale  While 


Mr.  T.  P. 
Mr.  T.  P.  Legg       . 
Dr.  Leonard  William* 
I  tf.  Leonard  Williams 

Mr.  T.  l\  Legg       . 
Dr.  Leonard  Williams 
Dr.  Leonard  William* 


49 
51 

54 

5$ 
62 

71 
72 

73 
75 

78 


VI 11 


Table  of  Contents. 


INJURIES    AND    DISEASES    OF 

INJURIES  OF  THE  SPLEEN  . 

SURGICAL  TREATMENT  OF  DIS- 
EASES OF  THE  SPLEEN  . 

SPLENOMEGALY  . 

CHRONIC  POLYCYTH.-EMIA  WITH 
CYANOSIS  AND  ENLARGED 
SPLEEN  

AFFECTIONS    OF    THE    LIPS. 

HARELIP 

OTHER  AFFECTIONS  OF  THE  LIPS 
DISEASES    AND    AFFECTIONS 
FRACTURES  OF  THE  JAWS  . 
INJURIES  AND  DISEASES  OF  THE 
TEMPORO-MAXILLARY  JOINT  . 
INFLAMMATORY  DISEASES  OF  THE 

JAWS 

BENIGN  GROWTHS  OF  THE  JAWS 
MALIGNANT    DISEASE    OF    THE 

JAWS 

AFFECTIONS 


THE    SPLEEN. 

PACK 

Mr.  Arthur  Connell         .         .       79 

Mr.  Arthur  Connell         .         .       81 
Professor  George  R.  Murray    .       82 

Professor  George  E.  Murray    .       84 


Mr.  James  Berry    . 
Mr.  James  Berry    . 
OF    THE    JAWS. 
Mr.  Ernest  W.  Hey  Groves 

JA/-.  Ernest  W.  Hey  Groves 

Mr.  Ernest  W.  Hey  Groves 
Mr.  Ernest  W.  Hey  Groves 

Mr.  Ernest  W.  Hey  Groves 
OF     THE     MOUTH     AND 


DISEASES     AND 
TONGUE. 

STOMATITIS        .... 

OTHER     AFFECTIONS     OF     THE 
MOUTH  

DISEASES  AND  AFFECTIONS  OF  THE 

TONGUE 

DISEASES    AND    AFFECTIONS 

CLEFT  PALATE  . 

OTHER     AFFECTIONS     OF     THE 

PALATE Mr.  t '.  H.  S.  FranJcau    . 

DISEASES   AND    AFFECTIONS    OF    THE   SALIVARY    GLANDS. 

INFLAMMATION  OF  THE  SALIVARY 
GLANDS Mr.  T.  P.  Legg 

OTHER    DISEASES    AND    AFFEC- 
TIONS OF  THE  SALIVARY  GLANDS   Mr.  T.  P.  Legg 
DISEASES    AND    AFFECTIONS    OF    THE    NECK. 


Dr.  Arthur  J.  Hall 
Dr.  Arthur  J.  Halt 

Mr.  Jonathan  Hutchimon 
OF    THE    PALATE. 
Mr.  James  Berry    . 


CUT  THROAT 

FISTUL2E     .... 

CYSTS        .... 

DISEASES    AND    AFFECTIONS 

STRICTURE  OF  THE  CEsopHAcrs 
IN.IUKIKS    AND    MALFORMATIONS 

OF  THE   (ESOPHAGI'S 


Mr.  T.  P.  Legg  . 
Mr.  T.  P.  Legg  . 
Mr.  T.  P.  Legg  . 

OF    THE    OESOPHAGUS. 

Mr.  T.  P.  Legg   .  •   . 

Mr.  T.  P.  Legy   . 


85 
96 

99 
104 

107 
109 

112 

120 
126 
182 

147 
156 

157 
159 

164 
166 
167 

171 

184 


Table  of  Contents. 


IX 


GENERAL    ARTICLES    IN    CONNECTION    WITH    THE    ALI 
MENTARY  TRACT  AND  ABDOMEN. 

DIETETICS 


THE  PRINCIPLES  OF 

INFANT  FEEDING 

FOOD  FEVER      . 

ABDOMINAL  INJURIES 

THE  PREPARATION  OF  PATIENTS 

FOR  ABDOMINAL  OPERATIONS  . 
THE  TREATMENT   OF    PATIENTS 

AFTER  ABDOMINAL  OPERATIONS 
AFFECTIONS  OF  THE  UMBILICUS. 


Dr.  E.  I.  Spriggs  . 
l)r.  E.  I.  Sjn-iggs  . 
Dr.  Eustace  Smith  . 
Mr.  Edred  M.  Corner 

Mr.  T.  Crisp  English 

Mr.  T.  Crisp  English 
Mr.  Ernest  W.  Hey  Groves 


PAUK 

190 
214 
233 

242 


262 

277 


DISEASES    AND    AFFECTIONS    OF     THE    STOMACH     AND 
DUODENUM. 


INJURIES  OF  THE  STOMACH 
ATONY  OF  THE  STOMACH    . 
ATROPHY  OF  THE  STOMACH 
CANCER  OF  THE  STOMACH 
THE    SURGICAL    TREATMENT   OF 

CANCER  OF  THE  STOMACH 
ACUTE     DILATATION     OF    THE 
STOMACH         .... 
ACUTE  POST-OPERATIVE  DILATA- 
TION OF  THE  STOMACH   .        ! 
CHRONIC    DILATATION    OF    THE 
STOMACH  (PYLORIC  STENOSIS) 
SURGICAL  TREATMENT  OF  PYLO- 
RIC STENOSIS  AND  OBSTRUCTIVE 
DILATATION    .... 
DISPLACEMENTS  OF  THK  STOMACH 
SURGICAL  TREATMENT   OF   GAS- 
TROPTOSIS       .... 

HEMORRHAGE  FROM  Til  E  STOMACH 

SritGicAL  TREATMENT  OF  H.EMA- 

TKMES1S 

HOUR-GLASS  STOMACH 

PERIGASTRITIS   .... 

HYPERTROPHIC  STENOSIS  OF  THE 
PYLORUS  .... 

SURGICAL  TREATMENT  OF  HYPER- 
TROPHIC  PYLORIC  STENOSIS  . 

INFLAMMATIONS  OF  THE  STOMACH 

XF.UVOTS  IMSFASES  OF  THE 
STOMACH 


Mr.  A.  W.  Mayo-Robson  .     282 

Dr.  W.  Soltau  Fenwk-k   .  .286 

Dr.  W.  Soltau  Fenwick   .  .     293 

Dr.  W.  Soltau  Fenwick   .  .     296 

Mr.  A.  W.  Mayo-Robson  .     302 

Dr.  W.  Soltau  Fenwick  .  .310 

Mr.A.W.Mayo-Rooson  .     311 

Dr.  W.  Soltau  Fenwick  .  311 


Mr.  A.  W.  Mayo-Robson  .  316 

Dr.  W.  Soltau  Femvick   .  .318 

Mr.  A.  IV.  Mayo-Robson  .  323 

Dr.  W.  Soltau  Fenwick  .  .  325 

Mr.  A.  W.  Mayo-Robson  .  331 

Mr.  A.  W.  Mayo-Robson  .  334 

Mr.  A.  W.  Mayo-Robson  .  336 

Dr.  Edmund  Cautley       .  .  337 

Mr.  A.  W.  Mayo-Robson  .  342 

Dr.  W.  Soltau  Fenwick  .  .  345 

Dr.  W.  Soltau  Feme  id    .  .  354 


Table  of  Contents. 


DISEASES     AND    AFFECTIONS    OF    THE     STOMACH    AND 
DUODENUM— conti  >i  tied. 


PARASITES  AND  CONCRETIONS  OF 


Dr.  W.  Sollau  Fen/rick   . 


STOMACH         .... 
SECRETORY  DISORDERS   OF   THE 

STOMACH         .... 
SYMPTOMATIC     TREATMENT     OF 

DISORDERED  DIGESTION  IN  THE 

STOMACH         .... 
ULCER    OF    THE   STOMACH    AND 

DUODENUM     .... 
THE   SURGICAL    TREATMENT    OF 

ULCER  OF  THE  STOMACH  .        .    Mr.  A.  W.  Mayo-Robson 
PERFORATING     ULCER    OF    THE 

STOMACH         ....     Mr.  A.  W.  Mayo-Robson 
SURGICAL  TREATMENT  OF  ULCER 

OF  THE  DUODENUM         .        .     Mr.  A.  W.  Mayo-Robson 
PERFORATING    ULCER    OF    THE 

DUODENUM     . 
SEA-SICKNESS 

TETANY  OF  THE  STOMACH  . 
BENIGN  TUMOURS  OF  THE  STOMACH     Mr.  A.  W.  Mayo-Robson 
VOLVULUS  OF  THE  STOMACH      .     Mr.  A.  W.  Mayo-Robson 


Dr.  W.  Sollau  Fentcirh    . 

I>r.  IT.  Soltau  fen  wick   . 
Dr.  W.  Soltau  Femrirlc   . 


Mr.  A.  W.  Mayo-Robson 
Dr.  W.  Sollau  Fenwick  . 
Mr.  A.  W.  Mayo-Robson 


DISEASES    AND    AFFECTIONS  OF    THE    INTESTINES. 


APPENDICITIS     .... 

Co: MAC  DISEASE 

COLIC  IN  CHILDREN   . 

CONSTIPATION  IN  CHILDREN 
„  „    ADULTS . 

THE  OPERATIVE  TREATMENT  OF 
CHRONIC  CONSTIPATION  DUE  TO 
DISEASE  OR  ABNORMALITIES  OF 
THE  COLON  .... 

DlARRHCEAL  DISEASES  IN 
CHILDREN  . 

ENTERITIS  (ACUTE  AND  CHRONIC) 
IN  ADULTS  . 

FISTULA  OF  THE  INTESTINES    . 

FOREIGN    BODIES    IN    THE    IN- 

TKS'HNES 

HERNIA 

INTESTINAL  OBSTRUCTION  . 

INTCSSUSCBPTION 

PERFORATION  OF  THE  INTESTINE 


Mr.  T.  Crisp  English 
Dr.  James  Torrens 
Dr.  G.  A.  Sutherland 
Dr.  G.  A.  Sutherland 
Dr.  Arthur  F.  Hertz 


Mr.  P.  Lockhart  Mummery 
Dr.  G.  A.  Sutherland      . 

Dr.  Robert  Saundby 

Mr.  Ernest  W.  Heij  Groves 

Mr.  Ernest  W.  Hey  droves 
Mr  <!.  /,'.  Ihtrner  . 
Mr.  6'.  T.  Dent       . 
Mr.  Harold  J.  Stiles 
Mr.  Ernest  W.  Hey  Groves 


359 
360 

370 
375 
382 
389 
391 

395 
398 
399 
400 
400 


401 
42G 
428 
432 
439 


479 
483 

493 

498 
528 
541 
550 


Table  of  Contents. 


XI 


DISEASES    AND    AFFECTIONS    OF    THE    COLON. 


ADHESIONS  OF  THE  COLON 

COLITIS 

THE   SURGICAL   TREATMENT   OF 

COLITIS 

CANCER  OF  THE  COLON 
CONGENITAL  ABNORMALITIES  OF 

THE  COLON  .... 
MULTIPLE  POLYPI  OF  THE  COLON 
PERFORATING  ULCER  OF  THE 

COLON    

TUBERCULOSIS  OF  TIIK  COLON     . 
VOLVULUS  OF  THE  COLON . 


PAOI 

Mr.  P.  Lockhart  Mummery  .  551) 

Dr.  W.  Hale  While          .  .  f»62 

Mr.  P.  L<>ckh<irt  Mummery  .  570 

Mr.  P.  Loekhart  Mummery  .  578 

.)//•.  /'.  Lockliftrf  Mummer//  .  685 

Mr.  P.  Lu<-l>hart  Mummery  .  588 

.)//•.  P.  Lock/tar  I  Mummer//  .  589 

Mr.  /'.  Ltickhart  Mummer//  .  .">!)( i 

Mr.  P.  Lockhurt  Mummer//  .  51)1 


DISEASES     AND      AFFECTIONS     OF     THE     RECTUM     AND 


ANUS. 

DISEASES  OF   THE  ANO-RECTAL 

AREA 

MALFORMATIONS  OF  THE  RECTUM 
RECTAL  NEUROSES  AND  OBSCURE 

RECTAL  PAIN 

HAEMORRHOIDS  .... 
PROLAPSE  AND  PROCIDENTIA  OF 

THE  RECTUM  .        ... 
Si  MPLE  TUMOURS  OF  THE  RECTUM 
MALIGNANT    GROWTHS    OF    THE 

RECTUM  . 


/S'/V  l-'reilericl;   \Vallis 
Sir  /•'/•>•</<'/•/<•/.•  Wa//is 


Sir  Freilerick    Wallix 
Sir  Freilerick  W»U  is 


Sir  Freilfrifk  Wai  I  is 
Sir  h'reilerick   Wallis 

Sir  Prctlerich  Wai  Us 


5'J3 
613 

6U 
615 

621 


625 


DISEASES    AND    AFFECTIONS    OF    THE    PERITONEUM. 


ASCITES 

ACITE  PERITONITIS  . 
SUBPHRENIC  ABSCESS 
TUBERCULOUS  PERITONITIS 


In:  If.  D.  RoUeston 
Mr.  Ldred  M.  Corner 
Mr.  Ldreil  M.  Corner 
/>/•.  .\rtlnir  Latham 


62C 
6.52 
648 
645 


DISEASES    AND    AFFECTIONS    OF    THE    LIVER. 


ABSCESS  OF  THE  LIVER  (THE 
SURGICAL  TREATMENT  OF) 

ACUTE  YELLOW  ATROPHY  . 

ANOMALIES  IN  FORM  AND  POSI- 
TION OF  THE  LIVEII 

CIRRHOSIS  OF  THE  LIVER. 

DISEASES  OF  THE  BLOOD  VESSELS 
OF  THE  LIVER 


Mr.  James  Cant/if  .  .  .  648 

In:  //.  I).  RoUeston  .  .  6:>7 

In:  II.  I).  RoUeston  .  .  6:)!) 

Dr.  //.  D.  Uullrstnn  .  .  660 

In :  //.  D.  RoUeston  .  666 


XI 1 


Table  of  Contents. 


DISEASES    AND    AFFECTIONS    OF    THE    UVER— continued. 


DEGENERATIONS  OF  THE  LIVER  . 
HYDATID  CYSTS  OF  THE   LIVER 

JAUNDICE 

LARDACEOUS  OR  AMYLOID    DIS- 
EASE OF  THE  LlVEE 
TROPICAL  LIVER 
TUMOURS  OF  THE  LIVER   . 


Dr.  H.  D.  Rolleston 
Mr.  T.  Crisp  Eni/lixh 
Dr.  H.  D.  Rolleston 

Dr.  H.  D.  Rolleston 
Dr.  G.  O.  Low 
Dr.  H.  D.  Rolleston 


668 
061) 
670 

675 
676 
C7<» 


DISEASES  AND  AFFECTIONS  OF  THE  GALL-BLADDER  AND 
BILE    DUCTS. 


INJURIES  OF  THE  BILE  PASSAGES 

CHOLELITHIASIS. 

THE   SURGICAL   TREATMENT   OF 

CHOLELITHIASIS 
FISTULA  OF  THE  GALL-BLADDER 

AND  BILE  DUCTS   . 
INFLAMMATORY    AFFECTIONS   OF 

THE  GALL-BLADDER  AND  BILE 

DTCTS 

TUMOURS  OF  THE  GALL-BLADDER 
TUMOURS  OF  THE  BILE  DUCTS  . 


Mr.  A.  W.  Mayo-Robson  .     680 

Dr.  H.  D.  Rolleston         .  ,.682 

Mr.  A.  W.  Mayo-Robson  .     686 

Mr.  A.  W.  Mayo-Rubxon  .     698 


Mr.  A.  W.  Mayo-Robson  .  700 
Mr.  A.  W.  Mayo-Robson  .  710 
Mr.  A.  W.  Mayo-Robson  .  713 


DISEASES   AND   AFFECTIONS   OF   THE   PANCREAS. 


INJURIES  OF  THE  PANCREAS 
ACUTE  PANCREATITIS 
SUBACUTE  PANCREATITIS    . 
CHRONIC  PANCREATITIS 
PANCREATIC  CALCULI 
PANCREATIC  CYSTS    . 
CANCER  OF  THE  PANCREAS 


Mr.  A.  W.  Mayo-Robson  .  716 

Mr.  A.  W.  Mayo-Robson  .  718 

Mr.  A.  W.  Mayo-Robson  .  720 

Mr.  A.  W.  Mayo-Robson  .  723 

Mr.  A.  W.  Mayo-Robson  .  724 

Mr.  A.  W.  Mayo-Robson  .  726 

Mr.  A.  W.  Mayo-Robson  .  72!) 


DISEASES    AND    AFFECTIONS   OF    THE    KIDNEY. 


URINARY  DISORDERS. 

BACILLURIA       , 

ANEURYSM     OF      THE      RENAL 

ARTERY 

RENAL  CALCULUS 

RENAL  AND  PERI-RENAL  FISTULA 

HYDRONEPHROSIS 

INJURIKS  OK  THK  KIDNEY. 

MOVABLE  KIDNEY 


Dr.  A.  E.  Garrod  .  .  730 

Dr.  Arthur  Latliam         .  .751 

Mr.  J.  W.  Thomson  Walker  .  752 

Mr.  J.  W.  Thomson  Walker  .  753 

Mr.  J.  W.  Thomson  Walker  .  767 

Mr.  J.  W.  Thomson  Walker  .  770 

Mr.  J.  W.  Thomson  Walker  .  780 

Mr.  J.  W.  Thomson  Walker  7<S5 


Table  of  Contents. 


Xlll 


DISEASES    AND    AFFECTIONS    OF    THE    KIDNEY- « 


A.OUTB    NEPHRITIS    (ACUTE 

BRIGHT'S  DISKASK) 
CHRONIC  INTERSTITIAL  NEPHRI- 
TIS  

CHRONIC     DIFFUSE    PARENCHY- 

MATOUS  NEPHRITIS 
SURGICAL  TREATMENT  OF  Nox- 

SUPPURATIVE  NEPHRITIS 
PERINEPHRITIC  ABSCESS    . 

PYELITIS 

PYELITIS  OF  INFANCY  AND  CHILD- 
HOOD        

PYKLITIS  (PYELONEPHRITIS  OF 
I'KKCNANCV)  .... 
PYELONEPHRITIS  (INFKCTIVK) 
I'YONEPHROSIS  .... 
TUBERCULOSIS  OF  THE  KIDNEY  . 
TUMOURS  OF  THE  KIDNEY  IN 

ADULTS 

TUMOURS    OF    THE    KIDNEY   IN 
CHILDREN       .... 

URJEMIA 

AMYLOID  DISEASE  OF  THE  KID- 
NEYS 


Dr.  W.  P.  Herringham   .  .  7!»2 

Dr.  W.  P.  Herringham   .  .  794 

Dr.  W.  P.  Herringham    .  .  796 

.)//•.  ./.  H'.  Thomson  Walker  .  798 

Mr.  ./.  IF.  Thomson  Walker  .  801 

Mr.  J.  W.  Thomson  Walker  .  803 

Mr.  J.  W.  Thomson  Walker  .  805 

Mr.  J.  W.  Thomson  Walker  .  806 

Mr.  J.  W.  Thomson  Walker  .  S07 

Mr.  J.  W.  Thomson  Walker  .  814 

Mr.  J.  W.  Thomson  Walker  .  819 

Mr.  J.  W.  Thomson  Walker  .  830 

Mr.  ./.  Jr.  Thomson  Walker  .  836 

///.  II'.  P.  Herringham    .  .837 

Dr.  W.  P.  Herringham   .  .  839 


DISEASES   AND   AFFECTIONS    OF   THE   URETER. 


WOUNDS  OF  THE  URETER  . 
FISTULA  OF  THE  URETER  . 
STONE  IN  THE  URETER 


Mr.  J.  W.  Thomson  Walker 
Mr.  J.  W.  Thomson  Walker 
Mr.  J.  W.  Thomson  Walker 


DISEASES    AND    AFFECTIONS    OF    THE    BLADDER. 


CALCULUS  OF  THE  BLADDER 
CYSTITIS    ... 
TUBERCULOUS  CYSTITIS 
DlVKKTK  TI.A    AND    SACCULI   OF 

THE  BLADDER 
ECTOPIA  VESIC.E 
I  N.I  Ul!  IKS  OF  THE  BLADDER 
TUMOURS  OF  THE  BLADDER 


J//-.  Sydney  G.  MacDonald  .  852 

Mr.  Sydney  G.  MacDonald  .  858 

Mr.  Sydney  G.  MacDonald  .  861 

Mr.  Sydney  C.  Mtirl  tonal  >l  .  864 

Mr.  Sydney  (!.  MacDonald  .  866 

Mr.  Sydney  G.  Murlxmuhl  .  ^68 

Mr.  Sydney  <,'.  McDonald  .  870 


XIV 


Table  of  Contents. 


DISEASES   AND   AFFECTIONS   OF    THE   PENIS. 

BALANITIS  AND  POSTHITIS  .  Mr.  Ivor  Back 

CAVERNOSITIS  ....  Mr.  Ivor  Back 
CONGENITAL  MALFORMATIONS  OF 

THE  PENIS  ....  Mr.  Ivor  Back 

INJURIES  OF  THE  PENIS  .  .  Mr.  Ivor  Back 
MALIGNANT  DISEASE  OF  THE 

PENIS  .....  Mr.  Ivor  Back 

PAPILLOMATA  OF  THE  PENIS  .  Mr.  Ivor  Back 

PARAPHIMOSIS  ....  Mr.  Ivor  Back 

PHIMOSIS  .  .  Mr.  Ivor  Back 


PACiK 

874 
874 

875 
876 

877 
879 
879 

880 


DISEASES    AND    AFFECTIONS    OF    THE    URETHRA. 


INJURIES  OF  THE  URETHRA 
STRICTURE 

EXTRAVASATION  OF  URINE 
FISTULA  OF  THE  URETHRA 
PERI-URETHRAL  ABSCESS  . 


Mr.  Ivor  Back 
Mr.  Ivor  Hack 
Mr.  Ivor  Back 
Mr.  Ivor  Back 
Mr.  Ivor  Back 


CHRONIC  URETHRITIS  (GLEET)  .     Mr.  C.  H.  8.  Frankau 


882 
886 
893 
894 
895 
897 


DISEASES      AND     AFFECTIONS 
OF    THE    SCROTUM  .       .        .     Mr.  Ivor  Back 


900 


DISEASES    AND    AFFECTIONS    OF    THE    TESTICLE. 


HERNIA  TESTIS. 

IMPERFECT    DESCENT    OF    THE 

TESTIS 

INFLAMMATION  OF  THE  TESTIS  . 
INJURIES  OF  THE  TESTIS  . 
SYPHILITIC    DISEASES    OF    THE 

TESTIS 

TORSION  OF  THE  TESTIS    . 
TUBERCULOUS  DISEASES  OF  THE 

TESTIS 

TUMOURS  OF  THE  TESTIS  . 
IMPOTENCE 


Mr.  Ivor  Back 

Mr.  Ivor  Back 
Mr.  Ivor  Back 
Mr.  Ivor  Back 

Mr.  Ivor  Back 
Mr.  Ivor  Back 

Mr.  Ivor  Back 
Mr.  Ivor  Back 
Mr.  J.  Ernest  Lane 


901 

902 
906 
907 

907 
907 

908 

910 
911 


DISEASES  AND   AFFECTIONS   OF    THE  TUNICA  VAGINALIS. 


H^EMATOCELE 
HYDROCELE 


Mr.  Ivor  Back 
Mr.  Ivor  Back 


913 
914 


Table  of  Contents. 

DISEASES    AND    AFFECTIONS    OF   THE    SPERMATIC    CORD. 

HJEMATOMA  ....  Mr.  Ivor  Back 
HYDROCELE  ....  Mr.  Ivor  Batk 
VABICOCELE.  (£/r  AFFKCTIONS  OF  VEINS,  VOL.  L,  p.  1323) 


XV 


PACK 

917 
917 


DISEASES   AND   AFFECTIONS  OF   THE   PROSTATE  GLAND. 


CALCULI  OF  THE  PROSTATE 
INJURIES  or  THE  PROSTATE 
ACUTE  PROSTATITIS  . 
CHRONIC  PROSTATITIS 
GOUTY  PROSTATITIS  . 
ONANITIC  PROSTATITIS 
SYPHILIS  OF  THE  PROSTATE 
TUBERCULOUS  PROSTATITIS 
TUMOURS  OF  THE  PROSTATE 
FIBROUS  ENLARGEMENT  OF  THE 
PROSTATE 


Mr.  John 
Mr.  John 
Mr.  John 
Mr.  John 
Mr.  John 
Mr.  John 
Mr.  John 
Mr.  John 
Mr.  John 


Pardoe 
Pardoe 
Pardoe 
Pardoe 
Pardoe 
Pardoe 
Pardoe 
Pardoe 
Pardoe 


Mr.  John  Pardoe 


918 
919 
920 
924 
926 
927 
927 
928 
930 

950 


DISEASES    AND    AFFECTIONS    OF    THE    BREAST. 


CYSTS 

DUCT  PAPILLOMA 

F  i  BRO- ADENOMATA  OF  THE 
BREASTS 

HYPERTROPHY  OF  THE  BREASTS 

INFLAMMATORY  AFFECTIONS  OF 
THE  BREAST  .... 

MALIGNANT  DISEASE  OF  THE 
BREAST 

NEURALGIA  OF  THE  BREAST 

AFFECTIONS  OF  THE  NIPPLES    . 

OPERATIVE  DIAGNOSIS  OF  DOUBT- 
FUL TUMOURS  OF  THE  BREAST 

TUBERCULOSIS  OF  THE  BREAST  . 


Mr.  T.  Crisp  English 
Mr.  T.  Crisp  English 

Mr.  T.  Crisp  English 
Mr.  T.  Crisp  English 

Mr.  T.  (  'risp  English 


Mr.  T.  Crisp 

Mr.  T.  Crisp  English 

Mr.  T.  Crisp  English 

Mr.  T.  Crisp  English 
Mr.  T.  Crisp  English 


952 
954 

955 
957 

958 

963 
976 

977 

979 
981 


CERTAIN   DISEASES  AND  AFFECTIONS  OF   THE  NERVOUS 
SYSTEM   OF   OBSCURE   ORIGIN. 


COMA. 

INFANTILE  CONVULSIONS  . 
EPILEPSY  .... 
THE  SURGICAL  TREATMENT 

EPILEPSY 
HYSTERIA  . 


.     Dr.  T.  Grainger  Stewart. 
.     Dr.  Alfred  M.  Gossage    . 
Dr.  William  Aldren  Turner 


OF 


Mr.  C.  H.  S.  Frankau     . 
Dr.  H.  Campbell  Thomson 


982 
986 
990 


1007 
1008 


XVI 


Table  of  Contents. 


CERTAIN  DISEASES   AND  AFFECTIONS  OF  THE  NERVOUS 
SYSTEM  OF  OBSCURE  ORIGIN-twrfi»K«7. 


INSOMNIA 

LUMBAR  PUNCTURE   . 
MIGRAINE    AND    OTHER    FORMS 

OF  PERIODIC  HEADACHE 
NIGHT  TERRORS 
NEURASTHENIA  .... 
PSYCH  ASTHENIA  .... 
Tics  AND  SPASMS 
TORTICOLLIS 


Dr.    Maarici'    Craij    and    Dr. 

E.  D.  Macnamara        .         .1014 
Dr.  Purees  Stewart          .         .  1025 

Dr.  James  Collwr    .         . 

Dr.  Edmund  Can  fie//       . 

Dr.  James  Taylor  .         . 

Dr.  James  Taylor   .         . 

Dr.  Wilfred  Harris          .         .1047 

Dr.  S.  A.  Kinnier  Wilson        .   1050 


GENERAL    DISEASES    OF    THE    NERVOUS    SYSTEM. 


AMYOTROPHIC  LATERAL  SCLERO- 
SIS  

ACUTE  ANTERIOR  POLIOMYELITIS 

INFANTILE  PARALYSIS,  XERVE 
ANASTOMOSIS  IN 

BULBAR  PALSY  .... 

CEREBRO- SPINAL  SYPHILIS. 

DISSEMINATED  SCLEROSIS  . 

GENERAL  PARALYSIS  OF  THE 
INSANE 

LANDRY'S  PARALYSIS 

PROGRESSIVE  MUSCULAR 
ATROPHY  .... 

SUB  -  ACUTE  COMBINED  DE- 
GENERATION OF  THE  SPINAL 
CORD 

TABES  DORSALIS 


Dr.  S.  A.  Kinnier  Wilson  .  ]u.V! 

Dr.  Judson  S.  Bury        .  r>55 

Mr.  James  Sherren.         .  .  ID.")!) 

Dr.  S.  A.  Kinnier  Witwn  .  luOl 

Dr.  E.  Farquhar  Buzzard  .  1063 

Dr.  J.  S.  Risien  Russell .  .  lo7<> 

Dr.  E.  Farquhar  Buzzard  .  in? 7 

Dr.  S.  A.  Kinnier  Wilson  .  1080 

Dr.  S.  A.  Kinnier  Wilson  .1081 


Dr.  Gordon  Holmes.         .         .1083 
Dr.  J.  S.  Risien.  Russell  .         .  1085 


DISEASES    AND    AFFECTIONS    OF    THE    NERVES. 


FACIAL  PARALYSIS     . 
HERPES  ZOSTER 
INJURIES  OF  NERVES 
TRAUMATIC  NEURITIS 
INJURIES  OF  SPECIAL  NERVES  . 
NEURALGIA        . 
'I'm;  SURGICAL   TREATMENT   OF 
NEURALGIA    .... 

NEURITIS 

DIVISION  OF  POSTERIOR  ROOTS  . 


Dr.  Judson  S.  Bury         .  .  1003 

Dr.  S.  A.  Kinnier  Wilson  .  1096 

J/r.  James  Sherren  .         .  .  1098 

Mr.  James  Sherren.         .  .  1106 

.)//-.  James  Sherren.         .  .  1108 

Dr.  Wilfred  Harris          .  .1114 

Mr*  James  Sherren .        •  .1127 

Dr.  T.  Grainger  Stewart .  .  1130 

J/r.  James  Sherren .  .  1133 


Table  of  Contents.  xvii 

DISEASES    AND    AFFECTIONS    OF    THE    NERVES  --cvntinwl. 


MULTIPLE  XEURITIS  . 
XYSTAGMUS     -  . 
TUMOURS  OF  NERVES 


Dr.  T.  Grainger  Stewart 
Dr.  Wilfred  Harris 

Mr. 


PACE 

1134 
1140 
1142 


DISEASES    AND    AFFECTIONS    OF    THE    BRAIN. 


APHASIA  AND  OTHER  SPEECH 
DEFECTS  OF  CEREBRAL  ORI- 
GIN   

APRAXIA 

THE  CEREBRAL  PALSIES  OF  IN- 
FANCY   

THE  SURGICAL  TREATMENT  OF 
CEREBRAL  PALSIES  OF  IN- 
FANCY   

CEREBELLAR  CONDITIONS  IN 
CHILDREN  .... 

CEREBRAL  EMBOLISM  . 

CEREBRAL  HEMORRHAGE  . 

CEREBRAL  THROMBOSIS 

HEMIPLEGIA       .... 

HERNIA  CEREBRI 

HYDROCEPHALUS 

SURGICAL  TREATMENT  OF  HYURO- 
CEPHALUS  .... 

MENINGOCELE    .        .        . 

PARAPLEGIA       .... 

THE  MEDICAL  TREATMENT  OF 
TUMOURS  OF  THE  BRAIN 

SURGICAL  TREATMENT  OF 
TUMOURS  OF  THE  BRAIN 


Dr.  James  Collier   .         .  .1148 

Dr.  -lames  Collier    .          .  .1150 

Dr.  Gordon  Holmes.         .  .   1153 

Mr.  Holier!  June*  (tnd  Mr.  D. 

McCrae  Ailken     .         .  .1157 

Dr.  Alfred  M.  Gossage    .  .1165 

Dr.  T.  Grainger  Stewart .  .  1167 

Dr.  T.  Grainger  Stewart  .  1  His 

Dr.  T.  Grainger  Stewart  .   1177 

Dr.  E.  Farquhar  Buzzard  .  1181 

Mr.  C.  H.  S.  FranTcaii     .  .1190 

Dr.  S.  A.  Kinnier  Wilson  .  1191 

Mr.  H.  S.  Pendlelniry      .  .1193 

Mr.  ('.  H.  S.  Frtinltau     .  .11  !»4 

Dr.  S.  A.  Kinnier   Wilson  .   1 1'.'"> 

Dr.  T.  (Ira  inner  ^ten-art  .  1200 

Mr.  Donald  Armour  .    I2ol 


DISEASES    AND    AFFECTIONS    OF    THE    SPINAL    CORD. 


CAISSON  DISEASE 
IL-EMATOMYELIA 

MYELITIS 

SYRINGOMYELIA  .... 
TUMOURS  OF  THE  SPINAL  CORD 


Dr.  A'.  Faniuliar  Blizzard  .   1208 

Dr.  E.  Farquhar  Buzzard  .1210 

Dr.  h'.  Farquhar  Huzza rd  .   1212 

Dr.  Gordon  Holmes         .  .1219 

Mr.  Donald  Armour  .  1221 


VASOMOTOR    AND    TROPHIC    DISEASES. 

ACROMEGALY       ....     Dr.  Alfred  M. 
ACHRONDROPLASIA      .         .         .     Dr.  A/fret/  M. 

S.T. VOL.    II. 


.    1226 
.    1227 


XV111 


Table  of  Contents. 


VASOMOTOR    AND    TROPHIC    DISEASES-"'/// ; 


ANGIONEUROTIC  (EDEMA    . 
ERYTHROMELALGIA     . 
FACIAL  HEMIATROPHY 
HYPERTROPHIC    PULMONARY 

OSTEO-ARTHROPATHY 
INTERMITTENT     CLAUDICATION  ; 

INTERMITTENT  LIMP 
LEONTIASIS  OSSEA     . 
OSTEITIS  DEFORMANS    (PAGET'S 

DISEASE)         .... 
OSTEOGENESIS  IMPERFECTA. 
RAYNAUD'S  DISEASE  . 
VASOMOTOR  NEUROSES 

FAMILIAL    DISEASES. 

AMAUROTIC  FAMILY  IDIOCY 

AMYOTONIA  CONGENITA 

CHRONIC  DISORDERS  WITH  CERE- 
BELLAR  SYMPTOMS  . 

THE  FAMILY  FORM  OF  MUSCULAR 
ATROPHY  ix  CHILDREN  . 

FAMILY  PERIODIC  PARALYSIS    . 

FRIEDRICH'S  DISEASE 

HEREDITARY    SPASTIC   PARA- 
PLEGIA     

HIXTINGDON'S  CHOREA 

MUSCULAR  DYSTROPHIES   . 

MYOTONIA  ATROPHICA 
..         CONGENITA 

PERONEAL   MUSCULAR  ATROPHY 


Dr.  Alfred  J/.  Gossage    .  .1228 

Dr.  Alfred  II.  Go*sa;ie    .  .1230 

Dr.  S.  A.  Ki'inier  Wil*on  .  1232 

Dr.  Alfred  J/.  Gossage    .  .  12 :'.:'. 

Dr.  S.  A.  Kinnier  Wilson  .  1284 

Dr.  Alfred  M.  Gossage    .  .1236 

"Dr.  Alfred  J/.  Gossage    .  .1237 

Dr.  Alfred I'M.  Gossage    .  .  1237 

Dr.  Alfred  M.  Gossage    .  .1238 

Dr.  S.  A.  Kin  trier  Wilson  .  1242 


Dr.  Gordon  Holmes  .  .1244 

Dr.  Gordon  Holmes  .  .  124.~> 

Dr.  Gordon  Holmes  .  .  1240 

Dr.  Gordon  Holmes  .  .1247 

Dr.  Gordon  Holmes  .  .1247 

Dr.  Gordon  Holmes  .  .1248 

Dr.  Gordon  Holmes  .  .1249 

Dr.  Gordon  Holmes  .  .1241* 

Dr.  Gordon  Holme*  .  .  12.~»u 

Dr.  Goi-don  Holmes  .  /  1852 

Dr.  Gordon  Holmes  .  .  1252 

Dr.  Gordon  Holmes  .   12."i.", 


DISEASES  CHARACTERISED  BY  DISORDERS  OF  MUSCULAR 
FUNCTION. 


MYASTHENIA  GRAVIS 
PARAMYOCLONUS  MULTIPLEX 


Dr.  James  Torrens 

Dr.  S.  A.  Kinnier  Wilson 


\  2:.  I 


DISEASES        OF        OBSCURE        ORIGIN        CHARACTERISED 
CHIEFLY    BY    DISORDERS    OF    MOTION. 


CHOREA 

OCCUPATION      NEUROSES 

CRAFT  PALSIES 
PARALYSIS  AGITANS  . 
TETANY 

JN  CHILDREN 


Dr.  Herbert  French 


AND 


Dr.  Wilfred 
Dr.  Pur  res  Stewart 
Dr.  Wilfred  Harris 
Dr.  Edmund  Cautley 


1257 

1264 

126!> 
1271 
1272 


Table  of  Contents.  xix 

MENTAL    DISEASES. 

PAOK 

GENERAL  CONSIDERATIONS.         .     Dr.    Maurice   Craig  antl  Dr. 

E.  D.  Macnamara        .         .  1274 

MANIA Dr.    Maurice   Craig  and  Dr. 

E.  D.  Macnamara        .         .  1284 
MELANCHOLIA     ....     Dr.    Maurice    Craig  and  Dr. 

E.  D.  Macnamara        .         .1290 
EXHAUSTION  PSYCHOSES     .         .     Dr.    Maurice    Craig    and   Dr. 

E.  D.  Marnamara        .         .  1299 
PSYCHOSKS  ASSOCIATED  WITH 

CIIANCKS     i.\     THE    THYROID     />/•.    Maurice    Crai//   and  Dr. 

ft  LAN i> E.  D.  Macnamara        .         .   1301 

Toxic  PSYCHOSES       .         .         .     Dr.    Mauris   Craig  and    Dr. 

/,'.  D.  Marnamara        .         .  1303 
DKMKNTIA  PR^ECOX    .         .         .     Dr.    Maurice   Craig  and  Dr. 

E.  D.  Marnamara        .         .  1305 

THE  MENTAL  ASPECTS  OF  Dr.   Maurice    Craig  and  Dr. 

HYSTERIA       .         .        .        .        E.  D.  Macnamara        .        .  130G 

PARANOIA Dr.    Maurice   Craig   and   Dr. 

E.  D.  Macnamara        .         .  1309 
THE    MENTAL    ASPECTS    OF     Dr.    Maurice   Craig  and    Dr. 

EPILEPSY        ....         H.  D.  Macnamara        .         .  1310 
OBSESSIVE      AND      IMPERATIVE     Dr.    Maurice    Craig  and  Dr. 

IDEAS E.  D.  Macnamara        .         .  1313 

PERVERSIONS      ....     Dr.    Maurice    Craig  and   Dr. 

E.  D.  Macnamara       .         .1315 
MASTURBATION  ....     Dr.    Maurice   Craig  and   Dr. 

E.  D.  Macnamara        .         .  131 G 
IDIOCY  AND  FEEBLE-MINDEDNESS     Dr.    Maurice   Craig  and   Dr. 

E.  D.  Macnamara        .         .1318 

DISEASES    AND    A'FFECTIONS    OF   MUSCLES    AND    FASCLE. 
INJURIES  OF  MUSCLES       .         .     Mr.  C.  H.  A'.  Prankau    .        .   1321 
INFLAMMATORY    AFFECTIONS   OF 

MTSCLK Mr.  C.  H.  8.  Frankau    .         .  1324 

Ni:w  GROWTHS  OF  MUSCLE        .     Mr.  <'.  H.  S.  Frankau    .        .  1325 

DISEASES    AND    AFFECTIONS    OF    TENDONS    AND    THEIR 
SHEATHS. 

INJURIES  OF  TENDONS       .        .     Mr.  C.  H.  8.  Frankau    .        .  1326 

AFFKITIONS      OF      THE       TENDON 

SHEATHS Mr.  C.  H.  S.  Frankau    .        .1330 

DISEASES  AND  AFFECTIONS  OF 
BURS/E Mr.  C.  H.  S.  Franlcan    .         .   1 3:34 

b  2 


XXI 


List  of  Contributors 

Adamson,  Horatio  G., 

M.D.,  M.R.C.P., 
Physician  in  charge  of  Skin  Dept.,  St.  Bartholomew's  Hospital. 

Aitken,  D.  McCrae, 

M.B.,  Ch.B.,  F.R.C.S., 

Assistant  Surgeon,  St.  Vincent's  Surgical  Home  for  Cripples;  Demon- 
strator of  Anatomy,  Middlesex  Hospital. 

Anderson,  Miss  McCall, 

Matron,  St.  George's  Hospital. 

Andrews,  H.  Russell, 

M.D.,  M.R.C.P., 

Obstetric  Physician,  London  Hospital;  Lecturer  on  Midwifery  and 
Diseases  of  Women,  London  Hospital  Medical  College. 

Armour,  Donald, 

F.R.C.S., 

Surgeon,  National  Hospital  for  Paralysed  and  Epileptic  ;  Surgeon, 
Belgrave  Hospital  for  Children  ;  Senior  Assistant  Surgeon,  West  London 
Hospital. 

Back,  Ivor, 

M.B.,  F.R.C.S., 

Assistant  Surgeon,  St.  George's  Hospital ;  Lecturer  on  Operative  Surgery, 
St.  George's  Hospital. 

Bagshawe,  Arthur  W.  G., 

M.B.,  B.C.,  D.P.H., 
Director  of  the  Sleeping  Sickness  Bureau,  Royal  Society. 

Ballantyne,  John  Wm., 

M.D.,  F.R.C.P.  Edin., 

Physician,  Royal  Maternity  Hospital,  Edinburgh ;  Lecturer  on  Midwifery 
and  Gynaecology,  Surgeons'  Hall  and  Edinburgh  School  of  Medicine  for 
Women. 
• 

Barwell,  Harold  S., 

M.B.,  F.R.C.S., 

Surgeon  for  Diseases  of  Throat,  St.  George's  Hospital ;  Surgeon  in 
charge,  Ear  and  Throat  Dept.,  Hampstead  General  Hospital. 

Bayly,  H.  Wansey, 

M.R.C.S.,  L.R.C.P., 

Assistant  in  Bacteriological  Dept.,  St.  George's  Hospital ;  Pathologist, 
London  Lock  Hospital. 


xxii  System  of  Treatment. 

Bell,  W.  Blair, 

M.D.,  B.S., 
Assistant  Gynaecological  Surgeon,  Royal  Infirmary,  Liverpool. 

Bennett,  Norman  G., 

M.B.,  B.C.  Cantab.,  L.D.S.  Eng., 

Dental   Surgeon,   Royal   Dental   Hospital,   London,   and    St.    George's 
Hospital. 

Bennett,  Sir  William, 

K.C.V.O.,  F.R.C.S., 

Senior  Surgeon,  Seamen's  Hospital;  Consulting  Surgeon,  St.  George's 
Hospital. 

Berkeley,  Comyns, 

M.D.,  B.C.  Camb.,  F.R.C.P., 

Obstetric  and  Gynaecological    Surgeon,    Middlesex    Hospital ;    Surgeon, 
Chelsea  Hospital  for  Women. 

Berry,  James, 

B.S.  Lond.,  F.R.C.S., 

Senior  Surgeon,  Royal  Free  Hospital;  Surgeon,  Alexandra  Hospital  for 
Hip  Disease. 

Blacker,  George, 

M.D.,  F.R.C.S.,  F.R.C.P., 

Obstetric  Physician,   University  College  Hospital ;  Teacher  of  Practical 
Midwifery,  University  College  Hospital  Medical  School. 

Bland-Sutton,  John, 

F.R.C.S., 
Surgeon,  Middlesex  Hospital    Member  of  Cancer  Investigation  Committee. 

Blumfeld,  Joseph, 

M.D.,  B.C.  Camb., 

Senior  Anaesthetist,  St.  George's  Hospital ;    Honorary  Anaesthetist,  St. 
Mary's  Hospital. 

Bonney,  Victor, 

M.D.,  M.S.,  F.R.C.S.,  M.R.C.P., 

Assistant   Obstetric   and    Gynaecological    Surgeon,   Middlesex    Hospital; 
Surgeon,  Chelsea  Hospital  for  Women. 

Brewis,  N.  T., 

M.B.,  F.R.C.P.,  F.R.C.S.  Edin., 
Gynaecologist,  Edinburgh  Royal  Infirmary. 

Briscoe,  J.  Charlton, 

M.D.,  F.R.C.P., 

Assistant  Physician,  King's  College  Hospital ;  Senior  Physician,  Evelina 
Hospital  for  Sick  Children. 

Brown,  W.  Carnegie, 

M.D.,  M.R.C.P., 
Joint  Secretary,  Society  of  Tropical  Medicine  and  Hygiene. 

Bruce,  J.  Mitchell, 

M.D.,  F.R.C.P.,  LL.D., 

Consulting  Physician  to  King  Edward  VII.  Sanatorium,  Charing  Cross 
Hospital  and  Brompton  Hospital  for  Consumption. 


List  of  Contributors.  xxiii 

Bruce,  W.  Ironside, 

M.D., 

Physician  in  charge,  X-ray  and  Electrical  Depts.,  Charing  Cross  Hospital ; 
Honorary  Radiographer,  Hospital  for  Sick  Children,  Great  Ormond 
Street. 

Buckley,  Charles  W., 

M.D., 
Late  House  Physician,  St.  Mary's  Hospital. 

Bury,  Judson  S., 

M.D.,  F.R.C.P., 
Physician,  Manchester  Royal  Infirmary. 

Buzzard,  E.  Farquhar, 

M.D.,  F.R.C.P., 

Physician  to  Out-patients,  St.  Thomas's  Hospital  and  National  Hospital 
for  Paralysed  and  Epileptic. 

Caiger,  F.  Foord, 

M.D.,  D.P.H.,  F.R.C.P., 

Medical  Superintendent  and  Lecturer  on  Infectious  Diseases,  South 
Western  Fever  Hospital. 

Cameron,  Samuel  J., 

M.B.,  Ch.B., 

Assistant  to  Regius  Professor  of  Midwifery,  University  of  Glasgow ; 
Gynaecologist  to  Out-patients,  Western  Infirmary,  Glasgow. 

Cantlie,  James, 

M.B.,  F.R.C.S.,  D.P.H., 

Surgeon,  Seamen's  Hospital ;  Lecturer  on  Surgery,  London  School  of 
Tropical  Medicine. 

Carr,  J.  Walter, 

M.D.,  F.R.C.P.,  F.R.C.S., 

Senior  Physician,  Victoria  Hospital  for  Children,  Chelsea;  Physician, 
Royal  Free  Hospital. 

Cathcart,  George  C., 

M.D., 

Surgeon,  London  Throat  Hospital ;  late  Lecturer  on  Voice  Production 
to  School  Board  for  London. 

Cautley,  Edmund, 

M.D..F.R.C.P., 

Senior  Physician,  Belgrave  Hospital  for  Children ;  Physician  Metropolitan 
Hospital. 

Charles,  Sir  R.  Havelock, 

G.C.V.O.,  M.Ch.,  F.R.C.S.I., 

Sergeant  Surgeon  to  H.M.  the  King;  Member  of  the  Medical  Board, 
India  Office. 

Cheatle,  G.  Lenthal, 

C.B.,  F.R.C.S., 
Surgeon,  King's  College  Hospital. 


xxiv  System  of  Treatment. 

Clarke,  Ernest, 

M.D.,  F.R.C.S., 

Senior  Surgeon,  Central  London  Ophthalmic  Hospital ;  Consulting 
Ophthalmic  Surgeon,  Miller  Hospital. 

Collier,  James, 

M.D.,  F.R.C.P., 

Physician,  St.  George's  Hospital  ;  Physician  in  charge  of  Out-patients, 
National  Hospital  for  the  Paralysed  and  Epileptic,  Queen  Square; 
Physician,  Royal  Eye  Hospital. 

Connell,  Arthur, 

F.R.C.S.  Edin., 

Honorary  Surgeon,  Sheffield  Royal  Infirmary ;  Lecturer  on  Surgery, 
Sheffield  University. 

Corner,  Edred  M., 

M.C.,  F.R.C.S., 

Surgeon  in  charge,  Out-patients,  and  Lecturer  on  Practical  Surgery, 
St.  Thomas's  Hospital ;  Surgeon,  Hospital  for  Sick  Children,  Great 
Ormond  Street. 

Craig,  Maurice, 

M.D..  F.R.C.P., 

Physician  for  Mental  Diseases  and  Lecturer  in  Mental  Diseases,  Guy's 
Hospital. 

Cuff,  Herbert  E., 

M.D.,  F.R.C.S., 

Medical  Officer  for  General  Purposes,  Metropolitan  Asylums  Board  ; 
late  Medical  Superintendent,  North  Eastern  Fever  Hospital. 

Cunningham,  Herbert  H.  B., 

M.D.,  F.R.C.S.I., 

External  Examiner  in  Ophthalmology  and  Otology,  National  University 
of  Ireland;  Examiner  in  Ophthalmology  and  Otology,  Royal  College  of 
Surgeons,  Ireland;  Ophthalmic  Surgeon,  Ulster  Hospital  for  Women 
and  Children. 

Dakin,  W.  R., 

M.D.,  F.R.C.P., 

Obstetric  Physician  and  Lecturer  on  Midwifery,  St.  George's  Hospital  ; 
Physician,  General  Lying-in  Hospital. 

Daniels,  C.  W., 

M.B.,  M.R.C.P., 

Lecturer  on  Tropical  Medicine,  formerly  Director,  at  London  School  of 
Tropical  Medicine  ;  Lecturer  on  Tropical  Diseases,  London  Hospital. 

Dent,  Clinton  T., 

M.C.,  F.R.C.S., 

Surgeon,  St.  George's  Hospital ;  Lecturer  on  Surgery,  St.  George's 
Hospital  Medical  School. 

Des  Vceux,  Harold  A., 

M.D.,  M.R.C.S. 


List  of  Contributors.  xxv 

Dobbie,  Mina  L., 

M.D.,  B.Ch. 

Dominici,  H., 

In  charge  of  Pathological  and  Physical  Depts.,  Radium  Laboratory,  Paris. 

Doyne,  Robert  W., 

F.R.C.S., 
Reader  in  Ophthalmology,  Oxford  University. 

English,  T.  Crisp, 

F.R.C.S., 

Senior  Assistant  Surgeon,  and  Lecturer  on  Practical  Surgery,  St.  George's 
Hospital;  Assistant  Surgeon,  Grosvenor  Hospital  for  Women. 

Fenwick,  W.  Soltau, 

M.D.,  M.R.C.P.; 
Senior  Physician,  London  Temperance  Hospital.     ' 

Fothergill,  William  E., 
M.D.,  C.M., 

Honorary  Assistant  Gynecological  Surgeon,  Manchester  Royal  Infirmary  ; 
Lecturer  on  Obstetrics  and  Gynaecology,  Victoria  University,  Manchester. 

Fox,  R.  Fortescue, 

M.D.,  M.R.C.P., 

Late  President,  British  Balneological  and  Climatological  Society ;  Con- 
sulting Physician,  Mineral  Water  Hospital,  Strathpefier  Spa. 

Fox,  Wilfrid, 

M.D.,  M.R.C.P., 

Physician  for  Diseases  of  the  Skin,  St.  George's  Hospital ;  Assistant 
Physician  for  Diseases  of  the  Skin,  Seamen's  Hospital,  Greenwich. 

Frankau,  Claude  H.  S., 

M.B.,  B.S.,  F.R.C.S., 
Surgical  Registrar,  St.  George's  Hospital. 

Fraser,  J.  S., 

M.B.,  Ch.B.,  F.R.C.S.  Edin., 

Assistant  Surgeon,  Ear  and  Throat  Dept.,  Royal  Infirmary,  Edinburgh  ; 
Lecturer  on  Diseases  of  Throat,  Nose  and  Ear,  School  of  Medicine  of 
Royal  Colleges,  Edinburgh. 

Freeland,  James  R., 

M.D., 
Late  Assistant  Master,  Rotunda  Hospital,  Dublin. 

French,  Herbert, 

M.D.,  F.R.C.P., 

Assistant  Physician,  Pathologist  and  Lecturer  on  Forensic  Medicine  at 
Guy's  Hospital. 


xxvi  System  of  Treatment. 

Gardiner,  Frederick, 

M.D.,  F.R.C.S.  Edin., 

Assistant  Physician,  Skin  Dept.,  Royal  Infirmary,  Edinburgh  ;  Lecturer 
on  Dermatology,  School  of  Medicine  for  Women,  Edinburgh. 

Garrod,  Archibald  E., 

M.D.,  F.R.C.P.,  F.R.S., 

Physician  with  charge  of  Out-patients  and  Lecturer  on  Chemical 
Pathology,  St.  Bartholomew's  Hospital ;  Physician,  Hospital  for  Sick 
Children,  Great  Ormond  Street. 

Gibbons,  Robert  A., 

M.D.,  M.R.C.P., 

Physician  Accoucheur  to  H.R.H.  Princess  Alexander  of  Teck  ;  Physician, 
Grosvenor  Hospital  for  Women. 

Goodall,  E.  Wilberforce, 

M.D.,  B.S., 

Medical  Superintendent,  Eastern  Hospital;  late  Teacher  of  Infectious 
"Diseases  in  Royal  Army  Medical  College. 

Gossage,  Alfred  Milne, 

M.D.,  F.R.C.P., 

Physician  to  Out-patients,  Westminster  Hospital  and  East  London 
Hospital  for  Children  ;  Joint  Lecturer  on  Medicine,  Westminster  Hospital 
Medical  School. 

Grimsdale,  Harold, 

M.B.,  B.C.,  F.R.C.S., 

Ophthalmic  Surgeon  and  Lecturer  on  Ophthalmic  Surgery,  St.  George's 
Hospital;  Surgeon,  Royal  Westminster  Ophthalmic  Hospital. 

Groves,  Ernest  W.  Hey, 

M.D.,  M.S.,  F.R.C.S., 

Assistant  Surgeon,  Bristol  General  Hospital ;  Senior  Demonstrator 
in  Anatomy,  Bristol  University. 

Griinbaum,  Otto  F.  F. 

M.D.,  F.R.C.P., 

Assistant  Physician,  London  Hospital;  late  Physician  to  Out-patients, 
City  of  London  Hospital  for  Diseases  of  the  Chest. 

Guthrie,  Thomas, 

M.B.,  B.C.,  F.R.C.S. 

Honorary  Anrist  and  Laryngologist,  Victoria  Central  Hospital,  Liscard. 

Hall,  Arthur  J., 

M.D.,  F.R.C.P., 

Lecturer    on    Practical    Medicine,    University   of    Sheffield;    Physician 
Sheffield  Royal  Hospital. 

Hamel,  Gust., 

M.V.O.,  M.D. 

Harris,  Wilfred, 

M.D.,  F.R.C.P., 

Physician  to,  and  Lecturer  on  Neurology  at,  St.  Mary's  Hospital; 
Physician,  Hospital  for  Epilepsy  and  Paralysis,  Maida  Vale. 


List  of  Contributors.  xxvii 

Haward,   Warrington, 

F.R.C.S., 
Consulting  Surgeon,  St.  George's  Hospital. 

Hay,  John, 

M.D.,  M.R.C.P., 
Senior  Assistant  Physician,  Royal  Infirmary,  Liverpool. 

Hellier,  John   B., 

M.D., 

Professor  of  Obstetrics,  University  of  Leeds  ;  Obstetric  Physician,  Leeds 
General  Infirmary. 

Herringham,  Wilmot  P., 

M.D.,  F.R.C.P., 

Physician,  St.  Bartholomew's  Hospital ;  Consulting  Physician,  Paddington 
Green  Children's  Hospital. 

Hertz,  Arthur  F., 

M.D.,  F.R.C.P., 
Assistant  Physician,  Guy's  Hospital. 

Hett,  G.  Seccombe, 

M.B.,  F.R.C.S., 

Surgeon    Laryngologist,    Mount    Vernon    Hospital    for    Consumption  ; 
Assistant  in  Ear  and  Throat  Dept.,  University  College  Hospital. 

Holland,  Eardley  L., 

M.D.,  F.R.C.S.,  M.R.C.P., 

Physician,    City    of    London    Lying-in     Hospital ;    Examiner,     Central 
Midwives'  Board. 

Holmes,  Gordon, 

M.D.,  M.R.C.P., 

Assistant  Physician,  National  Hospital  for  the  Paralysed  and  Epileptic, 
Queen  Square ;  Assistant  Physician,  Seamen's  Hospital,  Greenwich. 

Horder,  Thomas  J., 

M.D.,  F.R.C.P., 
Physician,  Great  Northern  Central  Hospital ;  Physician,  Cancer  Hospital. 

Huggard,  'William  R., 

M.D.,  LL.D.,  F.R.C.P., 
Visiting  Physician,  Queen  Alexandra  Sanatorium,  Davos. 

Hutchinson,  Jonathan, 

F.R.C.S., 

Surgeon,    London    Hospital ;    Lecturer   on    Surgery,    London    Hospital 
Medical  College. 

Inman,  A.   Conyers, 

M.A.,  M.B., 

Superintendent    of    Pathological    Laboratory,    Brompton    Consumption 
Hospital. 


xxviii  System  of  Treatment. 

Jackson,  Chevalier, 
M.D., 

Professor  of  Laryngology,  University  of  Pittsburg;  Laryngologist  to  Eye 
and  Ear  Hospital,  Pittsburg. 

Jaffrey,   Francis, 

F.R.C.S., 
Surgeon,  St.  George's  Hospital;  Surgeon,  Belgrave  Hospital  for  Children. 

Jones,  Henry  Lewis, 

M.D.,  F.R.C.P., 

Medical  Officer  in  charge  of  Electrical  Dept.,  St.  Bartholomew's  Hospital. 

Jones,  Robert, 

Ch.M.,  F.R.C.S.  Edin., 

Lecturer  on  Orthopaedic  Surgery  University  of  Liverpool ;  Honorary 
Surgeon,  Royal  Southern  Hospital,  Liverpool;  Surgeon,  Royal  Liverpool 
Country  Hospital  for  Children. 

Keith,  Arthur, 

M.D.,  LL.D.,  F.R.C.S., 

Hunterian  Professor  and  Conservator  of  Museum,  Royal  College  of 
Surgeons. 

Kelly,  Brown, 

M.D.,  C.M., 
Surgeon  for  Diseases  of  the  Throat  and  Nose,  Victoria  Infirmary,  Glasgow. 

Kerr,  J.  M.  Munro, 

M.D.,  C.M., 

Muir'aead  Professor  of  Midwifery  and  Gynaecology,  Glasgow  University  ; 
Obstetric  Physician,  Glasgow  Maternity  Hospital. 

Lack,    H.  Lambert, 

M.D.,  F.R.C.S., 

Surgeon,  Throat  Dept.,  and  Lecturer  on  Diseases  of  the  Throat,  London 
Hospital. 

Lake,  Richard, 

F.R.C.S., 

Lecturer  on  Otology,  London  School  of  Clinical  Medicine ;  Aural  Surgeon, 
Seamen's  Hospital;  Surgeon,  Royal  Ear  Hospital. 

Lane,  J.  Ernest, 

F.R.C.S., 

Senior  Surgeon  and  Lecturer  on  Clinical  Surgery,  St. 'Mary's  Hospital; 
Senior  Surgeon,  London  Lock  Hospital. 

Lane,  W.  Arbuthnot, 

M.S.,  F.R.C.S., 

Surgeon,  Guy's  Hospital  ;  Senior  Surgeon,  Hospital  for  Sick  Children, 
Great  Ormond  Street. 

Latham,  Arthur, 

M.D.,  F.R.C.P., 

Physician,  and  Lecturer  on  Medicine,  St.  George's  Hospital ;  Physician, 
Mount  Yernon  Hospital  for  Consumption  and  Diseases  of  the  Chest  ; 
Advisory  Physician,  Hospital  for  Diseases  of  the  Throat,  Golden  Square^ 
and  General  Lying-in  Hospital. 


List  of  Contributors.  xxix 

Latham,  P.  W., 

M.D.,  F.R.C.P., 

Late  Downing  Professor  of  Medicine,  University  of  Cambridge  ; 
Consulting  Physician,  Addenbrooke's  Hospital,  Cambridge. 

Lawson,  Arnold, 

F.R.C.S., 

Surgeon,  Royal  London  Ophthalmic  Hospital  ;  Assistant  Ophthalmic 
Surgeon,  Middlesex  Hospital. 

Lawson,  David, 

M.D.,  F.R.S.E., 

Senior  Physician,  Nordrach-on-Dee  Sanatorium. 

Legg,  T.  Percy, 

M.S.,  F.R.C.S., 
Surgeon,  Royal  Free  Hospital;  Assistant  Surgeon,  King's  College  Hospital. 

Lillingston,  Claude, 

B.A.,  B.C. 

Llewellyn,  R.  Llewelyn  Jones, 
M.B., 

Late  Medical  Officer,  Royal  Mineral  Water  Hospital,  Bath. 

Lockyer,  Cuthbert, 

M.D.,  F.R.C.S.,  M.R.C.P., 

Lecturer  on  Practical  Obstetrics,  Charing  Cross  Hospital'  Medical 
School ;  Senior  Physician  to  Out-Patients,  Samaritan  Hospital  and  British 
Lying-in  Hospital. 

Love,  James  Kerr, 
M.D., 

Aural  Surgeon,  Royal  Infirmary,  Glasgow  ;  Aurist,  Glasgow  Institution 
for  the  Education  of  the  Deaf  and  Dumb. 

Low,  George  C., 

M.A.,  M.D., 

Lecturer  on  Tropical  Diseases,  Post-Graduate  College,  West  London 
Hospital ;  Lecturer  in  Parasitology  and  Medical  Entomology,  King's 
College. 

Luff,  Arthur  P., 

M.D.,  F.R.C.P., 

Physician,  St.  Mary's  Hospital. 

MacDonald,  Sydney  G., 

M.B.,  F.R.C.S., 
Clinical  Assistant,  St.  Peter's  Hospital  for  Urinary  Diseases. 

Mackenzie,  Hector, 

M.D.,  F.R.C.P., 

Physician  and  Lecturer  on  Medicine,  St.  Thomas'  Hospital ;  Physician, 
Brompton  Hospital  for  Consumption. 

Mackenzie,  James, 

M.D.,  LL.D.,  M.R.C.P., 

Physician,  Mount  Vernon  Hospital. 


xxx  System  of  Treatment. 

MacLeod,  J.  M.  H., 

M.D.,  M.R.C.P., 

Physician  for  Diseases  of  the  Skin,  Charing  Cross  Hospital  and  Victoria 
Hospital  for  Children ;  Lecturer  on  Dermatology,  London  School  of 
Tropical  Medicine. 

Macnamara,  E.   D., 

M.D.,  F.R.C.P., 

Physician,  West  End  Hospital  for  Nervous  Diseases  ;  Assistant  Physician, 
and  Lecturer  on  Medicine,  Westminster  Hospital. 

Maddox,  Ernest  E., 

M.D.,  F.R.C.S.  Edin. 

Ophthalmic  Surgeon,  Royal  Victoria  and  West  Hants.  Hospital,  Bourne- 
mouth. 

Milligan,  William, 

M.D.,  C.M., 

Aurist  and  Laryngologist,  Manchester  Royal  Infirmary ;  Lecturer  on 
Diseases  of  the  Ear,  University  of  Manchester. 

Monsarrat,   Keith  W., 

M.B.,  CM.,  F.R.C.S.  Edin. 

Surgeon,  Northern  Hospital,  Liverpool ;  Lecturer  on  Clinical  and 
Operative  Surgery,  University  of  Liverpool. 

Mummery,   P.  Lockhart, 

M.B.,  B.C.,  F.R.C.S., 

Senior  Assistant  Surgeon,  St.  Mark's  Hospital  for  Diseases  of  the 
Rectum  ;  Senior  Surgeon,  Queen's  Hospital  for  Children. 

Murray,   George, 

M.D.,  D.C.L.,  F.R.C.P., 

Professor  of  Systematic  Medicine,  Victoria  University  of  Manchester ; 
Physician,  Royal  Infirmary,  Manchester. 

Ogle,  Cyril, 

M.D.,  F.R.C.P., 

Physician,  Lecturer  on  Therapeutics  and  Joint  Lecturer  on  Medicine, 
St.  George's  Hospital. 

Oliver,  Sir  Thomas, 

M.D.,  LL.D.,  F.R.C.P., 

Joint  Professor  of  Principles  and  Practice  of  Medicine,  College  of 
Medicine,  Newcastle-on-Tyne;  Physician,  Royal  Victoria  Infirmary, 
Newcastle-on-Tyne. 

Pardoe,  John, 

M.B.,  F.R.C.S., 

•  Senior    Assistant    Surgeon,    St.    Peter's    Hospital;    Assistant    Surgeon, 
West   London  Hospital. 

Paterson,  Donald  Rose, 

M.D.,  M.R.C.P., 

Surgeon,  Ear,  Nose  and  Throat  Dept.,  Cardiff  Infirmary;  Consulting 
Surgeon,  Diseases  of  the  Ear,  Nose  and  Throat,  Royal  Seamen's 
Hospital,  Cardiff. 


List  of  Contributors.  xxxi 

Paterson,  Marcus  S., 

M.B.,  L.R.C.P., 
Medical  Director,  King  Edward  VII.  Memorial  in  Wales. 

Pearson,  S.  Vere, 

M.B.,  M.K.C.P., 
Physician,  Mundesley  Sanatorium. 

Pendlebury,  Herbert  S., 

M.B.,  B.C.,  F.R.C.S., 

Surgeon,  and  Lecturer  on  Surgery,  St.  George's  Hospital ;  Surgeon,  Royal 
Waterloo  Hospital  for  Children  and  Women. 

Perkins,  J.  John, 

M.B.,  F.R.C.P., 

Physician,    Brompton   Consumption   Hospital;    Physician,   St.   Thomas' 
Hospital. 

Powell,  Llewelyn, 

M.B.,  B.C., 

Anaesthetist,  St.  George's  Hospital,  and  National  Hospital  for  Paralysed 
and  Epileptic,  Queen  Square. 

Price,  Frederick  W., 

M.D.,  M.R.C.P., 

Physician,  Great  Northern  Central  Hospital ;    Physician  and  Honorary 
Pathologist,  Mount  Vernon  Hospital  for  Consumption. 

Purslow,  C.  E., 

M.D.,  M.R.C.P., 

Honorary  Obstetric  Officer,  Queen's  Hospital,  Birmingham ;  Consulting 
Surgeon,  Birmingham  Maternity  Hospital. 

Ricketts,  Thomas  F., 

M.D.,  M.R.C.P., 

Medical    Superintendent,    Small-pox    Hospital    (Metropolitan    Asylums 
Board). 

Roberts,  C.  Hubert, 

M.D.,  F.R.C.S.,  F.R.C.P., 

Senior    Physician,    Samaritan    Hospital    for    Women;     Physician,    In- 
patients,  Queen  Charlotte's  Lying-in  Hospital. 

Roberts,  J.  Reid, 

C.I.E.,  Lt.-Col.  I. M.S.,  M.B.,  M.S.,  F.R.C.S. 

Robson,  A.  W.   Mayo-, 

C.V.O.,  D.Sc.,  F.R.C.S., 

Emeritus  Professor  of  Surgery,  University  of  Leeds ;  Consulting  Surgeon, 
Leeds  General  Infirmary. 

Rolleston,  Humphry  Davy, 

M.D.,  F.R.C.P., 

Senior  Physician,  St.  George's   Hospital ;    Physician,  Victoria   Hospital 
for  Children. 


xxxii  System  of  Treatment. 

Romer,  Frank, 

M.R.C.S., 

Consulting  Surgeon,  London  Guarantee  and  Accident  Co.  ;  Honorary 
Surgeon,  Royal  Academy  of  Music. 

Rowntree,  Cecil, 

M.B.,  B.S.,  F.R.C.S., 

Surgical  Registrar,  Middlesex  Hospital ;  Assistant  Surgeon,  Cancer 
Hospital. 

Russell,  J.  S.  Risien, 

M.D.,  F.R.C.P., 

Professor  of  Clinical  Medicine,  University  College  ;  Physician,  University 
College  Hospital;  Physician,  National  Hospital  for  Paralysed  and 
Epileptic,  Queen  Square. 

Sandwith,  F.  M., 

M.D.,  F.R.C.P., 

Gresham  Professor  of  Physic;  Consulting  Physician,  Kasr  el  Ainy 
Hospital,  Cairo  ;  Lecturer,  London  School  of  Tropical  Medicine  and  St. 
Thomas'  Hospital. 

Saundby,  Robert, 

M.D.,  F.R.C.P.,  LL.D., 

Professor  of  Medicine,  University  of.  Birmingham  ;  Senior  Physician, 
Birmingham  General  Hospital. 

Sherren,  James, 

F.R.C.S., 

Surgeon,  London  Hospital ;  Surgeon,  Poplar  Hospital  for  Accidents ; 
Examiner  in  Anatomy  for  Primary  F.R.C.S. 

Shrubsall,  Frank  C., 

M.D.,  M.R.C.P.,  D.P.H. 

Simpson,  W.  J.  R., 

C.M.G.,  M.D.,  F.R.C.P., 

Professor  of  Hygiene,  King's  College,  London  ;  Lecturer  on  Tropical 
Hygiene,  London  School  of  Tropical  Medicine. 

Smith,  A.  Lionel, 

M.B.,  M.R.C.P., 

Late  Physician  to  Out-patients,  General  Lying-in  Hospital,  Lambeth  ; 
late  Obstetric  Physician,  St.  Marylebone  General  Dispensary. 

Smith,  Eustace, 

M.D.,  F.R.C.P., 

Senior  Physician,  East  London  Hospital  for  Children;  Consulting 
Physician,  City  of  London  Hospital  for  Diseases  of  the  Chest. 

Smith,  G.  Bellingham, 

M.B.,  B.S.,  F.R.C.S., 
Obstetric  Surgeon,  Guy's  Hospital. 


List  of  Contributors.  xxxiii 

Smith,  G.  F.  Darwall, 

M.B.,  B.Ch.,  F.R.C.S., 

Senior  Surgeon  to  Out-patients,  Samaritan  Free   Hospital  ;    Physician, 
General  Lying-in  Hospital ;  Obstetric  Tutor,  St.  George's  Hospital. 

Smith,  S.  Maynard, 

M.B.,  B.S.,  F.R.C.S., 

Surgeon  to  Out-patients,  St.  Mary's  Hospital ;  Senior  Assistant  Surgeon, 
Victoria  Hospital  for  Children ;  Surgeon,  London  Fever  Hospital. 

Spencer,  C.  G., 

Major  R.A.M.C.,  M.B.,  F.R.C.S., 
Late  Professor  of  Military  Surgery.  Royal  Army  Medical  College. 

Spitta,  Harold  R.  D., 

M.D.,  D.P.H., 

Bacteriologist  to  Household  of  H.M.  the  King;  Assistant  Bacteriologis 
and  Lecturer  on  Public  Health  and  Hygiene,  St.  George's  Hospital. 

Spriggs,  Edmund  Ivens, 

M.D.,  F.R.C.P., 

Senior  Assistant  Physician,  St.  George's  Hospital ;  Physician,  Victoria 
Hospital  for  Children. 

Stevens,  Thomas  G., 

M.D.,  F.R.C.S.,  M.R.C.P., 

Physician    to    Out-patients,    Queen    Charlotte's    Hospital ;     Physician, 
Hospital  for  Women,  Soho  Square. 

Stewart,  Purves, 

M.D.,  F.R.C.P., 

Physician  to  Out-patients,  Westminster  Hospital ;  Physician,  West  End 
Hospital  for  Nervous  Diseases. 

Stewart,  T.  Grainger, 

M.B.,  M.R.C.P., 

Assistant    Physician,    National    Hospital  for   Paralysed   and   Epiteptic ; 
Assistant  Physician,  West  London  Hospital. 

Stiles,  Harold  J., 

M.B.,  F.R.C.S.  Edin., 

Surgeon,   Chalmers'   Hospital,    Edinburgh  ;   Surgeon,  Royal  Edinburgh 
Hospital  for  Sick  Children. 

Sunderland,  Septimus, 

M.D.,  M.R.C.P., 

Obstetric    Physician,    French    Hospital;     Physician,    Royal    Waterloo 
.Hospital  for  Children  and  Women. 

Sutherland,  G.  A., 

M.D.,  F.R.C.P., 

Physician,  Paddington  Green  Children's  Hospital  and  Hampstead  General 
Hospital. 

S.T. — -VOL. II  .  C 


xxxiv  System  of  Treatment. 

Swayne,  Walter  Carless, 

M.D.,  Ch.B., 

Professor  of  Obstetrics,  University  of  Bristol;  Obstetric  Physician, 
Bristol  Royal  Infirmary. 

Taylor,  Edward  H., 

M.D.,  B.Ch.,  F.R.C.S.I., 

University  Professor  in  Surgery,  Trinity  College,  Dublin ;  Surgeon, 
Sir  P.  Dun's  Hospital. 

Taylor,  Gordon, 

M.S.,  F.R.C.S., 
Assistant  Surgeon,  Middlesex  Hospital. 

Taylor,  James, 

M.D.,  F.R.C.P., 

Physician,  National  Hospital  for  Paralysed  and  Epileptic,  Queen 
Square ;  Physician,  Royal  London  Ophthalmic  Hospital. 

Telling,  W.  H.  Maxwell, 
M.D.,  M.R.C.P., 

Senior  Assistant  Physician,  Leeds  General  Infirmary;  Physician,  Hospital 
for  Women  and  Children,  Leeds;  Lecturer  on  Clinical  Medicine, 
University  of  Leeds. 

Thomson,  H.  Campbell, 

M.D.,  F.R.C.P., 

Physician  to  Out-patients,  Middlesex  Hospital;  Physician,  Hospital  for 
Epilepsy  and  Paralysis,  Maida  Vale. 

Thomson,  J.  C., 

M.D.,  D.P.H., 

Medical  Officer  of  Health,  County  of  Dumfries ;  late  Medical  Officer  in 
charge  of  Hong  Kong  Plague  Hospital. 

Thorburn,  William, 

M.D.,  B.S.,  F.R.C.S., 

Professor  of  Clinical  Surgery,  University  of  Manchester;  Surgeon, 
Manchester  Royal  Infirmary. 

Tod,  HuViter  F., 

M.D.,  F.R.C.S., 

Aural  Surgeon,  London  Hospital;  Lecturer  in  Aural  Surgery,  London 
Hospital  Medical  College. 

Torrens,  J.  A., 

M.B.,  B.S.,  M.R.C.P., 

Medical  Registrar,  St.  George's  Hospital ;  Physician  to  Out-patients, 
Paddington  Green  Children's  Hospital. 

Turner,  G.  R., 

F.R.C.S., 
Surgeon,  St.  George's  Hospital, 


List  of  Contributors.  xxxv 


Turner,  Philip, 

M.S.,  F.R.C.S., 

Assistant  Surgeon,  Guy's  Hospital. 


Turner,  W.  Aldren, 

M.D.,  F.R.C.P., 

Physician  and  Lecturer  on  Neurology,  King's  College  Hospital;  Physician 
to  Out-patients,  National  Hospital  for  Paralysed  and  Epileptic,  Queen 
Square. 


Tweedy,  E.  Hastings, 
F.R.  C.P.I., 

Obstetric  Physician  and  Gynaecologist,  Dr.  Steevens'  Hospital,  Dublin 
late  Master,  Rotunda  Hospital,  Dublin. 


Von  Eicken,  Carl, 
M.D., 
Professor  of  Oto-Laryngo-Rhinology,  University  of  Giessen. 


Waggett,  E.  B., 

M.B.,  B.C., 
Surgeon,  Throat  Dept.,  Charing  Cross  Hospital. 


Walker,  J.  W.  Thomson, 

M.B.,  C.M.,  F.R.C.S., 

Assistant  Surgeon,  St.   Peter's   Hospital  for   Stone ;    Surgeon  to   Out- 
patients, North  West  London  and  Hampstead  General  Hospital. 

Wallis,  Sir  Frederick  C., 

M.B.,  B.C.,  F.R.C.S., 

Surgeon,    Charing    Cross     Hospital ;    Surgeon,    St.    Mark's    Hospital ; 
Surgeon,  Grosvenor  Hospital  for  Women. 


Waterhouse,  Herbert  F., 
M.D.,  F.R.C.S., 

Surgeon   and   Lecturer  on   Surgery,    Charing   Cross   Hospital;    Senior 
Surgeon,  Victoria  Hospital  for  Children. 


Watson,  C.  Gordon, 
F.R.C.S., 

Assistant  Surgeon,  St.  Bartholomew's  Hospital;  Surgeon,  Metropolitan 
Hospital;  Assistant  Surgeon,  St.  Mark's  Hospital  for  Fistula. 


Watson-Williams,  P., 

M.D., 

Lecturer  on  Laryngology  and  Rhinology,  University  of  Bristol  ;  Surgeon 
Ear,  Nose  and  Throat  Dept.,  Bristol  Royal  Infirmary. 


xxxvi  System  of  Treatment. 

Wells,  A.  Primrose, 

M.A.,  L.R.C.S.,  L.R.C.P., 
Late  Electrical  and  Light  Physician,  St.  Luke's  Hostel. 

West,  C.  Ernest, 

F.R.C.S., 
Aural  Surgeon,  St.  Bartholomew's  Hospital. 

Westmacott,   Frederic  H., 

F.R.C.S., 

Surgeon,  Throat  and  Ear  Dept.,  Manchester  Children's  Hospital ;  Aural 
Surgeon,  St.  John's  Hospital  for  Ear  and  Eye,  Manchester. 

Wethered,  Frank  J., 

M.D.,  F.R.C.P., 

Physician,  Brompton  Consumption  Hospital ;  Physician  in  charge  of 
Out-patients,  Middlesex  Hospital. 

White,   W.  Hale, 

M.D.,  F.R.C.P., 
Senior  Physician,  Guy's  Hospital ;  Lecturer  on  Medicine,  Guy's  Hospital. 

Whitehead,   Arthur  L., 
M.B.,  B.S., 

Ophthalmic  and  Aural  Surgeon,  General  Infirmary,  Leeds  ;  Lecturer  on 
Clinical  Ophthalmology  and  Otology,  University  of  Leeds. 

Wilkinson,  George, 

M.B.,  B.C.,  F.R.C.S., 

Surgeon,  Ear  and  Throat  Dept.,  Sheffield  Royal  Hospital. 

Willcoxy  William  H., 

M.D.,  F.R.C.P., 

Physician  to  Out-patients,  St.  Mary's  Hospital;  Medical  Tutor  and 
Lecturer  on  Public  Health,  Pathological  Chemistry  and  Forensic  Medicine, 
St.  Mary's  Hospital. 

Williams,  Leonard, 

M.D.,  M.R.C.P., 

Physician,  French  Hospital;  Physician,  Miller  Hospital;  Assistant 
Physician,  Metropolitan  Hospital. 

Wilson,  S.   A.  Kinnier, 

M.D.,  M.R.C.P., 
Registrar,  National  Hospital  for  Paralysed  and  Epileptic,  Queen  Square. 

Wilson,  Thomas, 

M.D.,  F.R.C.S., 

Lecturer  on  Midwifery  and  Gynaecology,  University  of  Birmingham  ; 
Obstetric  Officer,  General  Hospital,  Birmingham ;  Senior  Physician 
to  In-patients,  Maternity  Hospital,  Birmingham. 


List  of  Contributors.  xxxvii 

Woods,  John   Francis, 

M.D.,  M.R.C.S., 
Late  Medical  Superintendent,  Hoxton  House  Asylum. 

Young,   Robert  Arthur, 

M.D.,  F.R.C.P., 

Assistant  Physician,  Brompton  Consumption  Hospital  ;  Physician  to 
Out-patients,  Middlesex  Hospital ;  Lecturer  on  Pharmacology  and 
Therapeutics,  Middlesex  Hospital  Medical  School. 


A  SYSTEM  OF  TREATMENT. 


DISEASES  OF  THE  BLOOD  AND  BLOOD 
FORMING  ORGANS. 

ADDISON'S    (PERNICIOUS)    ANAEMIA. 

THE  gist  of  the  treatment  of  pernicious  anaemia  is  :  Best  to  the 
extent  of  confinement  in  bed  during  the  severe  stages  ;  the  adminis- 
tration of  arsenic  in  one  form  or  another  if  it  can  be  borne ;  as 
liberal  a  diet  as  the  patient  can  take  and  retain  ;  and  attention  to 
the  gastro-intestinal  tract,  especially  the  relief  and  cure  of  any  oral 
sepsis  that  may  be  present.  The  all-important  point  is  to  diagnose 
the  condition  as  early  as  possible  and  to  stave  off  the  later  stages 
by  the  early  adoption  of  arsenical  treatment. 

Even  when  a  severe  stage  of  anaemia  has  been  reached  the 
tendency  is  for  temporary  recovery  to  come  about  even  if  no 
particular  treatment  is  adopted  ;  relapse  is  sure  to  take  place  in 
spite  of  treatment,  but  the  rallies  may  be  two,  three,  four,  five 
or  six,  or  more  before  the  fatal  ending  ensues ;  some  cases  die 
in  a  month,  more  survive  for  a  year,  and  some  for  ten  years  or 
more. 

General  Treatment. — Pernicious  anaemia  causes  so  marked  a 
loss  of  strength,  at  any  rate  by  the  time  it  is  recognisable  by 
present  tests,  that  when  it  has  been  diagnosed  the  patient  is  already 
so  weak  that  he  generally  takes  to  his  bed  willingly,  at  any  rate  for 
the  time  being.  He  need  not  be  kept  there  permanently,  for  within 
a  few  weeks  it  is  probable  that  the  blood  condition,  even  though  it 
has  not  got  back  to  normal,  will  have  so  much  improved  that  the 
patient's  strength  will  permit  of  his  wearing  his  clothes  again  and 
very  likely  of  his  going  for  a  change  of  air  or  even  returning  to 
business,  even  if  only  for  a  few  months.  If  any  severe  degree  of 
the  malady  has  been  reached,  however,  rest  in  bed,  preferably  in 
an  airy  room  into  which  the  sun  enters  freely,  is  to  be  advocated 
strongly.  The  patient's  temperature,  pulse  rate  and  respiration 

S.T. — VOL.  n.  1 


2  Addison's  (Pernicious)  Anaemia. 

should  be  charted  carefully,  for  there  is  nearly  always  a  certain 
amount  of  pyrexia  at  this  stage,  indicative  perhaps  of  the  toxic 
origin  of  the  complaint.  There  is  no  reason  why  he  should  not 
get  out  of  bed  to  use  the  commode  should  he  prefer  that  to  the 
bed-pan  ;  but  otherwise  than  this  he  should  remain  at  complete 
rest.  He  will  thereby  minimise  the  danger  there  is  of  his  heart 
becoming  dilated  to  a  sufficient  degree  to  cause  reflex  or  so-called 
"  anaemic "  vomiting.  Much  of  the  nausea  and  vomiting  of  per- 
nicious anaemia  is  due  to  the  patient  being  up  and  about  in  spite 
of  the  severity  of  his  anaemia,  though  an  additional  factor 
undoubtedly  is  the  arsenic  that  is  prescribed.  It  is  important 
to  minimise  the  tendency  to  vomiting  in  every  possible  way,  and 
one  such  way  is  to  avoid  physical  exertion. 

Diet. — There  is  no  particular  foodstuff  of  the  ordinary  whole- 
some kind  which  is  contra-indicated  in  pernicious  anaemia ;  indeed, 
the  more  the  patient  can  eat  and  the  more  varied  the  dietary  the 
better.  Partly  on  account  of  the  cardiac  dilatation,  however,  partly 
on  account  of  the  tendency  to  deficiency  in  the  hydrochloric  acid  in 
the  gastric  juice,  partly  owing  to  the  administration  of  arsenic  by 
the  mouth,  and  partly,  perhaps,  owing  to  lesions  in  the  gastric 
mucosa,  it  is  sometimes  exceedingly  difficult  to  enable  these  patients 
to  eat  even  the  simplest  foods  without  nausea  or  actual  vomiting. 
No  detailed  diet  sheets  can  be  made  out,  therefore,  for  whereas  one 
patient  can  take  tea,  toast  and  butter  and  an  egg  for  breakfast  ; 
boiled  fish,  potatoes  and  a  milk  pudding  at  mid-day  ;  a  cup  of  tea 
and  bread  and  butter  at  4  p.m.,  and  some  vegetables  or  a  plain 
pudding  or  stewed  fruit  and  custard  in  the  evening,  the  next 
patient  may  be  unable  to  take  anything  more  than  plain  milk  or 
perhaps  milk  thickened  with  Benger's  food  or  the  like,  and  even 
then  cannot  do  so  without  being  sick  sometimes.  The  only  rules 
that  can  be  laid  down  are,  that  each  case  must  be  treated  on  its 
own  merits  ;  that  the  patients'  own  wishes  as  regards  dietary  should 
be  strictly  consulted,  for  they  can  very  often  suggest  something 
which,  because  they  have  fancied  it,  they  can  keep  down,  when 
anything  suggested  by  others  would  be  brought  up  ;  that  all  articles 
of  diet  should  be  transmitted  to  the  patient  in  as  tasteful  and 
tempting  a  way  as  possible  as  regards  the  cooking,  the  amount  put 
upon  the  plate  at  one  time,  the  flavouring,  the  warmth  and  all  the 
other  little  things  which  make  for  success  in  invalid  cooking  in 
general ;  and  that  the  patient  should  be  allowed  as  liberal  a  diet  as 
may  be  found  possible  in  an  individual  case.  The  question  of 
alcohol  will  arise  ;  the  same  applies  to  beverages  as  to  foods,  the 
patient's  own  wishes  as  regards  champagne,  light  wine,  whisky 


Addison's  (Pernicious)  Anaemia.  3 

and  soda,  plain  water,  soda  water,  aerated  water,  tea,  cocoa,  coffee, 
milk,  being  used  as  a  guide,  though  naturally  the  amount  of  alcohol 
consumed  should  be  kept  within  moderate  limits. 

Arsenic  is  the  drug  par  excellence  for  the  relief  of  pernicious 
anaemia.  It  is  generally  prescribed  in  the  form  of  liquor  arsenicalis 
[U.S. P.  liquor  potassii  arsenitis]  in  a  simple  mixture  to  be  taken 
well  diluted  with  water  and  after  food.  The  dose  is  generally 
5  min.  three  times  a  day  to  begin  with,  increasing  by  1  min. 
in  each  dose  every  five  or  six  days  until  the  patient  may  be  taking 
10  min.,  12  min.,  or  even  more,  three,  or  even  four,  times  a  day. 
Some  patients  bear  even  large  doses  such  as  these  perfectly  well 
without  either  nausea,  vomiting,  or  diarrhoea,  and  in  these  cases 
relief  to  the  anremia  is  much  more  easy  to  obtain  than  it  is  in 
other  patients  in  whom  the  giving  of  arsenic  has  to  be  counter- 
manded on  account  of  the  distressing  gastro-intestinal  symptoms 
that  it  produces.  Some  cases  suffer  more  from  diarrhoea,  others 
more  from  nausea  and  vomiting ;  in  either  case  it  will  be  necessary 
as  a  rule  to  desist  from  giving  arsenic  altogether  for  the  time 
being  and  to  employ  gastro-intestinal  remedies  until  the  untoward 
symptoms  abate,  and  then  to  start  with  quite  small  doses  of  liquor 
arsenicalis  again,  increasing  them  with  great  caution  and  minimis- 
ing the  tendency  to  gastro-intestinal  derangement  by  giving 
remedies,  such  as  bismuth  and  morphia,  or  astringents,  such  as 
hfernatoxylum,  £  to  2  oz.  of  the  decoction  ;  krameria,  pulvis  catechu 
compositus  (B.P.),  10  to  40  gr. ;  kino,  pulvis  kino  compositus  (B.P.), 
5  to  20  gr. ;  tannic  acid,  2  to  5  gr. ;  gallic  acid,  5  to  15  gr. ; 
copper  sulphate,  T^  to  J  gr.  ;  tannigen,  10  gr. ;  laudanum,  5  to 
15  min.  [U.S.P.  8  to  9  min.];  pulvis  opii  compositus  (B.P.),  2  to 
10  gr. ;  pulvis  cretae  aromaticus  (B.P.),  10  to  60  gr.  [U.S.P.  pulvis 
aromaticus,  gr.  1  to  6,  pulvis  cretse  compositus,  gr.  10  to  60] ;  pulvis 
crette  aromaticus  cum  opio  (B.P),  10  to  40  gr.  [U.S.P.  pulvis 
aromaticus,  gr.  1  to  4,  pulvis  cretse  compositus,  gr.  10  to  40,  pulvis 
opii,  gr.  £  to  1].  It  is  impossible  to  give  all  the  prescriptions 
that  may  be  found  useful  in  different  cases  ;  one  can  but  indicate 
the  drugs  that  might  be  employed,  but  if  the  chief  tendency  is  to 
nausea  and  vomiting  with  epigastric  pain  the  following  prescription 
may  be  found  useful :  ty .  Bismuthi  Oxycarbonatis,  gr.  10 ;  Sodii 
Bicarbonatis,  gr.  10;  Liquoris  Morphinae  Hydrochloridi,  mi  10; 
Pulveris  Tragacanthse  Compositi,  gr.  10  ;  Aquam,  ad  §j  [U.S.P.  I£. 
Bismuthi  Subcarbonatis,  gr.  10 ;  Sodii  Bicarbonatis,  gr.  10 ; 
Morphinfe  Hydrochloridi,  gr.  -j^;  Pulveris  Tragacanthse,  gr.  2; 
Pulveris  Acacia?,  gr.  2  ;  Pulveris  Amyli,  gr.  2 ;  Sacchari,  gr.  6 ; 
Aquam,  ad  5]] .  Dose,  two  tablespoonfuls  thrice  daily  or  oftener, 

1—2 


4  Addison's  (Pernicious)  Anaemia. 

If  diarrhoea  is  so  troublesome  as  to  interfere  with  the  use  of  the 
arsenic,  one  might  employ  either  the  following  mixture  :  1^ .  Cretae 
Preparatae,  gr.  15  ;  Pulveris  Tragacanthae,  gr.  2 ;  Sacchari  Puri- 
ficati,  5ss;  Tincturae  Opii,  m.10;  Vini  Ipecacuanhas,  iitlO ;  Decoctum 
Haematoxyli,  ad  jj  [U.S.P.  1^.  Cretae  Preparatae,  gr.  15;  Pulveris 
TragacahthaB,  gr.  2;  Sacchari,  533;  Tincturae  Opii,  m&  ;  Vini 
Ipecacuanhas,  ii|6  ;  Decoctum  Haematoxyli,  ad  jj];  dose,  two  table- 
spoonfuls  thrice  daily  or  oftener;  or  in  very  severe  cases  a  pill 
containing  sulphate  of  copper,  as  in  the  following  prescription: 
R.  Cupri  Sulphatis,  gr.  | ;  Opii,  gr.  £;  Pulveris  Glycyrrhizae,  gr.  2 ; 
Glucosi  liquidi,  q.s.  Mix  for  one  pill.  Dose,  one  or  two  pills  as 
often  as  may  be  directed. 

If  arsenic  can  be  taken  in  the  form  of  the  liquor  when  pre- 
cautions such  as  the  above  are  taken,  well  and  good ;  otherwise  it 
may  be  necessary  to  give  it  in  some  other  form.  When  Fowler's 
solution  cannot  be  retained  it  sometimes  happens  that  liquor 
arsenii  hydrochloricus  [U.S.P.  liquor  acidi  arseniosi]  can  be  given 
in  doses  similar  to  those  of  Fowler's  solution,  but  in  an  acid 
instead  of  a  neutral  or  alkaline  mixture,  along  with  dilute  hydro- 
chloric or  dilute  sulphuric  acid,  in  10  to  15  min.  doses.  Other 
preparations  of  arsenic  may  be  tried  in  pill  form,  such  as  acid  urn 
arseniosum,  ^  to  i  gr. ;  sodii  arsenas,  ^  to  -^  gr. ;  arsenii 
iodidum,  ^  to  i  gr. ;  ferri  arsenas,  ^  to  J  gr.  The  sodium 
arsenate  may  be  given  alternatively,  not  as  a  pill,  but  in  the  form 
of  liquor  sodii  arsenatis,  which  contains  about  half  the  percentage 
of  metallic  arsenic  that  liquor  arsenicalis  does,  and  is  sometimes 
well  borne  in  doses  of  from  2  min.  upwards  when  Fowler's  solution 
is  not  tolerated.  Donovan's  solution  (liquor  arsenii  et  hydrargyri 
iodidi)  is  not  so  often  employed  in  cases  of  pernicious  anaemia  as 
it  is  in  the  anaemia  of  tertiary  syphilis,  but  in  some  cases  it  might 
be  used  when  other  varieties  of  arsenic  fail,  in  5  to  20  min.  doses, 
in  the  form  of  a  simple  mixture. 

When  all  efforts  at  giving  arsenic  by  the  mouth  prove  unsuc- 
cessful it  is  probable  that  attempts  will  be  made  to  give  it 
hypodermically,  in  which  case  the  cacodylate  of  sodium  (sodium 
dimethyl-arsenate)  may  be  employed  to  the  extent  of  J  to  § 
of  a  grain  daily,  or  every  other  day.  Much  has  been  written 
lately  about  certain  organic  compounds  of  arsenic,  especially  atoxyl 
(sodium  anil-arsenate),  soamin,  which  is  closely  related  to  atoxyl, 
and  other  similar  compounds,  of  which  the  most  recent  has 
been  termed  by  Professor  Erhlich  "  No.  606,"  and  it  was  thought 
at  one  time  that  these,  though  very  much  richer  in  arsenic  than 
the  inorganic  compounds,  were  free  from  any  toxic  effects;  they 


Addison's  (Pernicious)  Anaemia.  5 

were  given  hypodermically  in  doses  of  from  1  to  3  gr.,  but  the 
use  of  all  but  "  606  "  is  now  much  less  fashionable  than  it  was, 
because  many  patients  have  developed  acute  optic  atrophy  and 
other  lesions  as  the  direct  result  of  using  these  drugs,  whilst 
there  are  as  yet  no  reports  as  to  the  value  of  "  606  "  in  pernicious 
anaemia. 

Arsenical  waters  are  sometimes  serviceable,  especially  when 
other  means  of  giving  arsenic  fail.  The  patient  may  either  take 
them  at  home  in  bottle,  or  better  still,  if  it  is  possible  for  him  to 
travel,  he  may  go  to  the  spa  and  drink  the  natural  waters  upon  the 
spot.  Amongst  the  best  known  arsenical  waters  are  those  at  Levico, 
in  the  Austrian  Tyrol  (1,760  feet),  the  water  of  the  strong  spring 
containing  4*6  parts  per  1,000  of  sulphate  of  iron,  and  arsenic 
equivalent  to  0*006  parts  per  1,000  of  arsenious  acid.  The  quantity 
of  Levico  water  to  be  taken  daily  is  about  \  oz.  to  start  with, 
diluted  with  plain  water  and  drunk  after  food,  the  dose  being 
increased  until  the  patient  is  taking  as  much  as  3  oz.  a  day. 
Other  arsenical  springs  are  those  of  La  Bourboule,  in  Auvergne 
(2,770  feet),  the  Source  Perriere  containing  the  equivalent  of  0*028 
parts  per  1,000  of  sodium  ar senate,  the  dose  of  the  water  being 
from  \  to  \  pint,  hot,  three  times  daily  after  meals.  At  Royat, 
also  in  the  Auvergne  (1,460  feet),  the  St.  Victor  Spring  contains 
0*004  parts  per  1,000  of  sodium  arsenate,  the  dose  being  1  to 
3  pints  daily.  The  Celestines  Spring  at  Vichy  (850  feet)  con- 
tains the  equivalent  of  0*002  parts  per  1,000  of  sodium  arsenate,  1 
to  3  pints  being  taken  daily.  One  of  the  strongest  of  the  arsenical 
waters  is  that  of  Roncegno,  in  the  Tyrol,  which,  in  addition  to 
3'0  parts  per  1,000  of  iron  sulphate,  contains  the  equivalent  of  0*15 
parts  per  1,000  of  arsenious  acid  ;  the  dose  usually  being  a  table- 
spoonful  at  a  time,  gradually  increased  to  two  tablespoonfuls  well 
diluted  with  plain  water,  and  taken  only  when  the  stomach  contains 
food. 

There  is  no  particular  benefit  to  be  obtained  by  special  baths  or 
other  varieties  of  spa  treatment,  the  chief  value  of  the  spas  mentioned 
above  being  due  to  the  arsenic  in  the  waters  themselves. 

Iron. — It  is  a  remarkable  thing  that  iron,  which  is  of  such 
immense  benefit  in  cases  of  chlorosis,  is  of  relatively  little  value  in 
pernicious  anreniia,  at  any  rate  when  it  is  given  by  itself.  Never- 
theless, just  as  small  doses  of  arsenic  may  be  of  material  assistance 
along  with  iron  in  the  cure  of  chlorosis,  so  may  iron  be  of  undoubted 
benefit  in  assisting  the  cure  or  at  least  the  temporary  relief  of 
pernicious  anaemia  with  arsenic.  Dr.  Byroin  Bramwell1  who  was 
the  first  to  insist  upon  the  value  of  arsenic  in  these  cases,  has  recently 


6  Addison's  (Pernicious)  Anaemia. 

pointed  out  the  value  of  iron  as  an  accessory  in  this  way.  When 
the  red  corpuscles  have  risen  perhaps  from  545,000  to  1,600,000 
per  cubic  millimetre  under  arsenic,  the  disease  may  seem  to 
resist  and  not  improve  further  ;  on  then  prescribing  some  form  of 
iron  such  as  those  recommended  in  the  treatment  of  chlorosis— for 
instance,  two  Blaud's  pills  three  times  a  day — a  further  considerable 
improvement  may  often  be  produced  readily,  especially  if  the 
arsenic  is  continued  at  the  same  time.  It  is  always  difficult  to  be 
certain  in  cases  of  this  kind  whether  any  given  treatment  is  really 
beneficial,  seeing  that  with  rest  in  bed  and  suitable  care  the  patients 
tend  to  improve  up  to  a  certain  point  by  themselves ;  but  one  has  a 
very  distinct  impression  that  organic  forms  of  iron  are  even  more 
beneficial  than  inorganic  in  thus  assisting  the  effects  of  arsenic  in 
pernicious  anaemia,  and  amongst  such  organic  preparations  one 
would  like  to  mention  in  particular  some  that  are  directly  prepared 
from  animal  haemoglobin.  Nauseous  though  these  are  at  first,  it  is 
remarkable  how  the  patients  shortly  begin  to  realise  that  the  remedy 
is  doing  them  good,  so  that  they  become  unwilling  to  omit  it 
notwithstanding  the  nauseous  taste. 

Oral  and  gastro-intestinal  antiseptics. — Although  it  is  gene- 
rally held  nowadays  that  the  septic  anaemia  which  results  from 
long-standing  caries  of  the  teeth  and  pyorrhoea  alveolaris  is  not  the 
same  as  pernicious  anemia,  and  although  it  is  open  to  considerable 
doubt  whether  it  even  predisposes  to  or  develops  into  pernicious 
anaemia,  there  can  be  little  doubt  that  pernicious  anaemia  patients 
suffering  from  oral  sepsis  should  have  their  mouths  carefully 
attended  to.  It  is,  however,  unwise  to  be  too  energetic  in  the  matter 
of  eradicating  carious  teeth  ;  more  harm  than  good  has  sometimes 
been  done  by  extracting  too  large  a  number  of  septic  stumps  at  a 
time.  The  tearing  of  the  tissues  and  the  opening  up  of  capillary 
vessels  in  the  immediate  neighbourhood  of  the  sepsis  has  led  to  a 
dangerous  degree  of  acute  septic  absorption  or  even  fatal  septicaemia 
which  could  have  been  avoided  if  the  steps  taken  in  regard  to  the 
mouth  had  been  more  deliberate  and  if  a  smaller  amount  of  work 
had  been  done  at  a  time.  With  this  caution  the  treatment  required 
for  the  mouth  will  generally  be  obvious,  consisting  mainly  of 
stopping,  disinfection  and  extraction.  The  following  is  a  useful 
antiseptic  mouth  wash:  1^.  Salol,  gr.  12;  Thymol,  gr.  1J;  Olei 
Anisi,  rrij ;  Olei  Menthae  Piperitse,  in.2£ ;  Elixir  Glusidi,  in.12 ; 
Spiritus  rectificati,  jj. 

A  few  drops  of  this  should  be  added  to  a  wineglassful  of  water 
and  used  for  rinsing  out  the  mouth.  Another  useful  preparation  is 
ordinary  hydrogen  peroxide  solution,  of  which  as  many  drops  as  may 


Addison's  (Pernicious)  Anaemia.  7 

seem  good  to  the  patient  may  be  added  to  a  small  tumbler  of  water. 
A  good  firm  tooth  brush  should  be  used  at  least  three  times  a  day, 
together  with  an  antiseptic  tooth  powder  of  which  the  following  is 
an  example  :  R .  Potassii  Chloratis,  gr.  40  ;  Pulveris  Saponis  Duri, 
gr.  80;  Acidi  Carbolic!  Purissimi,  gr.  7  ;  Olei  Cinnamomi,  in.  10; 
Calcii  Carbonatis  Praecipitati,  3]. 

If  there  is  any  generalised  stomatitis  this  needs  treatment  by 
antiseptic  measures,  the  acuter  the  stomatitis  the  milder  the 
remedies  that  should  be  employed.  Ordinary  glycerine  and  borax 
may  be  sufficient  in  many  cases,  provided  it  is  efficiently  used,  being 
applied  best  upon  lint  by  means  of  the  nurse's  finger,  whilst  in 
less  acute  cases  an  active  antiseptic,  such  as  chinosol  solution  1  in 
500,  or  the  sulol  and  thymol  mouth  wash  prescribed  above  may  be 
employed.  Not  a  few  proprietary  mouth  washes  upon  the  market 
are  both  pleasant  and  efficient,  but  it  is  difficult  to  mention  any  of 
them  by  name  here. 

Vaccine  treatment  has  been  extensively  resorted  to  of  recent 
years,  especially  in  those  cases  in  which  pyorrhoaa  alveolaris  has 
been  a  prominent  feature.  It  may  be  pointed  out  that  a  certain 
proportion  of  cases  of  pernicious  anaemia  have  absolutely  perfect 
teeth  and  no  stomatitis  at  all,  so  that  oral  treatment  is  not  invari- 
ably required ;  but  when  sepsis  is  present  it  may  be  very  difficult 
to  overcome,  and  to  assist  in  relieving  the  mouth  vaccines  prepared 
from  cultures  made  from  the  patient's  own  teeth  and  gums  have 
been  used.  There  can  be  no  doubt  that  the  tendency  to  vaccine 
treatment  is  immensely  overdone,  but  at  the  same  time  in  suitably 
selected  cases,  undoubted  benefits  are  obtainable,  and  if  the  dosage 
and  the  intervals  between  the  doses  are  suitably  supervised  by  those 
who  are  familiar  with  their  use  vaccine  treatment  is  to  be  recom- 
mended in  a  certain  number  of  cases  of  pernicious  anaemia.  It  is 
impossible  to  lay  down  any  definite  rules  to  be  followed,  because 
each  case  needs  treating  upon  its  merits  in  this  respect,  and  whereas 
the  dose  would  be  5,000,000  bacteria  repeated  once  a  week  in  one 
case  it  may  need  to  be  5,000,000  repeated  once  in  three  weeks 
in  another  case,  or  100,000,000  repeated  every  four  or  five  days  in  a 
third,  and  so  on.  My  own  opinion  is  that  vaccine  treatment  should 
never  be  lightly  entered  into,  that  the  dosage  should  be  quite  small 
to  begin  with,  that  the  best  guide  as  to  whether  it  should  be 
repeated  or  as  to  whether  the  dose  should  be  increased  is  the 
general  condition  of  the  patient,  which  is  of  more  value  than  is  any 
estimation  of  the  opsouic  index.  I  should  add  that  I  am  not  at  all 
convinced  but  that  if  a  series  of  cases  were  treated  without  vaccines 
and  compared  with  another  series  of  cases  that  were  treated  with 


8  Addison's  (Pernicious)  Anaemia. 

vaccines  there  would  probably  not  be  a  great  deal  of  difference 
between  the  two. 

Anti- streptococcus  serum  was  advocated  some  years  ago  by 
those  who  regarded  streptococci  as  the  most  important  pathogenic 
organisms  in  the  pus  obtained  from  pyorrhoea  alveolaris.  When 
pernicious  anaemia  was  regarded  as  an  exjtreme  degree  of  the 
toxaemia  due  to  the  oral  sepsis  it  was  thought  that  the  adminis- 
tration of  an ti- streptococcus  serum  would  be  of  material  benefit  in 
the  cure  of  the  disease.  It  is  very  difficult  to  be  sure  whether  it 
does  any  good  or  not,  but  certainly  the  benefits  that  result  from  its 
use  have  not  come  up  to  expectations,  and  seeing  that  its  hypo- 
dermic administration  is  painful  and  that  it  cannot  be  repeated 
indefinitely  on  account  of  the  phenomena  of  anaphylaxis  and  the 
symptoms  of  so-called  serum  disease,  it  has  lately  gone  out  of 
fashion  in  the  cure  of  pernicious  anaemia.  Horse  serum  has  been 
employed  less  with  a  view  to  any  antiseptic  action  it  may  have  than 
as  a  means  of  promoting  nutrition  generally  in  the  same  way  that 
it  does  in  some  severe  cases  of  marasmic  children.  Upon  the  whole, 
however,  pernicious  anaemia  cases  do  not  become  marasmic,  but 
rather  remain  of  good  bulk,  and  in  these  cases  there  is  little  indica- 
tion for  the  use  of  horse  serum  as  a  remedy.  It  might  be  employed, 
however,  in  those  rarer  cases  in  which  marked  wasting  is  a  feature. 

Intestinal  antiseptics  have  been  very  generally  employed, 
especially  by  those  who  hold  the  view  that  whatever  the  toxin  may 
be  that  leads  to  pernicious  anaemia  it  is  probably  produced  by  or 
absorbed  from  the  gastro-intestinal  tract.  There  is  no  actual  proof 
that  the  alimentary  canal  is  the  site  of  absorption  of  the  supposed 
bacteria  or  hypothetical  toxins  of  pernicious  anaemia,  but  there  is 
undoubtedly  a  great  tendency  for  diarrhoea  to  occur  even  before 
arsenic  is  given  in  the  treatment  of  the  disease,  so  that  the  adminis- 
tration of  intestinal  antiseptics  would  seem  to  be  indicated  even  if 
there  is  no  proof  that  intestinal  putrefaction  is  the  cause  of  the 
disease.  Amongst  the  different  remedies  that  may  be  used  for 
the  purpose  may  be  mentioned  in  particular  glycerine  of  carbolic 
acid,  5  min. ;  boric  acid,  5  to  15  gr. ;  thymol,  £  to  2  gr.  as  a  pill ; 
creosote,  1  to  5  min.  suspended  in  mucilage  or  in  capsules,  diluted 
with  three  times  the  quantity  of  almond  oil,  these  capsules  being 
coated  with  keratin  if  it  is  desired  that  they  shall  not  be  dissolved 
until  they  have  passed  on  from  the  stomach  into  the  intestine ; 
naphthol,  10  gr. ;  bismuth  salicylate,  5  to  20  gr. ;  sodium  sulpho- 
carbolate,  5  to  15  gr. ;  salol,  5  to  15  gr.  in  cachets  or  suspended ; 
sulphurous  acid,  £  to  1  drachm ;  precipitated  sulphur  in  doses  of 
10  gr.  up  to  1  drachm  or  more.  Lactic-acid-producing  bacilli  and 


Addison's  (Pernicious)  Anaemia.  9 

their  products,  such  as  lacto-bacilline,  have  been  recommended 
recently  with  the  idea  of  replacing  inimical  bacteria  in  the  bowel 
by  those  which  are  more  useful;  thus  Dill2  found  much  benefit 
from  lacto-bacilline  in  a  case  of  pernicious  anaemia  in  which  the 
stools  contained  enormous  numbers  of  Streptococci  faecalis  and 
Bacilli  enteritidis  of  Gartner.  It  is  very  difficult  to  say  whether 
benefits  which  may  seem  to  be  due  to  this  treatment  are  really  due 
to  it  or  not,  but  judiciously  prescribed  and  carefully  watched  there 
would  seem  to  be  no  reason  why  this  line  of  treatment  might  not 
do  good,  particularly  in  those  cases  in  which  gastro-intestinal 
symptoms  are  prominent. 

Grawitz'  method  of  treating  pernicious  anaemia  is  to  resort  to 
lavage  of  the  stomach ;  the  diet  consisting  strictly  of  milk  and 
vegetables,  enemata  being  administered  daily,  arsenic  and  hydro- 
chloric acid  being  given  by  the  mouth.  The  stomach  is  washed  out 
through  a  tube  and  funnel  every  other  day.  When  vomiting 
is  itself  a  troublesome  symptom  there  is  something  to  be  said  in 
favour  of  this  treatment,  but  when  the  stomach  seems  to  be  per- 
forming its  functions  well  lavage  would  seem  to  be  an  unnecessarily 
uncomfortable  prescription. 

Both  infusion  and  transfusion  have  been  recommended  by  some 
authorities,  actual  blood  having  been  transfused  in  earlier  cases, 
though  infusion  of  normal  saline  at  body  temperature  into  the 
subcutaneous  tissues  of  the  axillae  is  more  frequently  recommended 
than  actual  blood  transfusion  nowadays.  The  most  recent  form 
of  infusion  is  by  the  use  of  deep-sea  water,  collected  specially  on 
shipboard,  sterilised  and  diluted  so  as  to  be  isotonic  with  the  blood, 
subcutaneous  injections  of  1  to  3  oz.  being  given  each  day,  if  need 
be  for  some  weeks.  The  inventors  of  this  line  of  treatment  have 
said  a  great  deal  in  its  favour  in  the  treatment  of  many  forms  of 
malnutrition,  but  pernicious  anaemia  cases  are  as  a  rule  not 
emaciated  or  ill-nourished  in  the  ordinary  sense,  so  that  infusion 
and  transfusion  do  not  generally  seem  to  be  indicated. 

Bone  marrow,  both  in  the  fresh  and  in  the  lightly  cooked  state 
in  the  form  of  thin  sandwiches,  or  as  specially  prepared  extract  of 
bone  marrow,  has  been  advocated  with  a  view  particularly  to  stimu- 
lating still  further  the  blood-forming  activities  of  the  bones  in 
pernicious  anaemia ;  theoretically  this  treatment  should  be  admir- 
able, but  in  practice  it  has  not  yielded  any  very  definite  results. 

Oxygen  inhalations  undoubtedly  do  good  in  those  cases  of 
pernicious  anaemia  in  which  the  haemoglobin  is  immensely  reduced, 
down  perhaps  to  20  or  even  15  per  cent,  of  normal ;  the  extremely 
low  oxygen  tension  of  the  blood  in  these  cases  would  seem  to  be 


io  Addison's  (Pernicious)  Anasmia. 

responsible  for  certain  of  the  secondary  symptoms  and  effects  of 
pernicious  anaemia,  particularly  the  changes  in  the  spinal  cord  and 
peripheral  nerves,  which  may  cause  extensive  degeneration  of  the 
long  tracts,  producing  symptoms  like  those  of  locomotor  ataxy  or 
spastic  paraplegia  or  more  scattered  lesions  of  the  peripheral  nerves, 
with  symptoms  of  acro-paraesthesia,  needles-and-pins  and  so  forth 
in  the  extremities.  As  the  blood  condition  improves  there  is  less 
need  for  oxygen,  but  during  the  severe  stages  it  is  well  to  give  it  by 
means  of  a  properly  fitting  mask  and  valves,  the  administration 
being  continued  for  five  minutes  at  a  time  every  half  hour  whilst 
the  patient  is  awake.  It  is  as  well  that  the  oxygen  should  be 
warmed  before  it  is  taken  into  the  lungs.  As  ordinarily  adminis- 
tered by  means  of  a  rubber  tube  and  funnel  oxygen  is  for  the  most 
part  wasted,  but  a  suitable  yet  simple  apparatus,  such  as  that 
devised  by  Professor  Leonard  Hill,  makes  oxygen  of  real  therapeutic 
value  in  cases  of  this  kind. 

TREATMENT   OF  COMPLICATIONS. 

Most  patients  suffering  from  pernicious  anaemia,  when  they  are 
going  downhill  in  their  final  relapse,  simply  grow  weaker  and 
weaker  until  they  finally  cease  to  live.  There  are  not,  as  a  rule, 
many  complications  that  need  active  treatment. 

There  is  a  tendency  to  oedema  of  the  legs  when  the  patient, 
having  been  kept  at  rest  in  bed,  begins  to  get  about  again  during 
convalescence;  massage  of  the  feet,  ankles  and  legs,  especially  simple 
rubbing  in  an  upward  direction  without  too  much  force  goes  far  to 
minimise  this  tendency,  and  even  when  oedema  occurs  it  is  not  as 
a  rule  painful.  Crepe  velpeau  bandages  as  a  local  support  to  the 
feet,  ankles  and  legs  are  very  grateful  in  many  cases. 

Nervous  symptoms  are  common,  especially  subjective  sensations 
of  numbness  in  the  hands,  tingling  or  peculiar  feelings  of  cold  or 
heat ;  actual  pain  in  various  parts  due,  doubtless,  to  ill-defined 
lesions  in  the  peripheral  nerves,  or  even  the  effects  of  actual 
lesions  in  the  spinal  cord,  may  all  need  treatment.  Bromides  may 
be  required  if  the  patient  suffers  at  the  same  time  from  much 
giddiness  and  difficulty  in  getting  to  sleep,  whilst  locally  gentle 
massage  with  or  without  use  of  faradic  electricity  may  often  give 
relief. 

Haemorrhages  are  not  uncommon,  but  they  are  very  seldom  in 
themselves  severe.  They  do  not  often  need  active  treatment,  and 
when  they  do  the  case  is  generally  a  very  severe  one  and  almost 
beyond  the  reach  of  treatment,  though  the  haematemesis,  haemoptysis, 
epistaxis,  metrorrhagia,  loss  of  blood  from  the  bowels,  and  so  forth, 


Addison's  (Pernicious)  Anaemia.  T  i 

will  each  be  treated  in  the  same  way  as  if  these  were  due  to  other 
causes,  whilst  calcium  salts,  either  the  chloride  or  the  lactate  or  the 
iodide  in  doses  of  from  2  to  60  gr.  will  be  resorted  to  in  the  vain 
hope  that  thereby  the  coagulability  of  the  blood  may  be  increased 
and  the  haemorrhage  stopped.  The  best  remedy  when  visceral 
haemorrhage  is  severe  is  opium  in  one  or  other  of  its  forms. 
Cerebral  haemorrhage  may  occur  spontaneously  in  pernicious 
ammuia,  but  little  can  be  done  to  prevent  its  ending  fatally. 

Intercurrent  maladies  may  develop  but  they  are  rare ;  when 
they  do  arise  they  need  treatment  on  the  same  lines  as  in  other 
cases;  one  would  mention  in  particular  lobar  pneumonia  and 
inflammation  of  the  serous  membranes — pleurisy  or  pericarditis, 
with  effusion,  or  ascites ;  when  fluid  accumulates  in  a  serous 
cavity  to  such  an  amount  as  to  cause  actual  distress  it  may  need  to 
be  removed  by  paracentesis. 

CONVALESCENCE. 

The  probability  is  that  the  patient  whose  pernicious  anaemia 
has  been  recognised  early,  and  who  has  at  once  been  treated 
by  rest,  arsenic,  generous  diet  and  fresh  air,  will  rally  within 
a  month  or  six  weeks,  and  in  not  a  few  cases  the  haemoglobin 
and  the  red  corpuscles  both  become  normal  or  nearly  normal  for 
the  time  being.  The  difficulty  is  that,  do  what  one  will,  the  patient 
is  almost  certain  to  relapse,  sometimes  within  a  few  months,  some- 
times in  a  few  weeks,  occasionally  not  for  a  year  or  more.  Seeing, 
therefore,  that  the  patient  is  never  really  cured,  one  may  speak  of 
the  whole  period  of  temporary  recovery  as  one  of  convalescence. 
During  this  time  there  is  no  reason  why  the  patient  should  not 
return  to  his  work,  provided  it  is  not  a  laborious  occupation  and 
provided  it  is  carried  out  under  healthy  surroundings.  This  return 
to  work  does  not  hasten  relapses,  and  it  takes  away  the  sense  of 
invalidism  and  incurability  which  is  so  apt  to  depress  patients 
when  they  are  prevented  from  carrying  on  any  occupation.  Even 
though  the  recovery  be  but  partial  it  is  wise  to  allow  the  patient 
to  do  some  work  in  the  interval  if  he  can.  The  diet  should  be  as 
generous  as  possible  though  the  appetite  is  not  as  a  rule  good,  and 
it  is  often  useful  to  prescribe  an  acid  mixture  such  as  :  1^ .  Extract! 
Nucis  Vomicae  Liquidi,  iril;  AcidiSulphuriciDiluti,  111 15  ;  Tincturse 
Gentianae  Compositse,  5^  ;  Aquam  Chloroformi,  ad  j|.  [U.S. P. 
1^.  Fluid  extracti  Nucis  Vomicae,  nil ;  Acidi  Sulphurici  Diluti,  ni.15  ; 
Tincturae  Gentianae  Composite,  5|;  Aquae  Chloroformi,  5ij  ;  Aquam, 
ad  5!].  Dose,  one  tablespoonful  in  a  little  water  thrice  daily 
between  meals. 


12  Addison's  (Pernicious)  Anaemia. 

It  is  also  wise  to  prescribe  arsenic,  not  continuously,  but  with  short 
intervals  of  a  few  days  or  a  week  or  two  during  which  none  is 
given.  Five  minims  of  liquor  arsenii  hydrochloricus  [U.S.P. 
liquor  acidi  arseniosi]  may  be  added  to  the  above  mixture,  in  which 
case  it  should  be  taken  immediately  after  food  instead  of  between 
meals  ;  or  the  patient  may  take  Levico  or  Koncegno  water  after 
meals  in  doses  of  1  to  2  tablespoonfuls  diluted  with  plain  water. 
Relapse  is  sure  to  occur  within  a  longer  or  shorter  time,  in  which 
case  it  is  wise  not  to  wait  too  long  before  the  patient  is  advised  to 
rest  upon  a  couch  or  in  bed  again,  and  carry  out  the  same  treat- 
ment as  in  the  first  attack.  It  is  most  important,  however,  not  to 
tell  the  patient  beforehand  that  speedy  relapses  are  likely  to  occur, 
and  as  far  as  possible  the  dangers  of  the  disease  should  be  entirely 
hidden  from  him.  If  he  should  be  alarmed  by  accidentally  hearing 
the  unfortunate  adjective  "  pernicious,"  he  can  be  honestly  assured 
that  taken  in  time  it  is  by  no  means  so  dire  a  malady  as  to  have 
merited  the  term.  If  only  on  account  of  the  ill-effect  upon  the 
patient  the  too-well-established  name  of  the  disease  should  if 
possible  be  changed,  and  as  an  alternative  it  might  well  be  spoken 
of  as  Addison's  anemia. 

HERBERT    FRENCH. 

KEFERENCES. 

1  Bramwell,  B.,  "Note  on  the  Treatment  of  Pernicious  Anoemia,"  Brit.  Med. 
Journ.,  1909,  I.,  p.  209. 

2  Lancet,  1908,  II.,  p.  1600. 


ANEMIA   DUE   TO    SOME    DEFINITE   MALADY  BUT 
NOT  DUE  TO  OBVIOUS  BLOOD  LOSS. 

THE  term  "  secondary  anaemia  "  has  been  used  in  so  loose  a  way  in 
clinical  medicine  that  it  is  now  best  not  used  at  all.  It  is  on  this 
account  that  so  long  a  heading  is  employed  above  to  denote  one 
group  of  conditions  in  which  anaemia  is  secondary,  another  group 
consisting  of  conditions  in  which  anaemia  is  the  result  of  actual 
blood  loss,  acute  and  abundant  or  recurrent. 

There  are  many  different  maladies  that  may  be  associated  with 
pronounced  anaemia,  and  one  may  say  of  all  of  them  that  the 
principles  of  treatment  are :  To  relieve  or  cure  the  primary  condition 
whenever  possible ;  to  encourage  as  liberal  a  diet  as  circumstances 
will  allow ;  to  advise  living  in  as  bright  and  airy  surroundings  as 
may  be,  out  of  doors  when  possible  or  in  a  large  room  with  open 
windows  and  a  southern  aspect  when  the  primary  malady  necessi- 
tates confinement  to  the  house  or  to  bed  ;  and  to  treat  the  anaemia 
itself  upon  the  same  lines  as  those  described  for  chlorosis  (p.  20). 
Iron,  arsenic  and  quinine  are  the  main  remedies  to  rely  upon, 
particularly  iron,  adopting  that  variety  which  is  found  not  to  upset 
the  gastro-intestinal  functions.  If  these  general  principles  are 
borne  in  mind,  there  is  little  more  to  be  said  about  the  treatment  of 
the  anaemia  itself,  seeing  that  the  therapeutics  of  each  individual 
primary  malady  are  discussed  elsewhere  in  this  work.  One  may 
enumerate  the  commoner  conditions,  however,  as  follows : 

Anaemia  caused  by  pulmonary  tuberculosis  :  The  best  cure  for 
the  anaemia  of  pulmonary  tuberculosis  is  sunshine ;  iron  needs  to  be 
used  with  considerable  caution,  because  the  appetite  is  already  apt  to 
be  capricious  and  the  patient  cannot  afford  to  run  the  risk  of  having 
it  made  worse.  Seaside  air  is  to  be  preferred  whenever  possible, 
particularly  if  the  patient  is  a  good  sailor  and  is  not  too  ill  to  spend 
most  of  the  day  actually  on  the  sea  in  a  small  sailing  boat.  Some 
patients  do  better  in  the  country,  however.  Fresh  air,  sunshine, 
no  work  if  there  is  pyrexia,  but  graduated  exercise  if  there  is  none, 
are  the  essentials,  and  it  is  much  better  for  the  patient  to  be  any- 
where than  amongst  other  patients  of  the  same  kind,  as  at  a 
sanatorium,  provided  he  has  learned  what  living  the  fresh-air  life 
means.  Small  doses  of  arsenic  are  most  serviceable  in  these  cases, 
and  sleep  should  be  encouraged  by  using  even  opiates  if  they  are, 
needed  to'  quieten  a  troublesome  night  cough. 


14  Symptomatic   Anaemia. 

Anaemia  in  ailing  children  :  Children  often  suffer  from  pallor 
when  they  are  not  well,  and  the  two  best  remedies  for  the  anaemia 
itself  are  cod-liver  oil  and  extract  of  malt  and  iron.  The  beneficial 
effects  of  the  latter  are  often  wonderful,  especially  in  children  who 
live  in  towns.  One  of  the  best  preparations  is  the  following  :  Take 
of  pyrophosphate  of  iron,  2  parts  ;  water,  3  parts ;  dissolve  and 
add  extract  of  malt,  95  parts.  Children  generally  take  this  with 
avidity  in  doses  of  from  one  to  four  teaspoonf uls  three  or  four  times 
a  day,  though  older  patients  tend  to  find  it  nauseating. 

It  is  essential  to  treat  whatever  cause  for  ill-health  may  be 
detected  in  any  particular  case.  Errors  of  diet,  particularly  the 
consumption  of  sweets  between  meals,  should  be  corrected.  If 
there  are  enlarged  glands  in  the  neck,  or  other  evidence  of  possible 
tuberculosis,  the  milk  supply  should  be  carefully  investigated,  and, 
if  possible,  only  milk  from  tuberculin-tested  cows  allowed.  The 
amount  of  surgical  tuberculosis  attributable  to  cow's  milk  both  in 
towns  and  in  the  country  is  incredible.  Mouth  breathing  should  be 
steadily  discouraged  until  a  child  who  has  acquired  that  habit  is 
gradually  broken  of  it.  Adenoids  or  enlarged  tonsils  may  need 
removal,  but  it  is  important  to  realise  that  the  object  of  the  opera- 
tion is  merely  to  restore  the  nasal  airway  and  that  the  adenoids 
will  recur  unless  nose-breathing  is  inculcated  and  re-established. 
Coli-bacilluria  is  not  an  uncommon  cause  of  ill-health  in  children, 
and  it  may  remain  undetected  unless  specimens  of  urine  are 
examined  for  pus  cells  microscropically ;  mild  cases  may  be  cured 
by  giving  urotropine  in  5  or  10  gr.  doses,  but  severer  cases  may 
require  confinement  to  bed,  potassium  citrate  in  5  or  10  gr.  doses, 
and  urotropine  or  helmitol  in  10  gr.  doses  ;  whilst  some  observers 
believe  that  coli-vaccine  treatment  is  also  beneficial.  Rickets  is 
often  associated  with  anaemia  ;  attention  to  the  diet,  administration 
of  malt  and  iron,  and  greater  care  in  keeping  the  child  out  of  doors 
and  as  much  as  possible  in  sunshine,  should  cure  both  the  rickets  and 
the  anaemia.  Pediculosis  capitis  is  a  common  cause  for  serious  ill- 
health  and  anaemia  amongst  the  poorer  classes,  especially  in  girls ; 
there  may  be  obvious  nits  with  or  without  sore  places  on  the  back 
of  the  neck  and  enlarged  occipital  and  mastoid  glands.  Weak  lysol 
compresses  to  the  head,  combing  with  sassafras  oil,  or  the  applica- 
tion of  methylated  spirits,  should  rapidly  expel  the  pediculi  ; 
sassafras  oil  is  preferable  to  methylated  spirits  if  there  are  actual 
sores,  because  the  spirits  cause  the  latter  to  smart  intensely  ; 
otherwise  there  is  no  better  eradicant  of  pediculi  than  methylated 
spirits. 

For  Pseudo-leuktemia  infantum  (von  Jaksch's  disease)  see  p.  42. 


Symptomatic  Anaemia.  15 

Acute  rheumatism  is  very  apt  to  cause  pronounced  anaemia, 
especially  when  it  recurs  at  short  intervals  and  necessitates  the  use 
of  sodium  salicylate  or  aceto-salicylic  acid  in  large  doses  over  long 
periods.  It  is  possible  that  the  remedy  itself  is  responsible  for 
part  of  this  anaemia  ;  to  obviate  this  it  is  usual  to  add  some 
preparation  of  iron  to  the  sodium  salicylate  mixture  after  the  first 
week  or  ten  days,  as  in  the  following  prescription  :  1^ .  Ferri  et 
Ammonii  Citratis,  gr.  5  ;  Sodii  Salicylatis,  gr.  15  ;  Glycerini,  5ss  ; 
Aquam,  ad  3].  Dose,  two  tablespoonfuls  thrice  daily  or  oftener. 

Heart  disease  sometimes  causes  plethora  rather  than  anaemia, 
especially  in  mitral  cases.  Two  forms  of  heart  disease  in  par- 
ticular, however,  tend  to  cause  serious  anaemia — syphilitic  aortic 
regurgitation,  and  fungating  endocarditis.  Iron  remedies  are 
indicated  in  both  cases,  together  with  arsenic  and  anti- syphilitic 
remedies  in  the  former  and  suitable  serum  or  vaccine  treatment  in 
the  latter. 

Intestinal  parasites,  particularly  Ankylostomum  duodenale  and 
Bothriocephahu  latiis,  and  to  a  less  extent  Tcenia  soliuin  and  Tcenia 
victUocaiK'Uata,  may  lead  to  profound  anaemia.  Early  diagnosis 
and  eradication  of  the  worms  afford  the  best  means  of  curing  the 
anaemia,  though  severe  cases  may  be  a  long  while  in  recovery,  even 
when  iron  remedies  are  employed  as  in  chlorosis.  Cases  of  this 
kind  often  do  better  at  a  spa  than  at  home,  one  of  the  best 
watering-places  for  the  purpose  in  the  late  spring,  summer  and  early 
autumn  being  Schwalbach  (1,042  feet),  or  if  a  higher  altitude  can 
be  borne,  Tarasp  (3,996  feet). 

Tropical  anaemia,  especially  that  which  has  resulted  from 
repeated  attacks  of  tertian,  quartan,  or  sestivo-autumnal  malaria, 
blackwater  fever,  dysentery,  or  some  of  the  many  less  well-defined 
febrile  maladies  of  the  tropics,  may  be  very  difficult  to  cure. 
Milder  cases  recover  completely  within  a  few  months  of  returning 
to  England,  even  when  no  particular  treatment  is  adopted.  Severer 
cases  require  active  treatment  with  iron,  quinine  and  arsenic,  upon 
lines  similar  to  those  advised  for  chlorosis,  except  that  it  is  only  in 
exceptional  cases  that  confinement  to  bed  is  necessary.  Residence 
in  a  warm  sunny  atmosphere  is  to  be  recommended,  so  that  winters 
may  be  spent  at  Mentone  or  elsewhere  in  the  Riviera,  rather  than 
in  England  ;  the  seaside  is  generally  better  than  the  country, 
especially  if  the  patient  can  spend  much  of  his  time  sailing  in  a 
small  boat,  though  much  benefit  is  also  obtainable,  especially  by 
women,  from  residence  at  a  chalybeate  spa. 

Convalescence  from  many  maladies,  especially  those  that  have 
entailed  long  confinement  to  bed,  such  as  typhoid  fever,  is  associated 


1 6  Symptomatic  Anaemia. 

with  anaemia.  Iron,  arsenic  and  quinine  are  usually  prescribed, 
but  change  of  air  and  scene,  especially  when  the  change  is  to  open- 
air  and  sunshine  afford  the  best  remedy. 

Septic  states  are  nearly  always  associated  with  more  or  less 
anaemia.  Iron,  quinine  and  arsenic,  will  assist  in  relieving  the 
latter,  but  the  best  treatment  is  to  remove  the  septic  cause  when- 
ever possible.  The  therapeutics  of  the  various  septic  conditions 
will  be  found  elsewhere  :  Oral  sepsis  ;  leucorrhoea  ;  enclometritis  ; 
constipation  and  intestinal  putrefaction  ;  acute,  chronic,  mucous, 
muco-membranous  colitis ;  totid  bronchitis ;  bronchiectasis  ; 
phthisis,  with  pyogenic  infection  of  the  lung  cavities  ;  ulcerative 
colitis ;  cystitis ;  pyelonephritis ;  acute  and  chronic  rheumatoid 
arthritis,  infective  synovitis  or  arthritis,  as  distinct  from  osteo- 
arthritis ;  infective  endocarditis  ;  long  continuing  sinuses  associated 
with  bone  necrosis ;  psoas  abscess,  hip-joint  disease,  empyema, 
mastoid  abscess,  pyosalpinx ;  chronic  appendicitis  ;  ischio-rectal 
abscess;  permeal  fistulae*;  recurrent  pyodermia,  and  so  on. 
Surgical  and  vaccine  treatments  may  suggest  themselves  in  many 
such  cases  in  addition  to  the  symptomatic  treatment  of  the 
anaemia. 

Cancer,  especially  when  it  involves  vital  organs  such  as  the 
oesophagus  or  stomach,  or  leads  to  foetid  ulceration,  or  to  sleepless- 
ness from  pain,  may  cause  progressive  and  severe  anaemia.  It  is 
seldom  possible  to  relieve  this,  because  the  end  is  not  far  off,  but 
sunshine,  iron,  morphia,  and  as  generous  a  diet  as  possible, 
especially  as  regards  meat,  will  be  the  best  measures  for  relieving 
the  anaemia. 

Plumbism  generally  causes  pronounced  anaemia,  and  so  may  the 
chronic  effects  of  other  chemical  substances  such  as  naphtha  vapour, 
carbon  bisulphide,  petrol,  and  many  other  substances  used  in 
different  commercial  processes.  The  best  treatment  is  prophylactic ; 
the  source  of  chronic  poisoning  having  been  discovered,  steps  should 
be  taken  to  obviate  it  for  the  future.  Sometimes  the  source  of  lead 
poisoning  is  clear  enough,  being  indicated  by  the  patient's  employ- 
ment as  a  plumber,  painter,  pottery  glazer  or  the  like ;  often, 
however,  it  is  most  difficult  to  trace  the  mischief  to  its  source,  for 
instance,  in  the  case  of  hairwashes,  water  supply,  foods  or  hobbies. 
The  anaemia  itself  is  best  treated  with  iron  and  iodides,  the  syrupus 
ferri  iodidi  (B.P.)  being  particularly  good  in  doses  of  from  £  to  1 
fluid  drachm.  The  bowels  should  be  kept  well  open  with  magnesium 
sulphate,  and  the  patient  should  drink  lemonade  made  artificially 
with  20  min.  of  dilute  sulphuric  acid  to  each  ounce,  and  syrup  of 
lemon  [U.S.P.  syrup  of  citric  acid]  to  taste. 


Symptomatic  Anaemia.  17 

Syphilis  is  sometimes  responsible  for  considerable  or  even 
severe  anaemia,  both  in  the  secondary  and  in  the  tertiary  stages. 
Iron  may  benefit  the  anaemia,  but  small  doses  of  arsenic  are  even 
more  beneficial ;  it  may  be  combined  with  mercury  and  iodide  in 
the  form  of  Donovan's  solution — liquor  arsenii  et  hydragyri  iodidi 
(B.P.) — of  which  5  to  20  min.  or  more  may  be  prescribed  in  a 
simple  mixture  to  be  taken  twice  or  thrice  daily  after  food.  The 
more  efficient  the  anti-syphilitic  treatment,  the  less  the  liability  to 
tertiary  anaemia,  and  mercurial  inunctions  will  generally  be  found 
better  than  giving  mercury  by  the  mouth.  Hypodermic  injections 
of  mercury  are  not  unaccompanied  by  disadvantages,  but  they  may 
be  required  in  a  few  cases.  A  course  of  treatment  at  Aix-la- 
Chapelle  is  to  be  recommended  in  many  instances. 

Bright' s  disease,  particularly  the  chronic  tubal  variety,  is  apt 
to  cause  pronounced  anaemia — the  large  white  person  with  the 
large  white  kidney.  It  is  important  to  minimise  the  anaemia  in 
these  cases.  If  it  is  associated  with  marked  oedema,  restriction 
of  salt  in  the  dietary  may  be  advocated,  though  this  has  proved  less 
beneficial  than  was  at  first  expected.  Iron  preparations  may  be 
ordered  as  in  chlorosis,  but  the  most  important  point  of  all  is  to 
allow  a  generous  diet,  including  meat.  Notwithstanding  the 
presence  of  abundant  albumin  in  the  urine  in  these  cases,  it  is 
important  to  realise  that  this  is  a  permanent  condition ;  the 
patients  should  be  encouraged  to  live  as  nearly  a  normal  life  as 
possible,  and,  provided  that  ordinary  moderation  is  observed,  the 
dietary  should  be  precisely  the  same  as  that  of  a  healthy  individual. 
The  anaemia  will  often  disappear  when  meat  is  allowed  in  this  way, 
and  the  patient  will  live  longer  rather  than  less  long  upon  the 
more  generous  dietary. 

HERBERT  FRENCH. 


ANAEMIA    DUE   TO   ACTUAL   LOSS    OF    BLOOD. 

ANEMIA  and  blood  loss  may  both  be  the  effects  of  some  common 
cause,  as  in  certain  cases  of  severe  purpura  (q.v.) ;  or  the  anaemia 
may  be  directly  due  to  blood  loss,  either  a  single  copious  bleeding, 
such  as  post-partum  haemorrhage,  haematemesis,  or  haemoptysis, 
or  recurrent  bleedings,  as  in  some  cases  of  uterine  fibromyomata  or 
rectal  polypi.  In  all  such  cases  it  is  important,  whenever  possible, 
to  stop  the  bleeding  either  by  means  of  absolute  rest,  morphia 
injections,  styptics,  or  by  means  of  ligatures,  excision  of  the  bleeding 
focus,  or  other  surgical  measures.  Details  of  the  treatment  to  be 
adopted  for  the  various  forms  of  bleeding  will  be  found  elsewhere  in 
this  work.  It  remains  to  cure  the  anaemia  itself. 

After  an  acute  bleeding,  when  the  latter  has  been  checked,  the 
first  thing  is  to  save  the  patient  from  dying  of  the  extreme  anaemia 
that  has  suddenly  developed.  He  should  be  kept  absolutely  still  in 
a  darkened  well-ventilated  room,  the  air  of  which  is  about  70°  F., 
with  warm  blankets  next  the  skin,  and  hot  bottles  to  the  feet  and 
flanks  ;  the  foot  of  the  bed  should  be  raised  by  means  of  bricks,  books 
or  otherwise,  so  that  the  patient's  feet  are  slightly  higher  than  his 
head  ;  the  legs  and  arms  should  be  gently  but  firmly  bandaged 
over  cotton-wool  from  their  distal  ends  up  to  the  trunk,  partly  to 
keep  them  warm,  and  partly  to  drive  as  much  blood  as  may  be  in 
towards  the  heart  for  use  in  the  brain  and  more  vital  organs.  The 
abdomen  may  be  bandaged  in  a  similar  way  if  the  bleeding  has  not 
been  intra-abdominal.  These  bandages  may  be  left  on  for  an  hour 
or  longer  until  the  patient  complains  of  their  being  irksome  ;  mean- 
while the  necessary  apparatus  and  solutions  for  saline  infusion  are 
got  ready  as  quickly  as  possible ;  two  pints  or  more  may  be  given 
rapidly  by  the  intravenous  method  or  into  the  subcutaneous 
tissues  of  the  axillae,  after  which  it  is  better  to  rely  rather  upon  the 
continuous  rectal  method. 

The  use  of  pituitary  extract  is  much  advocated  nowadays  as  a 
very  successful  way  of  overcoming  shock.  The  more  the  blood 
pressure  has  fallen  the  more  good  is  the  pituitary  extract  likely  to 
do.  It  is  issued  in  small  glass  phials  containing  1  c.c.  of  20  per 
cent,  sterile  extract,  equivalent  to  0'2  gramme  of  fresh  posterior 
lobe  of  the  pituitary  body.  This  may  be  given  by  intramuscular 
or  intravenous  injection,  or  it  may  be  added  to  the  saline  fluid  used 


Anaemia  due  to  Actual  Loss  of  Blood.       19 

for  infusion.  Its  effect  comes  on  in  less  than  half  an  hour  and 
continues  for  twelve  hours  or  more,  by  which  time  the  dose  may  be 
repeated  if  need  be. 

If  the  acute  bleeding  has  not  been  from  the  stomach,  hot  brandy 
and  water,  hot  coffee,  or  similar  warming  and  stimulating  drinks, 
may  be  allowed  ;  thirst  will  presently  be  extreme,  notwithstanding 
infusion ;  bland  fluids,  especially  water,  may  be  allowed  ad  libitum, 
preferably  in  small  quantities  at  a  time,  but  administered 
frequently. 

The  feeling  of  impending  suffocation  is  best  alleviated  by  the  use 
of  oxygen  inhalations,  especially  when  the  latter  are  given  through 
properly  fitting  apparatus  with  a  mask  and  valves. 

Strychnine  injections  are  less  used  than  formerly,  but  they  might 
be  employed  if  no  pituitary  extract  is  available. 

Sleep  should  be  encouraged,  but  it  is  too  risky  to  give  any 
powerful  hypnotic  such  as  morphia. 

When  the  immediate  danger  of  death  has  passed  the  ansemia 
itself  will  need  careful  treatment  upon  the  same  lines  as  those 
described  for  chlorosis  (p.  20).  There  is  a  strong  tendency  towards 
spontaneous  and  rapid  recovery,  so  that  in  six  weeks  or  two  months 
time  the  blood  has  often  become  normal  again.  This  tendency 
should  be  borne  in  mind  and  drug  treatment  should  not  be  too 
active.  Small  doses  of  iron  and  still  smaller  doses  of  arsenic  are 
likely  to  do  more  good  than  larger  ones  in  cases  of  sudden  acute 
anaemia,  though  this  is  less  true  of  patients  in  whom  the  bleeding, 
without  being  at  any  one  time  extreme,  has  been  recurrent  over  a 
long  period.  If  after  recovery  up  to  a  certain  point  there  are  signs 
of  the  cure  lagging,  a  change  of  air  and  scene,  particularly  to  some 
part  where  the  sun  shines,  will  often  prove  very  beneficial,  to 
Worthing,  Eastbourne,  Cornwall,  or  the  Channel  Islands,  if  it  is 
thought  wiser  not  to  go  abroad. 

HERBERT   FRENCH. 


2—2 


20 


CHLOROSIS. 

THEKE  are  a  very  large  number  of  different  conditions  that  may 
produce  ansemia  of  the  chlorotic  type,  the  essential  features  of  the 
blood  changes  being  great  diminution  in  the  percentage  of  haemo- 
globin, a  less  reduction  in  the  percentage  of  red  corpuscles,  so  that 
the  colour  index  is  less,  and  often  much  less,  than  1,  whilst  at 
the  same  time  the  leucocytes  exhibit  no  particular  change  either  in 
total  numbers  or  in  the  differential  leucocyte  count. 

Chlorosis  itself,  however,  is  a  distinct  malady  easily  recognisable 
in  most  cases,  confined  to  the  female  sex,  seldom  if  ever  developing 
before  puberty,  though  common  after  it  and  during  the  succeeding 
years ;  it  becomes  progressively  less  common  with  each  year  after 
twenty,  and  it  is  most  common  and  most  severe  between  seventeen 
and  twenty.  Typical  chlorosis,  with  the  greenish  yellow  hue  that 
gave  the  name  to  the  complaint,  is  not  so  frequent  as  are  minor 
degrees  of  the  malady,  which  may  show  any  stage  from  slight 
paleness  to  typical  and  unmistakable  chlorosis. 

The  essential  points  in  the  treatment  of  a  severe  case  are  four, 
namely :  Complete  rest  in  bed  for  the  time  being ;  sunshine  and 
fresh  air,  even  though  the  patient  is  in  bed  ;  the  administration  of 
iron ;  and  precautions  to  ensure  that  constipation  does  not  persist. 

The  omission  of  strict  attention  to  any  one  of  the  above  principles 
is  liable  to  be  followed  by  failure  in  the  cure  of  the  patient ;  if, 
however,  one  were  asked  to  say  which  of  the  four  principles 
enumerated  above  should  be  most  insisted  upon  it  would  be  the 
necessity  for  complete  rest  in  bed  in  severe  cases. 

Rest,  Sunshine,  Air. — The  patient  is  very  often  a  servant 
girl,  who,  working  indoors  most  of  the  week,  has  developed 
so  marked  a  degree  of  chlorosis  that  she  now  suffers  from 
shortness  of  breath  on  going  upstairs,  from  more  or  less  swelling 
of  the  feet  when  she  has  been  on  them  any  length  of  time,  from 
inability  to  take  food  properly  because  ordinary  diet  causes  severe 
pain  in  the  upper  part  of  the  abdomen  and  necessitates  vomiting 
in  order  to  relieve  this,  from  irregularity  of  the  monthly  periods 
or  complete  amenorrhoea  for  months  at  a  time  with  more  or 
less  constipation ;  such  a  patient  put  to  bed  in  a  sunny  room, 
attended  by  a  careful  nurse  and  supplied  with  an  abundance  of 
good  plain  food  of  every  kind,  including  meat  at  least  once  a  day, 


Chlorosis.  21 

will  very  often  become  perfectly  well  in  six  to  eight  weeks,  even 
though  no  iron  and  no  laxatives  are  administered.  The  most  that 
such  a  patient  should  be  allowed  to  do  in  the  way  of  physical 
exercise  should  be  to  get  out  of  bed  to  use  the  commode,  though 
even  this  might  be  interdicted  for  the  first  week  or  ten  days.  The 
sunny  bright  aspect  of  the  room  in  which  the  treatment  is  carried 
out  is  an  important  factor  in  tlie  cure,  and  it  is  even  probable  that 
servant  girls  and  others  would  not  become  chlorotic  at  all  if  from 
the  beginning  they  had  beeli  in  the  habit  of  living  in  sunny  rooms 
with  open  windows  and  had  had  some  pleasurable  outdoor  exercise 
every  day  instead  of,  as  so  often  happens,  spending  many  days  or 
even  weeks  at  a  time  within  doors,  perhaps  in  sunless  rooms,  often 
with  closed  windows,  and  frequently  without  outdoor  exercise 
except  in  the  evening,  when  it  is  already  dark.  It  is  true  that 
chlorosis  occurs  in  country  places  as  well  as  in  towns,  but  errors  in 
the  general  mode  of  living  will  almost  always  be  found  to  account 
for  it  in  country  cases,  for  life  in  a  cottage  may  be  as  much  indoor 
and  sunless  as  life  in  a  town  house. 

The  rest  in  bed  should  be  absolute  for  four  weeks  at  least,  unless 
both  haemoglobin  and  red  corpuscles  have  risen  to  normal  within 
this  time,  which  is  unlikely.  It  is  sometimes  advisable  to  continue 
treatment  in  bed  for  as  long  as  six  or  even  eight  weeks,  though  if 
by  this  time  the  haemoglobin  has  not  yet  risen  to  normal  it  will  be 
wise  to  let  the  patient  begin  to  sit  up  and  then  gradually  to  use  her 
feet  a  little  until  she  has  recovered  sufficient  ambulatory  power  to 
be  able  to  go  away  for  a  change  of  scene,  either  to  the  country  or  to 
the  seaside,  as  her  own  inclinations  and  the  circumstances  of  the 
case  most  indicate.  It  is  often  wise  to  go  from  one  place  to 
another  during  convalescence,  ending  at  a  higher  altitude  than 
that  at  which  the  treatment  was  begun.  Physical  exertion  should 
be  resumed  only  with  considerable  care  and  with  careful  attention 
to  the  amount  of  increase  allowed  each  day,  for  a  relapse  may 
readily  be  brought  about  by  too  quick  a  return  to  daily  avocations. 
The  severest  case  of  chlorosis,  however,  is  generally  curable  com- 
pletely within  twelve  weeks  if  circumstances  allow  of  full  attention 
to  details  in  the  treatment. 

Preparations  of  Iron. — The  administration  of  iron  is  beyond 
doubt  the  most  important  medicinal  factor  in  the  cure  of 
chlorosis.  We  need  not  enter  here  into  a  discussion  of  the  way 
in  which  the  iron  does  good ;  indeed,  nobody  really  knows  how 
it  does  so.  The  fact  remains,  however,  that  chlorosis  is  more 
rapidly  curable  with  iron  than  without  it,  though  iron  by  itself 
without  the  patient  being  put  to  bed  in  a  sunny  room  and  fed 


22  Chlorosis. 

•well  is  very  apt  to  fail  in  the  good  effects  that  may  have  been 
expected  of  it.  A  very  large  number  of  different  iron  prepara- 
tions have  been  recommended  by  different  observers  and  at 
different  times,  each  in  turn  having  been  vaunted  as  immensely 
better  than  the  others ;  this  multiplicity  of  preparations  almost 
certainly  indicates  that  no  one  variety  of  iron  is  essentially 
better  than  another,  and  the  best  line  of  treatment  to  adopt  is  to 
prescribe  in  the  first  instance  one  of  the  common  inorganic  forms, 
especially  the  sulphate,  the  carbonate  or  the  perchloride  ;  and  to 
continue  to  use  this  if  the  patient  can  take  it  without  developing 
gastric  or  other  ill-effects ;  but  to  change  it  for  one  of  the  many 
other  iron  remedies  if  the  stronger  types  cannot  be  tolerated.  The 
chief  ill-effects  of  iron  to  be  on  the  watch  for  are  marked  blacken- 
ing of  the  tongue  and  possibly  of  the  teeth,  unless  the  medicine  is 
taken  through  a  straw,  is  given  in  pill  or  other  solid  form,  or  unless 
a  mouth  wash  and  tooth  brush  are  employed  after  each  dose  ;  con- 
stipation, owing  to  the  astringent  action  of  the  drug,  which  usually 
necessitates  the  use  with  it  either  of  a  saline  laxative  or  else  of  some 
such  drags  as  aloes  and  nux  vomica ;  dyspeptic  symptoms,  followed 
by  nausea  and  a  disinclination  for  food,  which  are  very  much  less 
common  in  patients  confined  to  bed  than  in  those  who  are  up  and 
about,  but  which  if  they  should  arise  in  a  patient  who  is  not  in  bed 
are  very  difficult  to  relieve  except  by  changing  the  iron  prepara- 
tion that  is  being  administered  ;  and  a  continuous  dull  but  severe 
pain  either  in  the  back  about  the  region  of  the  tenth  dorsal 
vertebra  or  beneath  one  or  other  shoulder-blade,  particularly  the 
right  near  its  inferior  angle ;  this  pain  in  the  back  due  to  iron  may 
come  on  when  there  is  neither  constipation  nor  obvious  gastric 
derangement  or  loss  of  appetite,  and  it  is  difficult  to  remedy 
except  by  either  leaving  off  the  iron  altogether  or  at  least 
changing  the  iron  preparation  that  is  being  employed  for  some  other. 

Probably  one  of  the  best  remedies  for  all-round  use  is  Griffith's 
mixture,  mistura  ferri  composita  (B.P.),  the  active  ingredient  of 
which  is  ferrous  carbonate  formed  by  the  interaction  of  ferrous 
sulphate  and  ferrous  carbonate.  The  difficulty  is  that  the  prepara- 
tion will  not  keep,  changing  colour  by  oxidising  more  or  less  within 
a  few  days,  and  therefore  requiring  to  be  made  up  fresh  at  short 
intervals.  The  patient  should  be  able  to  take  a  fluid  ounce  three  or 
even  four  times  daily. 

The  perchloride  of  iron  is  generally  too  astringent  to  be  continued 
with  for  long  periods  at  a  stretch,  but  as  an  alternative  to  other 
iron  preparations,  or  for  use  in  a  case  in  which  improvement  has 
taken  place  up  to  a  certain  point,  but  in  which  it  is  desired  to  hasten 


Chlorosis.  23 

the  cure  as  much  as  possible,  ferric  chloride  may  often  be  used  with 
advantage,  the  solution  being  preferable  to  the  tincture,  and  a  suit- 
able mixture  being  :  R.  Liquoris  Ferri  Perchloridi,  in.15  ;  Glycerini, 
5J  ;  Magnesii  Sulphatis,  q.s.,  e.g.,  5^ ;  Acidi  Sulphurici  Diluti,  HI  10  ; 
Aquam  Chloroformi,  ad  jj  [U.S.P.  1^.  Liquoris  Ferri  Chloridi, 
ill  4 ;  Glycerini,  5] ;  Magnesii  Sulphatis,  q.s.,  e.g.,  5!  ;  Acidi  Sul- 
phurici Diluti,  111 10;  Aquae  Chloroformi,  3^;  Aquam,  ad  ^j] . 
Dose,  1  oz.  three  or  four  times  daily. 

The  chloride  may  also  be  prescribed  with  ammonia  in  a  mixture 
which  is  nearly  neutral  and  almost  free  from  astringent  taste,  as 
in  mistura  ferri  ammoniata  (B.P.C.),  which  is  as  follows:  1^. 
Liquoris  Ferri  Perchloridi,  i»ilO;  Spiritus  Ammonias  Arornatici, 
ill  10;  Syrupi  Simplicis,  lit 40;  Aquam,  ad  §j  [U.S.P.  ty.  Liquoris 
Ferri  Chloridi,  ir|,3;  Spiritus  Ammonias  Aromatici,  iij.10;  Syrupi, 
ii[40 ;  Aquam,  ad  gj] .  Dose,  1  oz.  three  or  four  times  a 
day. 

Ferrous  sulphate  may  also  be  prescribed  in  a  mixture  form  as  in 
the  following  prescription :  1^ .  Ferri  Sulphatis,  gr.  4 ;  Magnesii 
Sulphatis,  q.s.,  e.g.,  gr.  40;  Acidi  Sulphurici  Diluti,  rn.10;  Aquam 
Chloroformi,  ad  jj  [U.S.P.  1^.  Ferri  Sulphatis,  gr.  4;  Magnesii 
Su-lphatis,  q.s.,  e.g.,  gr.  40;  Acidi  Sulphurici  Diluti,  ntlO;  Aquae 
Chloroformi,  §|;  Aquam,  ad  ^j] .  Dose,  1  oz.  three  or  four  times 
a  day. 

More  often,  however,  the  sulphate  is  prescribed  in  pill  form  along 
with  a  carbonate,  so  that  when  the  pill  dissolves  within  the  stomach 
or  intestines  fresh  carbonate  of  iron  is  formed,  as  in  the  case  of  the 
well-known  Blaud's  pill  (pilula  ferri  (B.P.) )  [U.S.P.  Massa  Ferri 
Carbonatis] ,  of  which  the  dose  is  5  to  15  gr.  three  times  a  day, 
each  5-gr.  pill  containing  1  gr.  of  ferrous  carbonate.  When  cos- 
tiveness  is  a  troublesome  symptom,  and  Blaud's  pill  is  being  used, 
one  may  add  aloes  or  nux  vomica  or  both,  as  in  the  following  pre- 
scription :  R.  Extracti  Nucis  Vomicae,  gr.  J;  Ferri  Sulphatis 
Exsiccati,  gr.  1 ;  Extracti  Aloes  Barbadensis,  gr.  1 ;  Extracti 
Glycyrrhizje,  gr.  1;  Glucosi  Liquidi,  gr.  J ;  Misce,  fiat  pilula. 
Dose,  one  or  two  such  pills  twice  or  three  times  a  day  as 
directed. 

Carbonate  of  soda  may  be  incorporated  in  the  above  pill  if 
required. 

If  there  is  much  tendency  to  gastric  disturbances  in  spite  of  rest 
in  bed  it  may  be  wise  to  add  some  carminative  to  the  medicine  so 
that  the  prescription  might  read  as  follows :  R .  Tincturse  Ferri 
Perchloridi,  ttil2  ;  Glycerini,  5 £  ;  Tincturaa  Cardamomi  Cornpositae, 
5^;  Aquam,  ad  5]  [U.S.P.  1^.  Tincturae  Ferri  Chloridi,  nt9; 


24  Chlorosis. 

Glycerin!,  5^ ;  Tincturae  Cardamomi  Composite,  5^;  Aquam,  ad 
53] .  Dose,  one  to  two  tablespoonfuls  thrice  or  four  times  daily ; 
or,  R.  Ferri  Sulphatis,  gr.  4  ;  Sodii  Bicarbonatis,  gr.  15  ;  Tincturae 
Zingiberis,  rn,20 ;  Magnesii  Sulphatis,  53 ;  Syrupi,  5j ;  Aquam 
Chloroformi,  ad  jj  [U.S.P.  1^.  Ferri  Sulphatis,  gr.  4;  Sodii 
Bicarbonatis,  gr,  15  ;  Tincturae  Zingiberis,  111 10  ;  Magnesii  Sul- 
phatis, 5j ;  Syrupi,  5J ;  Aquae  Chloroformi,  §£;  Aquam,  ad  5]] . 
Dose,  two  tablespoonfuls  two  or  three  times  daily. 

The  amount  of  saline  laxative  will  naturally  be  varied  according 
to  circumstances,  and  it  is  wise  to  reduce  it  to  a  minimum. 

Keduced  iron  (ferrum  redactum),  of  which  the  dose  is  from  1  to 
15  gr.,  needs  to  be  freshly  prepared,  because  it  readily  oxidises, 
particularly  in  the  presence  of  any  damp  ;  it  is  held  by  some,  how- 
ever, that  it  is  more  efficacious  than  are  the  more  saturated  salts  of 
iron,  partly,  perhaps,  because  it  contains  a  large  percentage  of  iron 
in  small  bulk.  It  is  tasteless,  and  it  is  generally  prescribed  in  the 
form  of  lozenges  containing  1  gr.  of  reduced  iron  in  each  with 
a  simple  basis. 

Scale  Preparations. — To  write  all  the  various  prescriptions 
that  have  yielded  good  results  in  the  treatment  of  chlorosis  will 
be  to  overfill  the  space  allotted  to  this  article.  In  actual  practice 
it  will  be  found  that,  provided  the  patient  is  kept  in  bed,  one  or 
other  of  the  above  prescriptions  will  be  suitable  in  a  large  propor- 
tion of  cases.  Should  none  of  them  be  found  tolerable,  however, 
the  next  step  would  probably  be  to  employ  a  milder  form  of  iron, 
particularly  one  of  the  scale  preparations  (ferrum  tartaratum,  ferri 
et  ammonii  citras,  and  ferri  et  quinines  citras),  the  dose  of  all  of 
which  is  from  5  to  10  gr.  Unfortunately,  although  these  are  much 
better  borne  than  the  stronger  preparations  already  mentioned, 
they  are  generally  much  less  effective  in  the  cure  of  the  disease.  It 
may  be  necessary  to  resort  to  them,  however,  when  the  patient  is 
first  put  to  bed  until  as  time  goes  on  it  is  found  that  the  scale 
preparations  can  be  changed  in  a  week  or  ten  days  for  the  carbo- 
nate, the  sulphate  or  the  perchloride.  It  is  not  at  all  unusual  to 
prescribe  small  doses  of  arsenic  at  the  same  time,  as  in  the  follow- 
ing prescription :  1^.  Liquoris  Arsenicalis,  ir|,2;  Ferri  et  Ammonii 
Citratis,  gr.  10  ;  Syrupi,  5^  ;  Aquam  Anethi,  ad  §|.  Dose,  one 
tablespoonful  thrice  daily  after  food. 

Organic  Iron  Compounds. — There  are  a  very  large  number  of 
organic  iron  compounds  upon  the  market,  many  of  which  are 
decidedly  beneficial,  though  seldom  more  so  than  are  the  ordinary 
iron  compounds  when  the  latter  can  be  borne.  It  is  not  possible, 
for  obvious  reasons,  to  give  the  names  of  the  various  proprietary 


Chlorosis.  25 

compounds  of  iron  that  may  be  found  of  use  in  certain  cases  when 
any  particular  circumstances  render  the  inorganic  salts  ineligible. 
Preparations  from  eggs,  from  haemoglobin,  compounds  of  iron  with 
albumin,  with  meat  extract,  with  peptone,  with  somatose,  with 
glidine,  are  widely  advertised ;  one  can  only  say  that  the  form  of 
iron  employed  in  any  given  case  is  of  much  less  importance  than 
that  some  form  should  be  given.  One  might  mention,  in  particular, 
however,  that  "there  are  various  compounds  termed  "alginates," 
derived  directly  or  indirectly  from  seaweed,  and  that  the  iron  salt, 
alginate  of  iron,  which  may  be  prescribed  as  such,  but  which  is  also 
obtainable  in  a  proprietary  form,  seem  to  have  certain  advantages, 
of  which  the  chief  are  that  it  is  a  tasteless  powder,  that  it  is  not 
soluble  in  acids  and  therefore  does  not  have  any  action  on  the 
stomach,  being  only  dissolved  when  it  reaches  the  small  intestine, 
that  it  does  not  cause  constipation,  and  that  it  can  be  taken  when 
dyspeptic  symptoms  are  already  present  in  the  case  without 
increasing  that  dyspepsia.  The  dose  is  from  5  to  10  gr.,  and  it  is 
prescribed  preferably  in  cachets. 

Iron  Wines. — Two  other  and  entirely  different  ways  in  which 
iron  may  be  utilised  in  chlorosis  are  first  in  the  form  of  wine, 
whether  natural  or  artificial,  and  secondly,  as  a  mineral  water, 
either  in  bottle  or  at  a  spa.  There  are  two  wines  containing  iron 
in  the  British  Pharmacopoeia,  namely,  steel  wine,  or  vinum  ferri, 
which  is  a  solution  of  iron  wire  in  sherry,  the  strength  being  1  part 
in  20,  and  the  dose  1  to  4  fluid  drachms ;  the  other  is  vinum  ferri 
citratis,  1  gr.  of  iron  and  ammonium  citrate  being  dissolved  in  each 
fluid  drachm  of  orange  wine,  the  dose  being  from  1  to  4  drachms. 
It  will  depend  to  a  considerable  extent  upon  the  general  views  both 
of  the  patient,  of  her  parents  and  friends,  and  of  the  medical  atten- 
dant himself,  upon  the  whole  question  of  alcohol  whether  any  wine 
of  this  kind  should  be  used  or  not ;  upon  the  whole,  however,  the 
tendency  nowadays  is  not  to  prescribe  alcoholic  preparations  when 
others  will  do  as  well  and  steel  wine  is  g9ing  out  of  fashion ;  if  any 
wine  were  ordered  at  all  it  would  more  likely  take  the  form  of  a 
product  of  grapes  that  have  been  grown  upon  ferruginous  soil, 
particularly  certain  forms  of  Chianti  or  else  a  Burgundy  from  certain 
Australian  vineyards.  There  are  not  a  few  proprietary  remedies  of 
repute  in  which  iron  wine  is  combined  with  various  meat  extracts 
or  other  products. 

Chalybeate  "Waters  and  Spas. — As  regards  chalybeate  waters 
there  are  large  numbers  obtainable  in  bottle,  but  there  is  no 
particular  advantage  in  any  of  them  over  the  making  of  iron 
water  for  oneself ;  a  series  of  clear  glass  wine  bottles  filled  with 


26  Chlorosis. 

water,  and  a  rusty  nail  dropped  into  each,  will  make  an  iron 
mineral  water  at  home  which  is  quite  as  beneficial  as  any  water 
bottled  at  a  spa. 

There  are  many  natural  waters  that  contain  iron  either  in 
solution  or  in  suspension,  and  in  many  parts  of  the  British  Islands 
the  rusty  deposits  upon  the  stones  near  little  springs  that  have  no 
name  indicate  the  ferruginous  strata  from  which  they  come  ;  any 
of  these  are  beneficial  in  chlorotic  cases  if  uncontaminated  in  other 
respects.  The  three  best  known  chalybeate  watering-places  in 
Great  Britain  are  Harrogate,  Tunbridge  Wells  and  Woodhall  Spa, 
whilst  of  those  upon  the  Continent  the  most  familiar  are  perhaps 
St.  Moritz  and  Tarasp,  in  Switzerland,  Spa,  in  Belgium,  Homburg 
and  Schwalbach,  in  Germany,  Marienbad,  in  Bohemia,  and  Levico, 
in  Austria.  The  richest  of  all  these  in  iron  is  that  at  Levico,  whilst 
the  water  there  has  the  additional  advantage  of  containing  small 
quantities  of  arsenic  as  well.  As  a  general  rule  it  is  unusual  to 
take  a  patient  suffering  from  severe  chlorosis  to  a  spa,  because  a 
cure  is  so  readily  obtainable  without  this  if  only  the  patient  is  put 
to  bed ;  it  is  more  common  to  adopt  spa  treatment  for  anaemia 
due  to  other  causes,  such  for  instance  as  prolonged  and  delayed 
convalescence  after  some  serious  illness,  blood  loss,  and  so  forth. 
The  choice  of  a  spa  will  depend  largely  upon  the  circumstances  of 
each  individual  case ;  it  is  unwise  to  take  anaemic  patients  suddenly 
to  any  high  altitude,  so  that  whereas  St.  Moritz  (5,820  feet)  and 
Tarasp  (3,996  feet)  are  very  beneficial  as  places  for  the  completion 
of  a  cure,  Schwalbach  (1,042  feet)  is  much  better  to  begin  with. 
No  spa  treatment  is  really  advisable  in  these  cases  in  the  cold 
months  of  the  autumn,  winter  or  early  spring. 

Baths. — Those  who  are  strong  advocates  of  water  cures  advise 
carbonic  acid  baths,  sweat  baths,  wet  and  dry  rubbings  and  all 
the  various  douches  which  are  so  much  in  vogue,  but  none  of 
these  are  essential  to  the  successful  cure  of  chlorosis,  and  it 
is  very  probable  that  they  might  do  harm  in  the  treatment  of 
the  earlier  stages  of  a  severe  case  when  rest  is  so  essential. 
Later,  the  change  of  surroundings,  the  open-air  and  sunshine  are 
probably  much  more  curative  than  are  the  baths  themselves. 

Drugs  other  than  Iron. — Arsenic  is  so  valuable  in  many 
cases  of  severe  anaemia,  especially  pernicious  anaemia,  that  it 
is  surprising  that  it  is  of  such  relatively  little  value  in  chlorosis ; 
administered  without  iron  it  does  little  good,  but  many  observers 
hold  that  small  doses  of  the  liquor  arsenicalis  are  beneficial  when 
given  along  with  iron,  as  in  the  prescription  on  p.  24. 

Quinine   is   favoured   by  some   authorities.      It   may   be   given 


Chlorosis.  27 

combined  with  iron  in  the  scale  preparation  (iron  and  quinine 
citrate)  or  it  may  be  prescribed  in  small  doses  of  the  tincture  along 
with  whatever  liquid  form  of  iron  is  being  used.  During  late 
convalescence  it  may  be  prescribed  simply  as  a  tonic. 

Sulphur  is  administered  most  conveniently  in  cachets,  and 
although  it  is  not  easy  to  be  sure  how  it  acts  there  can  be  little 
doubt  that  it  is  beneficial  in  many  cases.  Sublimed  sulphur  may 
be  given  in  5  to  10  gr.  doses  twice  or  three  times  daily,  or  what  is 
perhaps  a  commoner  way  of  prescribing  the  remedy,  a  teaspoonful 
or  more  may  be  ordered  once  or  twice  a  week  either  in  cachets  or 
stirred  up  with  some  soft  foodstuff  with  which  it  can  be  readily 
swallowed.  Sulphur  seems  to  do  most  good  in  cases  in  which 
there  is  a  marked  tendency  to  constipation,  though  by  itself  it 
seldom  if  ever  cures  that  tendency. 

Manganese,  or  combinations  of  manganese  and  iron  with  peptone 
or  other  albuminoid  bases,  has  been  advocated  by  some  authorities, 
but  in  practice  there  is  little  advantage  in  this  treatment  over  that 
more  generally  followed.  The  same  applies  to  other  remedies 
which  have  been  advocated  from  time  to  time,  such  for  instance  as 
periodic  inhalation  of  oxygen ;  oral  administration  of  chloride  of 
gold  and  sodium  (auri  et  sodii  chloridi,  U.S.P.),  in  doses  of  about 
^  gr. ;  small  venesections ;  and  compressed  air  baths.  The 
patient  may  become  completely  well  when  any  or  all  of  these 
are  being  adopted,  but  there  is  really  little  to  indicate  that  they 
accelerate  the  cure. 

Digitalis  is  recommended  by  some  authorities  when  there  is 
considerable  shortness  of  breath  on  exertion  or  when  the  tendency 
to  O3clema  of  the  legs  is  considerable.  It  seldom  happens,  however, 
that  the  cardiac  symptoms  are  not  immediately  relieved  by  rest  in 
bed,  and  the  use  of  digitalis  as  a  means  of  stimulating  the  heart  to 
more  work  in  order  to  obviate  the  necessity  for  the  patient 
going  to  bed  is  erroneous  treatment  for  the  chlorosis  itself. 

Theocin-sodium  acetate  has  been  recommended  recently  in  a 
similar  way,  with  the  idea  of  expelling  the  surplus  of  water  from 
the  blood  ;  water  is  removed  by  the  bowel  at  the  same  time  by 
giving  suitable  doses  of  magnesium  and  sodium  sulphate.  Theocin- 
sodium  acetate  is  prescribed  in  5  gr.  doses  four  times  a  day, 
together  with  5  min.  of  tincture  of  digitalis  in  each  dose.  Patients 
undoubtedly  recover  under  this  treatment,  but  it  is  questionable 
whether  they  would  not  do  so  just  as  wrell  with  simple  rest  in  bed, 
good  diet  and  sunny  surroundings. 

Emetics,  such  as  zinc  sulphate  or  large  doses  of  ferrous  sulphate, 
have  been  highly  recommended  by  some,  emesis  being  produced 


28  Chlorosis. 

once  a  day  or  every  other  day,  generally  in  the  morning  ;  there  are 
some  instances  in  which  chlorosis,  having  obstinately  refused  to 
improve  upon  other  lines  of  treatment,  has  readily  got  better  when 
the  dose  of  iron  sulphate  reached  the  vomiting  point,  so  that  little 
if  any  of  it  passed  on  into  the  intestines. 

Restriction  of  common  salt  is  a  line  of  treatment  that  has  been 
adopted  by  those  who  regard  fluid  retention  and  hydrsemia  as 
an  important  part  of  the  pathology  of  chlorosis  and  think  that 
such  retention  may  be  due  to  difficulty  in  the  elimination  of  sodium 
chloride,  as  it  is  in  some  cases  of  nephritis.  Observers  who  hold 
this  view  restrict  the  amount  of  common  salt  used  both  in 
cooking  and  upon  the  patient's  plate  as  much  as  possible.  There 
is  little,  however,  to  show  that  this  is  necessary. 

Intestinal  antiseptics,  such  as  glycerine  of  carbolic  acid  in  5  min. 
doses,  beta-naphthol  in  10  gr.  doses,  creosote  in  1  min.  doses  in 
keratin-coated  capsules  to  ensure  it  not  being  liberated  until  it  has 
passed  on  into  the  intestines,  sodium  sulpho-carbolate  in  10  to  20 
gr.  doses,  and  various  brands  of  lactic  acid  producing  bacilli  or 
their  products,  have  been  prescribed  from  time  to  time  in  cases  of 
chlorosis  by  those  who  consider  constipation  and  hypothetical 
decomposition  in  the  bowel  to  be  an  essential  part  in  the  pathology 
of  the  complaint.  Some  patients  have  received  actual  harm  from 
advertised  bacillary- products,  but  upon  the  whole,  when  suitable 
care  is  adopted  in  prescribing  these  or  the  intestinal  antiseptics,  a 
certain  amount  of  benefit  has  accrued  in  many  cases. 

Bismuth  salts;  bicarbonate  of  soda;  carminatives,  such  as  ginger, 
peppermint,  dill ;  bitters,  such  as  gentian  ;  acids,  such  as  dilute 
hydrochloric,  nitro-hydrochloric,  or  sulphuric,  with  small  doses  of 
nux  vomica,  pepsin  or  extract  of  malt ;  and  perhaps  in  severe  cases 
of  gastric  disturbance  liquor  morphinse  hydrochloridi  along  with 
bismuth,  to  alleviate  the  epigastric  pain,  nausea  or  vomiting,  have 
all  been  used  when  it  has  been  necessary  for  monetary  or  other 
reasons  for  the  patient  to  remain  at  her  work  instead  of  going  to 
bed ;  but  by  far  the  best  remedy  for  the  gastric  symptoms  is  absolute 
rest  in  bed. 

Diet. — Many  patients  suffering  from  chlorosis  complain  of 
inability  to  take  ordinary  diet.  Often  indeed,  for  fear  of  getting 
fat,  the  anfemic  but  relatively  plump  chlorotic  girl  has  purposely 
been  refraining  from  food  as  far  as  possible,  and  has  even  tried  the 
raw  rice  and  lemon  juice  treatment  which  is  popular  from  the  point 
of  view  of  weight  reduction.  Sooner  or  later  a  stage  is  reached  at 
which  if  work  still  has  to  be  done,  nausea  and  not  infrequently 
actual  vomiting  of  food  supervenes,  and  not  a  few  cases  ,of  chlorosis 


Chlorosis.  29 

suffer  from  severe  pains  in  the  upper  part  of  the  abdomen,  inability 
to  keep  anything  down,  and  even  haematemesis,  so  that  a  diagnosis 
of  gastric  ulcer  may  be  suggested  when  really  no  actual  macro- 
scopic ulcer  is  present.  The  reason  for  the  gastric  symptoms  in 
these  cases  would  seem  to  be  cardiac  dilatation,  for  within  twenty- 
four  or  thirty-six  hours'  of  putting  such  a  case  to  bed  and  allowing 
the  heart  to  recover  its  tone,  the  diet  can  nearly  always  be  increased 
readily  until  within  a  day  or  two  ordinary  food  is  being  taken. 
It  is  important  that  full  diet  should  be  resumed  as  soon  as  it  is 
possible,  the  patient  having  the  ordinary  three  main  meals  a  day, 
and  meat  with  at  least  one  of  them.  Considerable  stress  has  been 
laid  by  some  observers  upon  the  particular  need  of  giving  such 
foodstuffs  as  are  relatively  rich  in  iron,  but  the  best  results  are 
obtained  not  by  being  guided  by  the  chemical  analyses  of  the  foods 
but  by  the  inclinations  of  the  patient,  provided  they  are  limited  to 
the  ordinary  plain  foodstuffs.  Bread,  toast,  butter,  jam,  marma- 
lade, eggs,  milk,  tea,  coffee,  cocoa,  fish,  whether  boiled  or  fried, 
potatoes,  peas,  beans,  cabbage,  cauliflower,  spinach,  butcher's  meat, 
puddings  made  witli  rice,  tapioca,  cornflour,  wheatflour,  stewed  fruits 
or  fresh  fruits  of  all  kinds — all  these  may  be  allowed.  Some 
observers  would  limit  the  liquids  taken  whilst  others  would  rather 
increase  them  with  a  view  to  diminishing  the  tendency  to  constipa- 
tion. The  best  line  of  treatment  to  aim  at  as  regards  diet  would  be 
that  though  resting  in  bed  the  chlorotic  girl  should  eat  the  same 
kind  of  foods  and  in  nearly  the  same  quantities  as  would  a  healthy 
girl  who  is  up  and  about.  It  may  be  necessary  to  assist  the 
digestion  in  the  earlier  stages  of  chlorosis  by  giving  extract  of  malt 
and  iron,  or  dilute  hydrochloric  acid  and  pepsin,  but  in  the  great 
majority  of  cases  it  is  surprising  how  little  carminative  medicines 
and  still  less  bismuth  or  morphia  are  required  even  in  severe 
chlorosis,  provided  the  patient  is  strictly  confined  to  bed.  Directly 
such  patients  get  up,  however,  unless  the  blood  condition  has 
returned  to  normal,  as  will  seldom  be  the  case  in  less  than  four  to 
six  weeks,  there  will  be  immediate  recurrence  of  the  epigastric  pain, 
the  nausea  and  the  vomiting,  when  physical  exertion  is  resorted  to 
and  the  heart  again  becomes  dilated.  The  best  treatment  for  the 
gastric  symptoms  of  chlorosis  is  to  minimise  the  work  of  the 
heart. 

Constipation. — Most  cases  of  chlorosis  are  very  constipated. 
This  constipation  is  very  difficult  to  relieve,  particularly  during  the 
time  the  patient  is  of  necessity  confined  to  bed  whilst  the  blood 
condition  is  being  restored  to  normal.  The  remedy  employed  must 
be  chosen  upon  the  merits  of  each  individual  case.  It  is  very 


30  Chlorosis. 

important  indeed,  however,  to  avoid  over-stimulating  the  bowel, 
for  it  is  to  so  doing  at  the  age  when  chlorosis  is  common  that  much 
of  the  severe  constipation  of  later  years  is  due.  The  commonest 
cause  of  constipation  in  middle  life  is  the  abuse  of  purgatives  when 
younger.  Bearing  this  fact  in  mind,  the  careful  physician  will 
rather  allow  his  patient  to  be  constipated  when  in  bed  than  adopt 
drastic  measures  for  the  opening  of  the  bowels.  It  is  most  unwise 
to  prescribe  calomel,  or  repeated  doses  of  castor  oil  or  increasing 
quantities  of  cascara  sagrada.  It  may  be  necessary  to  order 
minimum  doses  of  nux  vomica  and  aloes,  as  in  the  pill  prescribed 
on  p.  23  ;  magnesium  or  sodium  sulphate  may  be  incorporated  in 
minimum  quantities  in  the  iron  mixture  that  is  ordered  ;  but  wiser 
than  either  of  these  is  the  exhibition  of  suitable  quantities  of  fresh  or 
uncooked  fruits,  no  limitation  to  the  amount  of  simple  fluids  taken, 
an  avoidance  of  undue  anxiety  when  the  bowels  have  not  been 
opened  by  themselves  for  a  day  or  two,  and  if  the  constipation  is 
persistent  the  use  of  a  simple  soap  enema  every  third  day  instead 
of  the  prescription  of  purgatives  by  the  mouth.  When  in  six  or 
eight  weeks  time  the  chlorosis  itself  has  been  cured  and  the  patient 
is  again  up  and  about  the  most  important  point  in  the  treatment  of 
the  tendency  to  constipation  is  that  the  patient  should  each  day  try 
hard  at  the  water-closet  to  have  the  bowels  moved  at  a  fixed  time, 
until  with  the  constant  repetition  of  the  effort  daily  regularity  of 
the  colon  is  restored  within  a  few  months  and  constipation  ceases 
to  exist.  Every  time  an  active  purgative  is  prescribed  in  such  a 
case  the  re-education  of  the  colon  is  delayed. 

General  Hygiene. — There  may  be  many  small  points  about 
the  patient  which  may  not  be  normal  and  which  may  require 
treatment  simultaneously  with  the  cure  of  the  chlorosis.  Carious 
teeth,  for  example,  should  be  stopped  or  removed  ;  the  mouth 
should  be  kept  clean  with  a  tooth  brush  and  suitable  tooth  powder 
or  mouth  wash.  For  the  prevention  of  a  recurrence  of  chlorosis 
after  a  cure  it  is  most  important  that  the  patient  should  spend  as 
much  of  each  day  in  the  fresh  air  and  sunshine  as  possible,  and 
that  at  night  she  should  sleep  in  a  room  with  the  windows  open 
wide  and  with  as  much  fresh  air  entering  the  room  as  may  be.  It 
is  often  advisable  to  prescribe  a  morning  bath,  hot  or  cold  as  the 
case  may  be,  something  stimulating,  perhaps,  being  added  to  the 
water,  such  as  an  ammonia  preparation  or  the  like.  Over-fatigue 
is  to  be  avoided  and  ample  time  should  be  allowed  for  meals,  and 
upon  the  least  indication  of  a  return  of  the  chlorosis  iron  in  some 
form  or  other  should  be  prescribed,  and  the  patient  should  have  a 
daily  rest  in  addition  to  that  which  she  has  in  bed  at  night.  Iron 


Chlorosis.  31 

given  continuously  loses  its  effect,  but  given  intermittently  it  will 
often  prevent  a  relapse. 

(Edema  of  the  legs  may  show  a  tendency  to  persist  even  when 
the  chlorosis  itself  is  better  ;  in  such  cases  much  benefit  is  to  be 
expected  from  upward  rubbing  from  the  feet  towards  the  knees, 
preferably  by  somebody  who  understands  massage.  It  may  also  be 
a  comfort  in  such  cases  to  have  a  woollen  woven  elastic  bandage 
that  can  be  wound  smoothly  on  to  the  foot  and  leg  in  the  morning 
as  a  support. 

Marriage. — The  question  of  whether  or  not  a  chlorotic  girl 
should  marry  often  arises.  It  would  always  be  wiser  for  the 
patient  to  undergo  a  course  of  treatment  in  order  if  possible  to 
cure  the  chlorosis  before  marriage  took  place  ;  nevertheless  it  is 
worthy  of  note  that  severe  chlorosis  is  quite  uncommon  after 
marriage,  and  indeed  many  girls  and  young  women  who  have  been 
more  or  less  chlorotic  from  the  age  of  seventeen  upwards,  lose 
their  anaemia  altogether  when  they  marry.  Marriage  indeed, 
though  it  is  not  to  be  advocated  in  a  severe  case  of  chlorosis  until 
the  latter  has  been  relieved  as  far  as  possible  first,  is  in  itself  a  cure 
for  chlorotic  anaemia. 

HERBERT  FRENCH. 


HEMOPHILIA. 

HEMOPHILIA  itself  is  a  congenital  condition  which  we  do  not  know 
how  to  cure.  Nevertheless  a  haemophilic  patient  often  needs 
medical  assistance,  especially  for  the  stopping  of  continuous  bleeding 
from  trivial  wounds.  Treatment  of  such  a  case  resolves  itself  into 
three  parts,  namely,  prophylactic,  that  is  to  say,  the  prevention  of 
scratches  and  cuts;  the  checking  of  active  bleeding,  external, 
internal,  or  both ;  and  the  relief  of  the  profound  anaemia  that  may 
result  if  blood  loss  continues  in  spite  of  efforts  to  check  it. 

Prophylactic  measures  are  obvious  ;  no  pins,  buckles,  or  similar 
sharp  or  angular  bodies  should  be  permitted  in  the  clothing ;  no 
pocket  knife  should  be  allowed ;  teeth  should  not  be  extracted, 
the  milk  teeth  being  allowed  to  come  out  by  themselves,  whilst 
the  permanent  teeth  should  be  inspected  regularly,  and  if  need 
be  stopped  sufficiently  early  to  obviate  any  need  for  extraction  ; 
the  household  furniture  should  be  kept  free  from  projecting  nail 
ends,  tin-tacks,  splinters,  and  so  on.  The  lad  is  almost  certain 
to  scratch,  cut  or  lacerate  himself  sooner  or  later  by  some  accident, 
but  the  kind  of  precautions  that  can  be  taken  to  minimise  the  risk 
are  obvious. 

Should  some  scratch  or  cut  occur  in  spite  of  precautions  to  prevent 
it,  the  patient  has  sometimes  bled  to  death  in  spite  of  every  effort  to 
stop  the  steady  oozing.  The  chief  lines  of  treatment  that  may  be 
adopted  are  as  follows  : 

The  Encouragement  of  Coagulation  locally. — The  best  way  of 
accomplishing  this  in  some  cases  is  to  tease  out  sterile  cotton-wool 
into  the  finest  possible  fluff  and  to  apply  this  lightly  over  the  bleeding 
surface,  renewing  the  fluff  as  fast  as  it  is  saturated  with  blood,  but 
not  displacing  any  clot  that  may  become  attached  to  the  skin.  The 
object  of  the  cotton-wool  fluff  is  the  same  as  that  of  the  bundle  of 
twigs  used  to  whip  blood  in  making  fibrin,  the  greater  the  number 
of  foreign  particles  in  contact  with  shed  blood  the  greater  is  its 
tendency  to  clot.  Cobwebs  act  in  the  same  way,  but  there  is  the 
risk  of  their  being  dangerously  septic.  Matico  leaves  (B.P.,  1885) 
used  to  be  employed  for  the  same  purpose,  on  account  of  the 
numerous  hairs  on  their  under-surfaces. 

Styptics  may  also  be  applied,  especially  per-salts  of  iron,  of  which 
the  perchloride  is  perhaps  the  best.  The  liquor  perchloridi  (B.P.) 


Haemophilia.  33 

may  suffice,  but  more  often  the  liquor  ferri  perchloridi  fortis  (B.P.) 
[U.S. P.  liquor  ferri  chloridi]  is  employed  either  as  it  is  or  diluted 
with  a  little  plain  water.  The  liquor  ferri  persulphatis  (B.P.) 
[U.S. P.  liquor  ferri  tersulphatis]  is  also  very  astringent.  Lead 
salts  are  less  often  used  because  there  is  some  danger  of  undue 
absorption ;  the  liquor  plurnbi  subacetatis  fortis  (B.P.)  [U.S. P. 
liquor  plumbi  subacetatis]  is  a  very  astringent  preparation,  but 
it  is  strong  enough  to  irritate  the  skin  at  the  same  time.  Copper 
sulphate  is  another  styptic  ;  it  may  be  applied  directly  as  powdered 
crystals,  or  in  solution,  but  it  is  not  often  employed.  Hama- 
melis  and  tannic  acid  are  the  best  known  vegetable  styptics  :  1  part 
of  either  the  tinctura  or  the  liquor  hamamelidis  may  be  diluted 
with  anything  up  to  20  parts  of  water,  or  tannic  acid  powder  may  be 
applied  as  such. 

Local  vaso-constriction  may  be  used  as  a  means  of  lessening 
the  bleeding,  the  most  powerful  vase-constrictor  being  adrenalin 
chloride,  which  may  be  applied  in  a  sterile  solution  of  a  strength  of 
1  in  1,000,  either  by  means  of  a  brush  or  on  lint  or  cotton-wool. 
Its  effect  does  not  last  long,  but  the  immediate  blanching  of  the 
bleeding  part  generally  checks  the  oozing  for  the  time  being ;  the 
application  has  to  be  repeated  at  short  intervals.  The  simultaneous 
use  of  adrenalin  chloride  and  of  strong  solution  of  perchloride  of 
iron  may  effectually  stop  the  bleeding. 

Ergot  as  a  local  application,  or  liquid  extract  of  ergot  by  the 
mouth;  or  injectio  ergotse  hypodermica  (B.P.),  or  subcutaneous 
administration  of  ergotine  or  ergotinine,  are  all  useless  in 
haemophilia. 

Extreme  cold  applied  locally  by  means  of  ice,  or  ethyl-chloride 
spray,  may  assist  materially  in  checking  bleeding  from  a  superficial 
cut,  but  it  is  difficult  to  continue  the  cold  application  long  enough 
to  prevent  recurrence  of  the  oozing  when  the  part  is  allowed  to  get 
warm  again. 

Local  pressure  naturally  suggests  itself  as  another  line  of 
treatment ;  the  trouble  is  that  it  is  very  difficult  to  apply  sufficient 
pressure  continuously  to  the  skin  in  one  spot  without  causing  the 
patient  unbearable  discomfort,  and  possibly  risking  local  gangrene. 
When  it  is  a  tooth  socket  that  is  bleeding  the  gum  may  be  blanched 
with  adrenalin  chloride  solution,  1  in  1,000,  and  then  the  cavity 
can  sometimes  be  packed  with  wool  rapidly  but  firmly,  and  the  latter 
covered  over  with  a  rubber  dressing  that  may  serve  to  prevent  further 
bleeding ;  but  it  is  astoundingly  difficult  sometimes  to  check  the 
oozing  even  in  this  way.  Other  surgical  measures  have  often  proved 
successful.  Notwithstanding  the  risk  of  further  bleeding,  the 

S.T. — VOL.  n.  3 


34  Haemophilia. 

superficial  vessels  above  and  below  the  bleeding  point  have  sometimes 
teen  underrun  with  needles  and  the  oozing  checked  by  silk  liga- 
tures passing  figure-of-eight- wise  over  the  skin  between  the  pro- 
jecting ends  of  the  needles;  in  desperate  cases  use  has  been  made 
of  the  curious  fact  that  whereas  small  cuts  in  haemophilics  often 
ooze  excessively,  deep  incisions  sometimes  bleed  but  little  more  than 
they  do  in  healthy  persons  ;  a  scalpel  has  been  used  to  convert  a 
scratch  or  superficial  cut  into  a  decided  incision  that  can  then  be 
either  packed  and  firmly  bandaged,  or  even  in  some  cases  successfully 
stitched  up. 

The  actual  cautery  has  been  resorted  to  sometimes,  and  occasionally 
with  success. 

Internal  remedies  for  the  relief  of  the  bleeding  will  certainly 
be  tried,  but  none  of  them  has  any  proven  value.  Calcium  chloride 
will  probably  be  given  in  doses  varying  from  5  to  60  gr.  twice,  thrice 
or  four  times  daily.  This  salt  has  a  very  nauseous  taste,  but  it 
cannot  be  given  in  cachet  because  it  is  so  deliquescent.  It  may  be 
made  up  in  gelatin-coated  capsules,  or  it  may  be  prescribed  with 
syrup  of  lemon,  as  in  the  following  mixture  :  1^ .  Calcii  Chloridi, 
gr.10;  Syrupi  Limonis,  5Jss  ;  Mucilaginis  Simplicis,  5ij  ;  Aquam 
Chloroformi,  ad.  jj  [U.S.P.  1^.  Calcii  Chloridi,  gr.  10;  Syrupi 
Acidi  Citrici,  5jss  :  Mucilaginis  Acaciae,  51]  ;  Aquae  Chloroformi,  §ss  ; 
Aquam,  ad  ^j] .  Dose,  two  tablespoonfuls  two-hourly.  It  is 
given  with  the  object  of  increasing  the  coagulability  of  the  blood, 
but  it  is  very  doubtful  whether  it  really  does  any  good. 

.Calcium  lactate  is  an  alternative  which  may  be  given  in  simple 
suspension  or  in  cachets  in  doses  of  10  to  60  gr.  several  times  a 
day.  Calcium  iodide  is  preferred  by  some ;  it  is  deliquescent  and 
has  a  bitter  taste,  but  it  can  be  taken  in  doses  of  from  1  to  5  gr. 
in  the  form  of  a  mixture  containing  simple  syrup  and  water : 
1^,  Calcii  lodidi,  gr.  5;  Syrupi  Simplicis,  5ij  ;  Aquam  Chloroformi, 
ad  ;y.  [U.S.P.  1^.  Calcii  lodidi,  gr.  5  ;  Syrupi,  5ij ;  Aquae  Chloro- 
formi, 388  ;  Aquam,  ad  gjj .  Dose,  two  tablespoonfuls  as  often  as 
directed. 

Oil  of  turpentine  has  been  used  for  internal  administration  in 
some  cases,  but  there  would  seem  to  be  some  danger  in  this  because 
haematuria  may  occur  spontaneously  in  haemophilics,  and  there- 
fore turpentine  would  perhaps  be  unduly  prone  to  affect  the 
kidneys. 

Gelatine  injected  subcutaneously  has  been  used  to  increase  the 
coagulability  of  the  blood  in  other  maladies,  notably  in  cases  of 
aortic  aneurysm  ;  but  it  is  scarcely  admissible  in  a  haemophilic  on 
account  of  the  extreme  probability  that  the  injection  itself  would 


Haemophilia.  35 

cause  extensive  local  bleeding.     The  administration  of  gelatine  by  the 
mouth  does  not  answer  the  same  purpose. 

Some  observers  have  advocated  injecting  serum  from  animals, 
such  as  the  horse,  or  even  fresh  human  serum,  intravenously,  with 
the  idea  of  supplying  some  factor  which  is  deficient  in  the  patient's 
blood ;  but  there  is  a  risk  of  persistent  bleeding  at  the  site  of  the 
injections  themselves,  and  there  is  little  evidence  to  show  they  are 
beneficial. 

When  spontaneous  haemorrhages  occur  they  may  take  place  from 
mucous  membranes — epistaxis,  bleeding  from  the  mouth,  haematuria, 
haemorrhage  per  rectum,  less  often  haematemesis  and  seldom 
haemoptysis  ;  or  they  may  take  the  form  of  subcutaneous  haemato- 
mata,  haemarthrosis,  and  sub-periosteal  haemorrhages.  Treatment 
in  such  cases  is  very  difficult  indeed ;  calcium  salts  will  be  adminis- 
tered by  the  mouth ;  mucous  membranes  that  can  be  reached  will 
be  irrigated  with  adrenalin  solution  or  treated  with  styptics  ;  opium 
or  morphia  by  the  mouth,  not  hypodermically,  may  be  required, 
partly  to  check  internal  haemorrhage,  partly  to  relieve  the  acute 
pain  associated  with  recent  haemorrhage  into  a  joint  or  beneath  a 
periosteum.  Local  applications  of  cold  would  be  better  than  heat 
on  theoretical  grounds,  but  for  the  relief  of  pain  hot  fomentations, 
or  opium  stupes,  may  be  necessitated ;  or  belladonna  liniment  may 
be  applied  under  lint,  cotton-wool,  and  bandage.  If  any  haematoma 
should  suppurate,  as  it  may  do,  it  should  be  fomented  until  it  is  on 
the  verge  of  pointing  before  it  is  incised,  for  the  risk  of  further 
haemorrhage  is  thereby  rendered  far  less  than  it  would  be  if  it  were 
opened  earlier  through  thicker  intervening  tissues. 

Careful  nursing  is  essential,  not  only  on  account  of  the  acuteness 
of  the  pains  at  the  sites  of  recent  internal  haemorrhages,  but  also  in 
order  to  prevent  the  further  bleeding  that  may  result  from  the 
slightest  injury  or  after  any  but  gentle  handling.  Bedsores  may 
readily  form  unless  the  patient  is  kept  clean  and  carefully  attended 
to.  Whilst  taking  care  not  to  injure  any  part,  it  is  at  the  same 
time  important  to  see  that  the  limbs  do  not  lie  in  any  one  position 
so  long  that  contractures  or  other  deformities  unexpectedly  arise. 
The  mouth  should  be  carefully  rinsed  out  with  a  simple  antiseptic 
mouth  wash  several  times  a  day,  particularly  if  blood  clot  forms 
in  it. 

Diet. — The  diet  should  be  as  generous  as  may  be  compatible  with 
the  circumstances  of  any  particular  case.  Haernatemesis  is  fortunately 
rare,  though  when  it  does  occur  feeding  by  the  mouth  may  need  to 
be  changed  for  a  time  to  nutrient  enemata.  The  mouth  may  some- 
times bleed  so  easily  or  become  so  sore  that  no  solid  food  can  be 

3—2 


36  Haemophilia. 

swallowed.  Otherwise  nearly  all  plain  foods  are  permissible,  includ- 
ing cooked  butcher's  meats.  If  anything  is  to  be  avoided,  it  would 
be  such  foods  as  contain  substances  that  might  drain  the  body  of 
calcium,  especially  things  containing  citric  acid,  such  as  lemons. 
The  grounds  for  omitting  these  are  purely  theoretical,  however  ;  in 
practice  all  simple  foodstuffs  are  good  if  the  patient  can  digest  them. 
Iron. — So  anaemic  may  a  ha3mophilic  patient  become  that  active 
treatment  similar  to  that  described  for  acute  haemorrhage  (p.  18) 
may  be  required,  with  the  exception  that  infusion  should  seldom  if 
ever  be  intravenous  or  subcutaneous,  but  should  rather  be  given  by 
the  continuous  rectal  method  from  the  start.  Similarly,  pituitary 
extract  should  be  added  to  the  fluid  that  is  given  per  rectum  instead 
of  being  injected  hypodermically ;  8  c.c.  of  20  per  cent,  solution 
being  employed  instead  of  the  1  c.c.  that  would  be  given  with 
syringe  and  needle.  If  the  patient  survives  the  acute  bleeding,  he 
will  need  treatment  for  his  anaemia.  Best  in  bed,  sunshine,  air, 
good  food,  and  the  absence  of  further  bleedings,  rapidly  lead  to 
restoration  of  the  patient's  colour.  A  month  or  six  weeks  may 
suffice  to  restore  the  red  corpuscles  and  haemoglobin  to  normal, 
particularly  if  small  doses  of  iron  are  given  as  described  under 
chlorosis  (p.  21).  Change  of  air  and  scene  will  complete  the  cure 
of  the  anaemia  if  only  another  haemorrhage  does  not  supervene ;  the 
difficulty  is  that  bleedings  are  very  liable  to  recur,  especially  when 
the  patient  is  subject  to  those  of  the  spontaneous  type  ;  with  each 
successive  drain  of  strength  it  becomes  more  difficult  to  cure  the 
resultant  anaemia  with  iron  and  the  other  remedies  at  our  disposal. 

-HERBERT    FRENCH. 


37 


APLASTIC    ANAEMIA. 

BESIDES  the  so-called  blood  diseases  that  have  distinctive  blood 
changes,  spleno-medullary  and  lymphatic  leukaemia  and  pernicious 
anaemia  and  those  which  have  more  or  less  definite  clinical  signs 
although  they  have  no  pathognomonic  blood  counts,  Hodgkin's 
disease,  lyniphademona,  lymphoma,  pseudo-leukaemia  infantum, 
chloroma,  there  are  a  number  of  severe  anaemias  which  are  as  yet 
difficult  to  classify ;  of  these  some  are  associated  with  decided 
enlargement  of  the  spleen  and  are  therefore  styled  splenic  anaemia 
though  this  group  probably  includes  more  conditions  than  one, 
and  many  such  cases  prove  ultimately  to  have  been  early  stages 
of  cirrhosis  of  the  liver  (Banti's  disease) ;  another  group  is  more 
closely  allied  to  pernicious  anaemia,  but  differs  from  the  latter  in 
that  there  is  little  megalocytic  and  no  megaloblastic  reaction  in  the 
blood,  whilst  post-mortem  examination  reveals  pallor  of  the  marrow 
of  the  long  bones  instead  of  the  redness  that  is  found  in  pernicious 
anaemia.  Such  cases  are  now  differentiated  under  the  title  of 
aplastic  anemia.  It  is  difficult,  however,  to  advise  any  different 
treatment  for  this  malady  to  that  already  described  for  pernicious 
anaemia — rest,  fresh  air,  sunshine,  arsenic,  oxygen  and  as  generous 
a  diet  as  the  patient  can  take.  The  difficulty  is  that  no  details 
are  known  of  the  pathology  of  the  affection,  and  hitherto  it  has 
always  proved  fatal  in  a  comparatively  small  number  of  months. 

HERBERT   FRENCH. 


LEUKAEMIA. 

IN  describing  the  treatment  of  leukaemia  it  will  be  most  convenient 
to  deal  with  the  two  chief  varieties,  viz.  : — spleno-medullary 
leukaemia  (or  myelaemia)  and  lymphatic  leukaemia  separately. 

SPLENO-MEDULLARY  LEUKAEMIA. 

This  form  of  leukaemia  is  characterised  by  great  and  uniform 
enlargement  of  the  spleen  and  by  a  high  degree  of  leukaemia  in 
which  the  number  of  the  granular  leucocytes  may  be  increased  to 
300,000  or  more  in  the  cubic  millimetre  of  blood.  The  character 
and  proportion  of  the  different  varieties  of  leucocytes  is  also  altered  ; 
the  polymorphonuclear  cells  constitute  about  one  half  the  total 
number  and  myelocytes  about  one  third,  while  the  eosinophils  may 
be  increased  up  to  5  or  10  per  cent.  Our  knowledge  of  the 
causation  and  of  the  pathology  of  the  disease  is  still  very  limited, 
and  consequently  treatment  is  largely  empirical  and  based  on  the 
results  of  clinical  experience.  The  beneficial  effect  of  X-rays 
appears  to  be  due  to  their  power  of  breaking  up  the  superabundant 
leucocytes,  and  possibly  also  of  diminishing  the  rapidity  of  their 
formation  and  discharge  into  the  blood- stream.  This  result  is  due 
to  the  development  of  leucolytic  substances  in  the  body  under  the 
influence  of  the  rays.  Both  the  serum  of  an  animal  which  has 
been  treated  by  X-rays  and  the  extract  of  a  spleen  which  has  been 
exposed  to  them  before  removal  when  injected  into  another  animal 
cause  a  reduction  in  the  number  of  leucocytes.  Similar  leucolytic 
substances  have  been  found  to  be  present  in  the  blood  of  patients 
suffering  from  leukaemia  who  were  improving  under  X  -  ray 
treatment. 

General  Treatment. — In  the  more  acute  forms  of  the  disease 
rest  in  bed  is  required  as  long  as  there  is  any  fever.  If  the 
temperature  is  normal  the  patient  may  be  allowed  to  go  about,  but 
it  is  not  advisable  for  him  to  do  any  work  which  can  be  avoided. 
He  is  unfit  for  any  laborious  occupation,  and  he  should  not  be 
exposed  to  the  risk  of  any  injury  to  the  abdomen  in  the  region  of 
the  enlarged  spleen,  as  any  severe  blow  may  cause  rupture  of  its 
capsule  and  fatal  intra-peritoneal  haemorrhage.  Rest  in  the  open 
air,  or  in  an  open  shelter,  is  useful,  and  the  general  level  of  health 
must  be  well  maintained  by  an  ample  but  easily  digested  diet,  any 
excess  being  carefully  avoided. 


Leukaemia.  39 

Medicinal  Treatment. — Arsenic  is  by  far  the  most  useful  drug  in 
the  treatment  of  leukaemia.  Five  minims  of  liquor  arsenicalis 
[U.S. P.  liquor  potassii  arsenitis]  may  be  given  three  times  a  day  after 
meals.  This  dose  should  be  gradually  increased  by  the  addition  of 
1  min.  of  the  liquor  arsenicalis  every  other  day  until  the  limit  of 
toleration  is  reached.  In  some  cases  any  increase  in  the  dose  beyond 

7  or  8  min.  induces  pain  in  the  stomach  or  diarrhoea;   in  others 
large   doses   are   tolerated,  and   in   a  few   cases   the  dose  can  be 
increased  up  to  as  much  as  25  min.  four  times  a  day.     Arsenic 
and  atoxyl  have  been  injected  beneath  the  skin  and  even  directly 
into  the  spleen,  but  no  special  advantage  is  gained  by  this  method 
of    administration.      Under  the   influence   of   arsenic    the    spleen 
decreases  in  size  and  the  number  of  leucocytes   in   the  blood  is 
materially  diminished.     Quinine  and  phosphorus  have  also  been 
used  with   benefit  in    some  cases.     Dr.  J.   H.   Drysdale  obtained 
remarkably   good    results    in    one   case    by  the  administration    of 

8  gr.  of  naphthalene  tetrachloride  every  three  and  later  every  two 
hours. 

X-ray  Treatment.— Undoubtedly  the  regular  application  of 
X-rays  is  (at  the  present  time)  the  most  valuable  means  we  possess 
for  treating  myeloid  leukaemia. 

In  early  cases  the  action  in  reducing  the  size  of  the  spleen  is  very 
marked.  It  becomes  softer  and  more  movable  and  may  return 
almost  if  not  quite  to  its  normal  dimensions,  so  that  it  is  no  longer 
palpable  below  the  left  costal  margin.  The  leucocytes  are  broken 
up,  as  is  shown  by  their  rapid  reduction  in  number  and  by  the 
increase  in  the  amount  of  uric  acid  in  the  urine.  It  is  chiefly 
the  granular  cells  which  are  destroyed,  the  lymphocytes  being 
unaffected.  It  is  probable  that  the  excessive  formation  of  leucocytes 
is  also  held  in  check  by  the  X-rays,  for  experiments  in  animals 
have  shown  that  this  function  of  the  bone  marrow  may  be  arrested 
altogether.  The  effects  of  the  treatment  generally  appear  within  a 
week  or  two,  and  after  a  course  of  two  or  three  months'  treatment 
they  are  well  marked.  The  myelocytes,  eosinophiles  and  mast 
cells  become  reduced  in  numbers,  while  the  polynuclear  neutrophiles 
are  at  first  relatively  increased  in  number.  In  some  cases  the 
blood  -count  may  become  quite  normal. 

I  am  indebted  to  Dr.  A.  E.  Barclay  for  the  following  technical 
details  of  the  treatment  as  it  is  applied  in  the  electrical  department 
of  the  Manchester  Royal  Infirmary.  The  current  is  obtained  from 
a  coil.  At  each  sitting  one  Sabouraud  dose(=  5  Holzknecht  units) 
is  given  through  a  filter  composed  of  four  layers  of  boiler  felt. 
Bather  a  high  vacuum,  about  fi  on  the  Benoist  scale,  is  used.  A 


Leukaemia. 


current  of  1  milliampere  is  passed  through  the  tube.  Each 
application  lasts  about  ten  minutes.  The  rays  are  applied  over 
the  spleen ;  if  the  skin  becomes  red  they  are  applied  over  the  ends 
of  the  long  bones  instead  until  the  redness  disappears.  By  this 
means  dermatitis  is  avoided.  The  treatment  is  generally  given 
twice  a  week,  the  effects  upon  the  blood  being  watched  by  weekly 
blood  counts.  If  the  number  of  leucocytes  diminishes  too  rapidly 
the  treatment  is  given  only  once  a  week  or  even  once  in  a  fortnight. 
It  is  advisable  to  regulate  the  treatment  so  as  gradually  to  reduce 
the  number  of  leucocytes  to  20,000  per  cubic  millimetre  of  the 
blood,  and  then  to  give  one  dose  of  the  X-rays  each  fortnight. 
The  urine  must  also  be  tested  for  albumin  between  each  dose  of 
the  rays.  If  any  albumin  is  found  it  is  an  indication  of  too  rapid  a 
destruction  of  leucocytes,  and  the  dose  must  be  diminished  at  once. 

The  results  of  the  treatment  are  illustrated  by  the  case  of  a  man 
aged  thirty-eight,  who  was  under  my  care  at  the  Manchester  Royal 
Infirmary  for  three  months.  During  this  time  X-ray  treatment  was 
applied  by  Dr.  Barclay  and  arsenic  was  given  as  well  nearly  all  the 
time.  Examination  of  the  blood  by  Dr.  Loveday  on  admission 
showed  per  cubic  millimetre  1,853,000  red  corpuscles  and  96,600 
leucocytes,  58  per  cent,  of  which  were  polymorphonuclear  cells  and 
25  per  cent,  myelocytes.  The  spleen  was  greatly  enlarged,  extending 
below  the  level  of  the  umbilicus  and  across  the  middle  line.  After 
two  months'  treatment  the  red  corpuscles  were  found  by  Dr.  Leech 
to  be  4,856,000  and  the  leucocytes  2,000,  of  which  43  per  cent, 
were  polymorplioneucleas  and  1  per  cent,  myelocytes.  The  spleen 
was  much  diminished  in  size,  but  was  still  easily  to  be  felt, 
extending  well  below  the  left  costal  margin. 

In  the  case  of  a  woman  who  was  also  under  my  care  at  the  Man- 
chester Royal  Infirmary  the  changes  in  the  blood  were  as  follows, 
the  first  examination  being  made  before  the  treatment  by  X-rays  : 


— 

Leucocytes 
per  c.mm. 

Erythrocytes 
per  c.mm. 

Haemoglobin. 

May  30th      . 

212,000 

5,056,000 

66  per  cent. 

June  18th 

68,000 

2,992,000 

56 

July  4th        ... 

34,000 

2,080,000 

48 

Jul/  28th      . 

5,000 

4,320,000 

60        „ 

The  rapid  fall  in  the  number  of  leucocytes  is  clearly  shown.  The 
decrease  in  the  number  of  the  red  blood  corpuscles  and  in  the 
percentage  of  haemoglobin  in  the  earlier  stages  of  the  treatment 
and  their  final  increase  is  also  noteworthy. 


Leukaemia.  41 

After  two  or  three  months  treatment  the  number  of  applications 
may  be  reduced  to  one  or  two  in  a  month.  In  some  cases  the 
improved  condition  persists  for  several  weeks  or  even  months  after 
the  X-ray  treatment  has  ceased.  Dr.  Cabot  mentions  that  he  only 
knows  of  one  case  in  which  the  patient  remained  healthy  for  more 
than  a  year.  It  is  advisable,  therefore,  to  continue  the  treatment 
or  else  a  relapse  will  occur  sooner  or  later.  There  is  as  yet  no 
definite  evidence  that  a  permanent  cure  can  be  established,  but  the 
disease  can  be  held  in  check  and  the  patient  may  enjoy  a  very  fail- 
measure  of  health  for  several  years,  if  the  treatment  is  continued 
at  intervals. 

Partly  owing  to  the  haemorrhagic  tendency  in  this  disease 
removal  of  the  spleen  has  proved  to  be  a  very  dangerous  operation, 
and  even  when  the  immediate  effects  of  the  operation  have  been 
survived  no  appreciable  benefit  to  the  patient  has  accrued. 
Excision  of  the  spleen  is  therefore  useless  and  should  not  be 
attempted. 

LYMPHATIC    LEUKAEMIA. 

In  this  form  of  leukaemia,  which  may  be  either  acute  or  chronic, 
there  is  an  enlargement  of  one  or  more  groups  of  lymphatic  glands, 
the  spleen  is  increased  in  size  and  there  is  an  absolute  and  relative 
increase  in  the  number  of  the  lymphocytes.  The  total  number  of 
leucocytes  may  be  from  100,000  to  200,000  per  cubic  millimetre  of 
the  blood. 

Acute  lymphatic  leukaemia  generally  runs  a  rapid  course  and 
ends  fatally  in  a  few  weeks.  Little  can  be  done  beyond  treating 
symptoms  as  they  arise.  Thus  haemorrhages  from  mucous  surfaces 
can  be  treated  by  the  local  application  of  1  in  1,000  solution  of 
adrenalin  chloride.  No  drug  appears  to  exercise  any  influence 
upon  the  progress  of  the  disease.  The  application  of  X-rays  is  not 
only  useless,  but  in  some  cases  has  appeared  to  be  harmful. 

Chronic  lymphatic  leukaemia  runs  a  more  prolonged  course 
and  considerable  benefit  may  be  derived  from  the  administration  of 
arsenic  in  increasing  doses  in  the  same  manner  as  already 
described  above,  though  it  does  not  prevent  the  ultimate  fatal  ter- 
mination. The  application  of  X-rays  to  the  spleen  and  to  the 
enlarged  lymphatic  glands  produces  very  little  effect  upon  the 
condition  of  the  blood  in  this  form  of  leukaemia,  as  the  rays  do  not 
affect  the  lymphocytes.  The  enlarged  lymphatic  glands  may  be 
reduced  in  size  and  so  may  become  discrete  and  more  movable. 
Occasionally  an  enlarged  gland  may  disappear.  On  the  whole, 
however,  the  results  of  the  X-ray  treatment  are  very  much  less 


42  Pseudo-Leukaemia. 

marked  than  in  myelaemia.    The  application  of  an  ice-bag  over  the 
spleen  may  cause  some  reduction  in  its  size.    Inhalations  of  oxygen 

have  been  found  beneficial  by  some. 

GEORGE  R.  MURRAY. 
KEFERENCES. 

Muir,  E.,  Allbutt  and  Kolleston's  "System  of  Medicine,"  2nd  edit.,  1909, 
Vol.  V.,  p.  825.  Gulland,  G.  L.,  Hutchinson  and  Collier,  "  Index  of  Treatment,'' 
6th  edit.,  1911,  p.  543.  Lazarus.  A.,  "NothnageTs  Encyclopaedia  of  Practical 
Medicine  "  (Diseases  of  the  Blood),  1905,  pp.  613  and  675.  Cabot,  B.  C.,  Osier 
and  Macrae's  "  System  of  Medicine,"  1908,  Vol.  IV.,  p.  672.  Harris,  H.  (Abstract) 
Med.  Chron.,  Manchester,  1909,  XLIV.,  p.  274. 


PSEUDO-LEUKAEMIA. 

THERE  is  not  sufficient  unanimity  of  opinion  as  to  what  disease 
or  symptom  complex  is  meant  when  the  term  "  pseudo-leukaemia  " 
is  used.  In  England,  for  the  most  part,  the  term  is  now  used  to 
denote  the  infantile  form  of  splenic  anaemia  or  the  anaemia  pseudo- 
leukaemica  infantum  of  von  Jaksch.  Paltauf  and  others  have 
described  under  this  heading  the  condition  which  is  more  generally 
known  as  lymphadenoma ;  while  Bamberger  and  other  German 
writers  have  described  as  pseudo-leukaemia  a  condition  of  lymphatic 
leukaemia  without  the  characteristic  blood  picture,  a  state  which 
may  be  considered  as  analogous  to  the  aplastic  form  of  pernicious 
anaemia. 

In  view  of  this  uncertainty  the  inevitable  conclusion  is  that  it 
would  be  better  if  the  term  "pseudo-leukaemia"  were  either  no 
longer  employed  or  strictly  limited  in  application  to  cases  of 
von  Jaksch's  disease. 

From  the  point  of  view  of  treatment  it  is  important  sharply  to 
differentiate  between  the  adult  type  of  splenic  anaemia  occurring 
in  children  and  von  Jaksch's  disease.  This  may  readily  be  done 
by  a  blood  examination.  In  the  former  case  there  is  a  leucopenia 
ivith  a  relative  lyinphocytosis,  while  in  the  latter  there  is  a  marked 
leucocytosis  (often  up  to  50,000)  and  usually  many  myelocytes  and 
erythroblasts.  In  both  conditions  there  is  a  secondary  anaemia. 

For  most  cases  of  splenic  anaemia  splenectomy  is  probably  the 
best  treatment  (sea  pp.  81 — 83  of  this  volume).  For  von  Jaksch's 
disease  the  spleen  should  never  be  excised  :  the  treatment  should 
be  dietetic,  hygienic  and  tonic,  being  directed  at  the  underlying 
defect  in  metabolism  which  is  often  of  a  rachitic  nature.  Great 
benefit  will  often  result  from  the  exhibition  of  meat  juice,  malt  and 
cod-liver  oil,  combined  with  such  drugs  as  iron,  arsenic,  and  the 
glycerophosphates. 

JAMES    TORRENS. 


43 


PURPURA. 

ALL  varieties  of  purpura  are  characterised  by  the  occurrence  of 
haemorrhages  in  the  skin,  mucous  membranes  and  viscera.  In 
some  forms  there  may  be  external  bleeding  from  mucous  mem- 
branes as  well.  As  the  causes  of  the  disease  are  still  obscure, 
treatment  is  directed  to  the  care  of  the  patient,  so  as  to  avoid 
the  ill-effects  of  the  disease  and  to  the  prevention  or  arrest  of 
haemorrhages  by  the  best  means  we  have  as  yet  at  our  disposal. 

General  Treatment. — In  all  forms  of  purpura  any  movement 
or  exposure  of  the  surface  of  the  body  to  changes  of  temperature 
favours  the  recurrence  of  haemorrhage.  It  is  therefore  essential  that 
the  patient  should  be  confined  to  bed  as  long  as  fresh  haemorrhages 
occur  and  it  is  advisable  to  prolong  the  rest  in  bed  for  at  least  a 
week  after  the  last  crop  of  purpuric  spots  has  appeared.  Fresh  air 
is  beneficial  and,  weather  permitting,  the  bed  may  be  placed  near 
an  open  window  or  even  out  of  doors,  during  the  daytime,  provided 
the  patient  is  kept  warm  so  as  to  avoid  any  risk  of  chill  to  the 
surface  of  the  skin. 

The  surroundings  should  be  bright  and  cheerful  and  freedom 
from  worry  and  anxiety  should  as  far  as  possible  be  ensured. 
Careful  nursing  is  important,  as  the  patient  requires  very  gentle 
handling,  and  in  moving  him  as  little  pressure  as  possible  should 
be  exerted  at  any  one  point  as  fresh  ecchymoses  are  easily  produced 
by  any  rough  handling  or  pressure.  The  bed  should  be  comfort- 
able and  the  under-sheet  smooth  and  free  from  creases.  While  the 
hemorrhages  are  recurring  the  diet  should  chiefly  consist  of  milk 
and  foods  prepared  with  milk.  Fresh  fruit  and  vegetables  may  also 
be  given.  When  the  attack  is  over  food  which  contains  iron,  such 
as  fresh  beef  or  mutton,  eggs,  spinach  and  asparagus,  is  to  be 
recommended  during  convalescence.  If  there  is  constipation,  fruit, 
honey  or  marmalade  ma}7  be  taken  with  advantage.  As  long  as 
fresh  haemorrhages  occur  baths  are  not  advisable  and  no  friction 
must  be  applied  to  the  skin  as  long  as  any  rash  is  visible.  When 
the  haemorrhages  have  ceased  to  appear  warm  baths  may  be 
employed.  Dr.  Pratt  advises  a  daily  bath  at  95°  F.  for  ten 
minutes  at  first,  the  temperature  of  the  water  being  one  degree 
lower  each  day  until  87°  or  85°  is  reached.  Sulphur  baths  are 
employed  in  some  of  the  hospitals  in  Paris.  Fitten  recommends 


44  Purpura. 

the  use  of  warm  carbon  dioxide  baths  or  warm  salt  water  baths 
while  arsenic  is  taken  internally. 

Medicinal  Treatment. — As  long  as  the  haemorrhages  continue 
calcium  salts  should  be  given.  Of  these  calcium  lactate  is  the 
most  suitable  and  may  be  given  in  the  following  form :  fy .  Calcii 
Lactatis,  gr.  10  to  15;  Aq.  Chloroformi,  5]  [U.S.P.  1^.  Calcii 
Lactatis,  gr.  10  to  15 ;  Aquae  Chloroformi,  jss ;  Aquam,  ad  3J]  ; 
three  times  a  day,  or  every  three  or  four  hours  in  severe  forms. 
It  is  advisable  to  continue  the  administration  of  this  drug  for  a 
week  or  ten  days  after  the  occurrence  of  the  last  petechial  eruption. 
Oil  of  turpentine  is  a  valuable  remedy  in  many  cases,  so  much  so 
that  it  was  regarded  by  Sir  S.  Mackenzie  as  a  specific  in  many 
cases  of  so-called  purpura  rheumatica.  It  may  be  given  in  doses  of 
10  to  20  min.  three  or  four  times  in  the  twenty-four  hours.  It  is 
most  conveniently  administered  either  in  capsules,  in  suspension 
with  mucilage,  or  in  the  following  combination  as  recommended 
by  Mackenzie:  1^.  01.  Terebinth,  irj,10;  Tinct.  Quillaiae  Sapon., 
ir^lO ;  Aq.  Cassiae,  ad  5].  Much  larger  doses  than  these  have  been 
recommended  by  Dr.  Eustace  Smith  in  the  case  of  well-nourished 
children.  He  gives  2  drachms  of  turpentine  with  an  equal  quantity 
of  castor  oil  to  a  child  six  years  of  age  and  even  larger  doses  to 
older  children.  The  aperient  action  of  the  castor  oil  probably 
prevents  the  absorption  of  any  large  proportion  of  the  turpentine. 

In  purpura  haemorrhagica  bleeding  from  the  mucous  membranes 
should  be  treated  by  the  local  application  of  1  in  1,000  solution  of 
adrenalin  chloride.  The  mouth  or  nose  may  be  irrigated  with  the 
solution.  If  this  proves  insufficient  a  small  pad  of  absorbent  wool 
or  lint  saturated  with  the  solution  should  be  held  in  contact  with 
the  bleeding  point,  whenever  this  is  accessible,  for  several  minutes. 
If  there  is  epistaxis  the  nasal  cavity  may  be  packed  with  gauze  or 
lint  soaked  in  the  adrenalin  solution,  which  is  left  in  situ  for  twenty- 
four  hours.  As  an  alternative,  the  application  of  a  2  per  cent,  solu- 
tion of  gelatine  to  the  bleeding  surface  is  useful  in  some  cases. 
Where  there  is  haemorrhage  from  the  oesophagus,  stomach  or  other 
part  of  the  alimentary  canal,  the  adrenalin  chloride  solution  may  be 
given  by  the  mouth  in  doses  of  10  to  30  min.  at  intervals  of  three 
or  four  hours. 

Henoch  recommended,  in  the  form  of  purpura  which  was  first 
described  by  him,  the  application  of  an  ice-bag  to  the  abdomen  and 
feeding  with  iced  milk. 

Ergot  and  hamamelis  have  been  employed,  but  are  less  reliable 
than  the  remedies  already  mentioned. 

During  convalescence  and  especially  in  the  more  chronic  forms  of 


Purpura.  45 

purpura,  arsenic  and  iron  rna}7  be  given  on  account  of  the  secondary 
anaemia  produced  by  the  attack.  A  course  of  arsenic  in  small  doses, 
such  as  from  3  to  5  min.  of  Fowler's  solution,  may  be  given 
two  or  three  times  a  day  for  several  weeks,  as  it  appears  to  diminish 
the  liability  to  recurrence.  Change  of  climate  is  also  advisable  at 
this  stage,  country  or  mountain  air  at  a  moderate  elevation  being 
the  most  suitable. 


GEORGE  R.  MURRAY. 


REFERENCES. 


Pratt,  J.  II.,  Osier  and  Macrae's  "  System  of  Medicine,"  1908,  Vol.  IV.,  p.  715. 
Mackenzie,  Sir  S.,  Allbutt  arid  Rolleston's  "  System  of  Medicine,"  1909, 
Vol.  V.,  p.  8(54.  Ilenoch,  E.,  "  Vorlesungen  iiber  Kinderkrankheiten,"  Berlin, 
1899,  4te,  Aufi.,  p.  803. 


46 


DISEASES    OF    THE    DUCTLESS    GLANDS. 

DISEASES    OF   THE  ADRENAL  GLANDS  (ADDISON'S 

DISEASE). 

UNTIL  recently  the  treatment  of  Addison's  disease  has  been 
considered  hopeless.  Without  being  unduly  optimistic,  we  may 
believe  that  shortly  we  shall  be  able  to  do  much  to  ameliorate  the 
condition  of  sufferers  from  this  disease.  There  is  no  doubt  that 
when  the  suprarenal  glands,  together  with  all  the  cells  of  a  similar 
character  in  other  parts  of  the  abdomen,  have  been  destroyed,  life 
becomes  impossible.  In  spite  of  the  great  advance  in  arterial 
surgery  there  is  but  little  prospect  in  the  near  future  of  successful 
transplantation.  It  must  be  remembered  that  in  addition  to 
disease  of  the  suprarenal  glands  some  pathological  conditions  of  the 
sympathetic  system  may  give-  rise  to  symptoms  indistinguishable 
from  Addison's  disease ;  in  all  probability  this  is  not  due  to 
destruction  of  the  chromaffin  cells  lying  in  its  neighbourhood  but 
to  alteration  in  the  nervous  mechanism. 

The  progress  of  diagnostic  methods  will  lead  to  the  recognition 
of  suprarenal  disease  at  an  earlier  date,  a  date  sufficiently  early  to 
permit  in  a  certain  number  of  cases  of  means  being  adopted  to 
prevent  the  total  destruction  of  the  glands.  This  will  be  feasible  in 
a  few  morbid  conditions,  but  since  the  greater  number  of  cases  of 
Addison's  disease  are  due  to  tuberculous  infection  of  the  suprarenal 
glands,  any  treatment  which  is  successful  when  applied  to  local 
tuberculosis  will  arrest  this  complaint. 

Treatment  therefore  at  the  present  day  may  be  divided  under 
three  headings  :  (1)  Curative ;  (2)  Palliative  ;  (3)  Symptomatic. 

Curative  Treatment. — In  order  to  establish  the  curative  treat- 
ment we  must  determine  whether  the  adrenal  glands  are  being 
destroyed  by  an  infection  with  the  tubercle  bacillus,  the  spirochaete 
of  syphilis,  by  a  new  growth,  or  by  an  increase  of  fibrous  tissue. 
Occasionally  differential  diagnosis  is  far  from  easy.  Since  the 
tubercle  bacillus  is  the  commonest  cause  we  must  determine  first 
whether  the  patient  is  infected  with  this.  The  manifold  tests,  such 
as  that  ascribed  to  Koch,  to  Pirquet  and  to  Calmette,  along  with 
the  variability  of  the  tuberculo-opsonic  index,  permit  us  to  decide 
whether  there  is  any  tuberculosis  in  the  body  of  the  patient,  but 


Addison's  Disease.  47 

none  of  these  tests  assist  in  localising  the  site  of  the  infection.  The 
Wassermann  reaction  will  determine  the  presence  or  absence  of  the 
spirochaste  infection. 

Repeated  careful  examination  of  the  abdomen  may  permit  us  to 
decide  upon  the  presence  of  a  suprarenal  tumour,  but  since  a  small 
tumour  may  be  very  destructive  and  placed  in  an  inaccessible 
position,  it  is  only  in -a  low  percentage  of  cases  that  palpation 
will  give  a  hint  of  its  presence.  The  diagnosis  of  fibrosis  of  the 
suprarenal  can  be  arrived  at  only  by  a  method  of  elimination,  there 
being  no  definite  signs  of  the  condition. 

Having  come  to  the  conclusion  that  the  disease  is  due  to  a  tubercu- 
lous infection  of  the  suprarenal  the  question  of  treatment  arises. 
In  the  main  it  should  be  the  same  as  that  of  any  other  tuberculous 
infection,  namely,  fresh  air  and  appropriate  food.  In  addition  to 
this,  minute  doses  of  tuberculin  should  be  given,  controlled  by  their 
effect  upon  the  opsonic  index.  The  initial  doses  of  tuberculin 
should  be  even  less  than  that  usually  given  to  patients  suffering 
from  localised  tuberculosis,  because  a  marked  reaction  of  the 
suprarenal  glands  would  prove  fatal  immediately,  therefore  the 
amount  chosen  must  be  such  as  to  make  this  impossible.  It  is  true 
that  Lenhartz  has  reported  a  successful  result,  or  at  any  rate 
improvement  lasting  over  many  months,  by  injecting  large  quantities 
of  the  original  Koch's  tuberculin,  but  we  must  not  place  too  much 
reliance  upon  a  single  observation. 

If  the  Wassermann  reaction  is  positive,  a  course  of  anti-syphilitic 
treatment  is  indicated  or  an  injection  of  an  appropriate  dose  of 
Ehrlich's  606  preparation. 

If  there  is  any  suggestion  of  a  tumour,  laparotomy  should  be 
performed  in  case  the  new  growth  is  removable. 

Palliative  Treatment. — Palliative  treatment  consists  in  supply- 
ing suprarenal  secretion.  The  substance  manufactured  by  the 
suprarenal  glands  stimulates  the  sympathetic  system,  and  by  this 
means  maintains  the  tone  of  the  blood-vessels.  Usually  the  blood 
pressure  falls  below  100  mm.  Hg.  in  cases  of  suprarenal  disease,  and 
this  is  an  indication  for  the  administration  of  suprarenal  extract. 
The  dose  should  be  large,  3  or  4  grammes  of  the  dried  gland 
may  be  given  with  advantage ;  occasionally  vomiting  coincides  with 
the  administration  of  the  preparation,  but  conclusive  evidence 
should  be  obtained  that  it  is  propter  and  not  post  before  orders  are 
given  to  cease  the  treatment.  If  the  blood  pressure  does  not  rise 
after  the  administration  of  the  drug  for  several  days,  it  is  useless  to 
continue  it,  because  either  the  patient  is  not  suffering  from  supra- 
renal inadequacy,  or,  if  he  is,  the  sympathetic  system,  too,  is  diseased, 


48  Addison's  Disease. 

and  there  is  no  advantage  in  supplying  the  hormone  when  the 
tissue  upon  which  it  should  act  cannot  respond. 

Treatment  of  Symptoms. — Symptoms  are  manifold,  but  possibly 
the  most  distressing  is  vomiting,  whilst  constipation  and  diarrhoea 
may  be  of  long  standing  and  extremely  difficult  to  treat  with  drugs. 
Vomiting  frequently  persists  in  spite  of  the  administration  of 
alkalies,  bismuth,  oxalate  of  cerium  and  drugs  of  that  type,  and  it 
is  wiser  to  use  some  sedative  to  the  gastric  mucous  membrane  and 
to  the  nervous  system,  such  as  chloretone  or  cocaine,  in  small  but 
frequent  doses.  Constipation  is  due  to  want  of  tone  of  the  plain 
muscle  of  the  intestine,  and  there  is  very  great  difficulty  in  exciting 
peristaltic  action  in  this,  whilst  if  once  excited  uncontrollable 
diarrhoea  may  set  in;  therefore  we  should  adopt  some  means  to 
prevent  the  contents  of  the  intestine  becoming  dry  and  hard.  Two 
methods  are  at  our  disposal,  either  the  administration  of  some  oil 
which  will  not  be  absorbed  by  the  intestine,  or  the  administration 
of  some  colloid  which  will  refuse  to  part  with  water  after  having 
once  absorbed  some  in  the  upper  part  of  the  intestine.  Therefore 
we  may  prescribe  either  5  grammes  of  liquid  paraffin  three  or 
four  times  a  day — this  can  with  advantage  be  made  into  an  emul- 
sion with  a  little  syrup  of  ginger — or  we  may  give  3  or  4 
grammes  of  powdered  agar  two  or  three  times  a  day  along  with 
food.  Either  of  these  methods  will  prevent  the  faeces  becoming 
hard.  An  attempt  to  stimulate  the  peristalsis  may  be  made  by 
giving  a  combination  of  cascara,  aloes  and  nux  vomica,  in  minute 
doses,  but  it  is  wiser  to  have  recourse  to  enemata. 

Occasionally  diarrhoea  is  persistent.  Bismuth  in  large  doses 
may  be  administered,  but  it  must  be  remembered  that  the  bowel 
is  asthenic,  and  that  bismuth  may  conglomerate  and  lead  to 
obstruction,  and  therefore  it  should  be  used  with  caution. 

Another  symptom  which  may  give  rise  to  much  annoyance  is 
want  of  muscular  power,  but  as  a  rule  it  is  sustained  effort  which 
fails  rather  than  single  movements,  and  therefore  if  the  patient  be 
kept  in  bed  this  myasthenia  does  not  become  a  serious  symptom. 

Loss  of  appetite  may  be  treated  with  bitter  stomachics  and  by 
general  massage. 

OTTO  GRUNBAUM. 


49 


DISEASES    OF    THE    THYROID    GLAND. 

THE    ADMINISTRATION    OF    THYROID    EXTRACT 

THE  dosage  of  thyroid  extract  as  advertised  in  books  of  phar- 
macology stands  in  urgent  need  of  revision.  The  dos9  originally 
decided  upon,  namely,  5  gr.  three  times  daily,  was  based  upon 
experiences  gained  from  cases  of  myxoBdema  which  had  previously 
been  treated  by  subcutaneous  injection.  In  the  light  of  the  know- 
ledge which  has  since  been  accumulated  on  the  subject  it  is  quite 
evident  that  15  gr.  a  day  is  an  enormous  dose,  which,  if  it  be  given 
at  all,  should  be  gradually  arrived  at  from  very  small  beginnings. 
One  of  the  most  remarkable  things  in  connection  with  thyroid 
extract  is  the  fact  that  the  patients  who  stand  most  in  need  of  it  are 
precisely  those  who  most  readily  show  signs  of  intolerance.  It  is  to 
be  supposed  that  the  tissues  of  people  suffering  from  high  degrees  of 
thyroid  insufficiency  are  loaded  with  mucin,  and  that  if  this  is  set 
free  too  rapidly  for  efficient  excretion  symptoms  of  intolerance  will 
ensue.  The  dose  with  which  to  begin  treatment  by  thyroid  extract 
should  therefore  never  exceed  \  gr.  twice  daily.  This  may  be  rapidly 
increased  after  the  first  week  of  treatment,  more  especially  if  it  has 
produced  a  definite  increase  in  the  urinary  output.  The  first 
subjective  sign  of  intolerance  is  the  consciousness,  the  obtrusive 
consciousness,  of  the  heart's  action.  This  will  frequently  appear 
long  before  any  heart  hurry  has  been  produced.  One  patient, 
a  comparatively  spare  man,  complained  of  it  while  his  pulse  rate 
was  still  below  70  per  minute.  Another  early  symptom  is  a  coryza 
of  much  the  same  type  as  that  produced  by  iodide  of  potassium. 
Tachycardia,  high  temperature,  diarrhoea,  or  rapid  emaciation, 
should  never  be  allowed  to  occur.  They  indicate  a  high  degree  of 
excess,  and  patients  under  treatment  with  thyroid  extract  ought  to 
be  kept  under  careful  observation.  Some  drugs  seem  to  enhance 
the  action  of  thyroid  extract,  and  it  is  often  possible  to  attain  the 
desired  end  with  very  small  doses  of  the  extract  by  associating  with 
it  two  or  three  drops  of  Fowler's  solution,  and  2  or  3  gr.  of  calcium 
iodide,  in  ^  oz.  water.  One  of  the  difficulties  in  connection  with 
prescribing  thyroid  extract  is  that  the  public  seem  to  know  more 
about  it  than  they  do  about  most  drugs.  Many  people,  in  the  days 
of  heroic  dosage,  had  some  very  unpleasant  experiences  with  it,  and 

S.T. — VOL.  n.  4 


50      The  Administration  of  Thyroid  Extract. 

many  women  have  taken  it  sub  rosa  with  a  view  of  improving  their 
complexion,  their  figure  or  their  hair,  usually  in  large  doses,  with 
disastrous  results.  For  this  reason  it  is  desirable  to  be  able  to 
prescribe  the  extract  in  some  form  which  is  not  easily  recognisable 
to  the  eye  of  the  layman.  Messrs.  Squire  &  Co.,  of  Oxford  Street, 
have  arranged  that  the  name  "  elixir  colloid  "  (Squire)  shall  be 
synonymous  among  chemists  with  "elixir  thyroid"  (Squire),  and 
under  circumstances  such  as  the  above  I  always  prescribe  this 
preparation,  which  I  have  found  quite  reliable.  It  has  the  further 
advantage  that  it  can  be  given  in  very  small  doses.  The  only  other 
preparation  which  I  have  used  is  that  of  Messrs.  Burroughs 
Wellcome  &  Co.,  in  tabloid  form,  which  I  have  also  found  to  be 
entirely  trustworthy. 

LEONARD  WILLIAMS. 


CONGESTION    AND    INFLAMMATION    OF    THE 
THYROID    GLAND. 

THE  thyroid  gland  is  liable  to  become  congested  under  certain 
temporary  physiological  circumstances,  such  as  puberty,  menstrua- 
tion, pregnancy  and  sexual  excitement.  The  gland  enlarges  and 
occasionally  becomes  tender,  as  though  increased  demands  were 
being  made  upon  its  activities.  The  condition  generally  subsides 
when  the  cause  which  provoked  it  is  over.  It  may,  however,  persist 
and  prove  to  be  the  commencement  of  a  goitre.  The  enlargement 
thus  caused  is  usually  described  as  "hypertrophy,"  a  term  which  is 
incorrect  and  misleading.  In  the  case  of  pregnancy  this  condition 
should  be  treated,  because  the  congestion  almost  certainly  means 
that  the  amount  of  available  colloid  is  insufficient  for  the  mother 
1)1  us  the  embryo,  so  that  if  allowed  to  continue  the  health  of  one  or 
both  may  be  jeopardised,  the  mother  by  having  her  thyroid 
activities  exhausted  and  thus  requiring  a  prolonged  convalescence ; 
the  child  by  being  inadequately  supplied  with  a  material  which  is 
essential  to  its  normal  development.  The  treatment  consists  of 
the  exhibition  of  small  doses  of  thyroid  extract,  if  necessary,  during 
the  whole  period  of  pregnancy.  Where  the  condition  is  due  to  any 
of  the  other  causes  referred  to  above  no  treatment  is  necessary  in 
the  vast  majority  of  cases ;  but  if  there  should  be  any  persistence 
of  the  enlargement,  thyroid  extract  should  be  prescribed. 

It  is  to  be  supposed  that  among  the  many  functions  of  the 
thyroid  secretion  there  is  one  which  protects  the  organism  against 
certain  forms  of  infective  invasion  ;  that  the  gland,  in  short,  con- 
tributes something  to  the  natural  defences  of  the  body.  It  is  only 
on  this  supposition  that  it  is  possible  to  explain  the  fact  that 
the  thyroid  becomes  enlarged,  tender,  congested,  and  even 
inflamed  in  the  course  of  certain  acute  specific  fevers.  This  is  liable 
to  occur  in  all  the  exanthemata  ;  it  is  common  in  typhoid  fever,  and 
has  been  observed  in  malaria  and  cholera.  It  is,  however,  in  con- 
ditions of  true  rheumatism,  whether  it  be  in  the  form  of  rheumatic 
fever,  erythema  nodosum,  or  tonsilitis,  that  congestion  and  inflam- 
mation most  readily  appear.  When  slight  the  local  discomfort  is 
seldom  complained  of,  but  it  may  become  so  severe  as  to  cause 
great  pain  in  swallowing,  considerable  dyspnoea  and  pressure  effects 
in  varying  degree  upon  the  cervical  and  brachial  nerves.  When 

4—2 


52    Congestion  and  Inflammation  of  Thyroid  Gland. 

the  inflammation  is  severe  the  danger  of  its  extension  to  the 
trachea  and  glottis  should  not  be  overlooked.  Except  as  the  result 
of  typhoid  fever  (metastatic  abscesses)  and  pyaemia,  the  inflammatory 
condition  seldom  proceeds  to  the  stage  of  suppuration.  Should  it 
do  so,  no  time  must  be  lost  in  invoking  the  aid  of  the  surgeon, 
because  the  pus  readily  escapes  from  the  capsule  of  the  gland 
to  find  its  way  into  the  tissues  of  the  neck,  a  complication  which 
may  easily  prove  fatal.  The  kind  of  treatment  to  be  adopted  in 
the  presence  of  a  congestive  or  inflammatory  state  of  the  thyroid 
must  be  dictated  by  circumstances.  In  mild  cases  nothing  more 
than  hot  fomentations  are  required.  In  those  which  threaten 
to  cause  symptoms  such  as  dysphagia  or  dyspnoea,  more  especially 
if  an  inflammation  which  is  acute  is  tending  to  spread  so  as  to 
cause  oedema  of  the  glottis,  recourse  should  be  had  to  the  local 
abstraction  of  blood  by  means  of  leeches.  As  many  as  three  or 
four  leeches  should  be  placed  over  the  inflamed  area,  preferably 
along  its  lower  border,  so  that  later  on  the  clothes  may  the  more 
easily  conceal  the  rather  unsightly  scars.  If  these  means  fail 
in  affording  the  necessary  relief  to  urgent  symptoms  it  will  be 
necessary  to  ask  the  surgeon  to  undertake  the  anxious  task  of 
removing  as  much  of  the  inflamed  gland  as  will  ensure  the 
preservation  of  life. 

LEONARD  WILLIAMS. 


53 


SURGICAL    TREATMENT    OF    INFLAMMATORY 
AFFECTIONS    OF    THE   THYROID   GLAND. 

Acute  Inflammation  may  occur  in  a  normal  thyroid  or  in  one 
which  is  the  seat  of  a  goitre.  It  is  not  a  common  condition.  As  an 
idiopathic  affection  it  occurs  in  pyaemia,  or  in  the  course  of  one  of 
the  specific  fevers,  such  as  typhoid  fever,  and  then  generally  in  the 
later  stages  of  the  diseases.  Traumatic  inflammation  is  rarely 
seen  in  a  healthy  thyroid ;  it  is  not  uncommon  after  tapping  and 
injection  of  a  goitre.  Suppuration  frequently  occurs  as  a  result  of 
acute  inflammation ;  the  pus  is  very  likely  to  penetrate  the  capsule 
of  the  gland,  burrowing  into  the  cellular  tissue  of  the  neck  or 
bursting  into  the  trachea  or  pharynx. 

In  the  early  stages,  before  the  formation  of  pus,  hot  fomenta- 
tions should  be  applied  locally  and  other  means  used  to  alleviate 
the  pain.  As  soon  as  it  is  evident  that  suppuration  is  present, 
the  pus  should  be  evacuated  by  incision  and  drainage  if  the 
gland  is  otherwise  healthy  or  is  the  seat  of  a  parenchymatous 
goitre.  If,  however,  the  pus  is  within  an  encapsuled  tumour,  it 
may  be  possible  to  enucleate  the  tumour  ;  but  when  the  tumour  is 
firmly  adherent  to  surrounding  parts  it  is  better  not  to  attempt 
enucleation  but  to  incise  and  drain  the  abscess  cavity.  A  large 
tube  should  be  employed  and  healing  must  be  encouraged  to  take 
place  from  the  bottom  of  the  cavity,  so  that  a  fistula  is  not  left. 

Other  Inflammatory  Affections. — Tuberculosis  usually  occurs 
in  the  form  of  miliary  tubercle  and  as  a  part  of  general  tuberculosis. 
Syphilis  in  the  early  secondary  stages  of  the  disease  may  cause 
a  general  enlargement  of  the  gland  and,  in  the  late  stages, 
gumruata  may  form.  When  gummata  occur,  the  pressure  on  the 
trachea  may  cause  so  much  dyspnoea  as  to  necessitate  tracheotomy. 
A  very  rare  piimari/  chronic  inflammation  of  the  gland  occurs  and 
is  characterised  by  the  formation  of  a  tumour  of  great  density 
which  becomes  adherent  to  and  even  infiltrates  the  surrounding 
tissues  and  structures.  It  thus  simulates  malignant  disease.  If 
the  disease  is  seen  before  it  has  penetrated  the  capsule,  extirpation 
of  the  affected  lobe  is  the  proper  treatment.  In  advanced  cases 
tracheotomy  may  be  required. 

T.  P.  LEGG. 


54 


EXOPHTHALMIC    GOlTRE. 

A  FEW  cases  of  exophthalmic  goitre  recover  without  any  treatment, 
for  I  have  written  to  patients  who  have  left  the  hospital  without 
deriving  any  benefit  from  their  stay  in  it,  and  have  heard  from 
some  of  them  that  they  slowly  mended  without  treatment,  became 
well  and  able  to  follow  their  employment,  and  that  their  health 
was  still  good  when  they  received  my  letter,  many  years  after  they 
regained  their  health.  We  have  no  means  of  telling  in  any 
particular  case  whether  the  patient  will  recover  without  treatment, 
and  the  number  who  so  recover  is  few  ;  therefore  we  ought  always 
to  try  to  persuade  the  patient  to  undergo  treatment. 

Rest. — By  far  the  most  important  part  of  treatment,  and  must  be 
complete.  The  patient  must  go  to  bed,  usually  for  many  weeks, 
often  for  several  months.  Even  those  who  are  very  slightly  ill  will 
get  well  quicker  if  they,  to  begin  with,  go  to  bed  for  a  few  weeks. 
The  air  of  the  room  should  be  fresh  and  the  surroundings  cheerful. 
Best  of  all,  a  bedroom  in  the  country,  with  windows  almost  always 
open  and  so  arranged  that  the  patient  can  see  out  of  them ; 
during  fine  weather  the  bed  may  if  possible  be  wheeled  into  the 
garden  or  the  patient  may  live  on  a  balcony.  Should  she  not 
object,  a  bedpan  and  bed-urinal  should  be  used,  so  that  the  rest  in 
bed  will  be  complete ;  but  often  she  finds  a  difficulty  in  using  a  bed- 
pan ;  then  she  may  be  allowed  to  get  out  of  bed  to  empty  the 
bowels,  but  she  should  use  a  bed-urinal  to  relieve  the  bladder. 
The  length  of  stay  in  bed  will  depend  upon  the  progress  made, 
but  as  just  mentioned  the  least  will  generally  be  many  weeks. 
The  best  guide  is  the  pulse,  when  that  has  been  regular  and  of 
normal,  or  very  nearly  normal,  rate  for  three  or  four  weeks,  then 
the  patient  may  lie  on  a  sofa  for  an  hour  or  two  every  day.  After 
a  few  days  more  she  may  sit  in  an  arm-chair  for  an  hour  a  day,  and 
so  gradually  do  a  very  little  more  each  day.  The  secret  of  success 
is  only  to  allow  a  very  little  latitude  each  time  any  alteration  is 
made.  If  the  case  has  been  severe  the  patient  ought  not  to  be 
allowed  out  of  her  room  until  three  or  four  weeks  after  she  has 
got  up,  and  especially  any  progress  with  walking,  particularly  up 
and  down  stairs,  must  be  very  slow. 

Exophthalmic  goitre  is  often  partly  due  to  nervous  shock,  and 
sufferers  from  it  usually  have  tremor,  which  is  worse  when  they 


Exophthalmic  Goitre.  55 

are  excited,  and  they  are  very  excitable;  therefore  they  must 
lead  quiet,  peaceable  lives  while  they  lie  in  bed.  The  mistress  of 
the  house  and  children  must  resign  her  duties  of  management 
and  must  be  spared  all  domestic  and  other  worries.  The  most 
that  may  be  allowed  is  a  little  very  light  reading  that  requires  no 
mental  effort  and  does  not  excite.  Usually  it  is  well  not  even  to 
allow  this. 

Diet. — It  is  quite  exceptional  to  see  a  sufferer  from  exophthalmic 
goitre  who  is  fat,  indeed  most  of  them  are  very  thin ;  therefore,  as 
they  lie  in  bed  they  should  be  carefully  fed  so  that  they  may  gain 
weight.  Ordinary  plain  simple  food,  such  as  they  are  accustomed 
to  take,  is  best,  with  the  addition  of  milk  and  egg.  A  good  plan  is 
to  beat  up  one  egg  in  J  pint  of  milk  and  let  the  patient  drink 
a  little  every  two  hours,  so  that  she  gets  through  a  pint  of  this 
mixture  in  the  day.  If  the  taste  of  it  is  disagreeable  a  little  vanilla 
or  coffee  may  be  added.  Should  the  patient  not  gain  weight  more 
may  be  taken  or  she  may  have  Benger's  or  some  similar  food. 
Inasmuch  as  the  milk  and  blood  serum  of  thyroidectomised  goats  is 
by  some  thought  to  be  beneficial,  Dr.  Hector  Mackenzie  has 
suggested  that  sufferers  from  exophthalmic  goitre  should  take  very 
little  milk  and  meat.  I  have  not  been  in  the  habit  of  restricting 
them  in  these  articles  of  food,  but  if  such  restriction  is  made  other 
food  must  be  given  instead,  e.g.,  carbohydrates  and  fat,  for  whatever 
diet  is  given  it  must  be  abundant,  so  that  the  patient  may  gain  in 
weight.  Some  advise  that  the  patients  should  drink  large  quan- 
tities of  water  to  wash  out  the  poison  that  must  be  circulating  in 
them.  This  seems  reasonable. 

Drugs  have  very  little  effect  on  the  disease  itself.  Belladonna 
is  often  prescribed,  but  as  the  patients  are  usually  put  to  bed  it  is 
impossible  to  tell  whether  it  does  any  good.  There  is  no  evidence 
that  it  does,  and  as  it  increases  the  rapidity  of  the  pulse  and 
produces  nervous  excitement  it  hardly  appears  to  be  a  suitable  drug. 
Digitalis  is  almost  equally  popular,  and  if  the  pulse  is  very  rapid 
it  may  be  given,  say  ten  drops  of  the  tincture  or  1  gr.  of  the 
powdered  leaves  as  a  pill,  or  1  fluid  drachm  of  the  infusion  in  some 
simple  mixture  three  or  four  times  a  day.  But  in  many  cases  the 
patient  feels  sick  or  is  sick,  or  the  digitalis  obviously  interferes 
with  digestion ;  then  it  certainly  should  not  be  given.  When 
nervous  symptoms  are  very  evident,  it  is  wise  to  order  15  to  20  gr. 
of  bromide  of  potassium  three  times  a  day.  This  is  best  taken 
directly  after  meals  in  plenty  of  water.  If,  as  is  sometimes  the 
case,  the  patient  has  diarrhoea,  she  should  be  put  to  bed  at  once 
and  allowed  to  take  only  small  quantities  of  milk  every  hour  until 


56  Exophthalmic  Goitre. 

the  diarrhoea  stops,  and  if  necessary  chlorodyne  should  be  given, 
for  this  seems  to  be  the  best  drug  to  correct  the  diarrhoea.  Aperients 
are  rarely  needed  and  must  be  given  with  great  caution,  lest  they 
start  an  intractable  diarrhoea.  Arsenic  has  been  used,  but  it  is  not 
to  be  recommended,  for  it  may  cause  diarrhoea  and  other  gastro- 
intestinal symptoms  that  are  difficult  to  check.  Some  apply  Leiter's 
coils  to  the  thyroid,  others  give  thymus  gland,  others  iodine,  but 
without  benefit.  Thyroid  gland  tablets  have  often  been  given.  It 
is  difficult  to  see  how  they  can  be  of  help ;  indeed,  one  would  have 
thought  that  they  would  do  harm  ;  but  several  cases,  especially  of 
the  chronic  variety,  appear  to  be  a  little  better  for  taking  thyroid. 
The  anaemia  will  improve  as  the  patient  improves,  and  no  drugs 
are  needed  for  it. 

Moebius's  antithyroid  serum  is  the  blood  serum  of  rams  upon 
whom  thyroidectomy  has  been  performed  six  weeks  previously.  It 
has  often  of  late  years  been  given  for  exophthalmic  goitre.  Whether 
it  does  good  is  doubtful.  My  impression  gained  as  a  result  of 
often  ordering  it  is  that  it  certainly  does  no  harm,  and  in  some 
cases  probably  slightly  aids  the  other  means  towards  recovery  used 
in  any  particular  case.  Usually  5  min.  dropped  into  a  little  milk 
are  given  three  times  a  day  after  meals.  The  dose  is  quickly 
increased  until  the  patient  is  taking  20  or  30  min.  for  a  dose.  It  is 
an  expensive  drug.  Rodagen  is  a  white  powder  consisting  of  the 
dried  milk  of  goats  whose  thyroid  has  been  removed.  Milk  sugar 
is  added  as  a  preservative  ;  it,  too,  has  been  much  given  lately  to 
those  suffering  from  this  disease,  but  no  demonstrable  benefit  to 
the  cardial  symptoms  has  followed  its  use ;  nevertheless  some 
patients  seem  better  for  it ;  they  say  they  feel  better  and  they  are 
quieter.  The  usual  dose  is  60  gr.  three  times  a  day,  but  some  authors 
consider  that  two  or  three  times  this  amount  should  be  given.  It  is 
very  expensive. 

Various  electrical  treatments  have  been  employed  without 
benefit ;  nor,  as  far  as  my  experience  goes,  has  success  followed 
the  application  of  the  X-rays. 

Climate. — Circumstances  are  sometimes  such  that  the  patient 
cannot  lie  up,  or  in  a  few  instances  the  disease  is  so  very  slight 
that  it  is  thought  to  be  unnecessary  that  she  should.  In  such 
cases  we  must  consider  where  to  send  her,  and  the  same  considera- 
tions guide  us  in  selecting  a  place  to  which  to  send  a  patient  who 
has  benefited  after  a  long  rest  in  bed.  The  place  chosen  must  be 
quiet;  there  must  be  none  of  the  distractions  of  a  fashionable 
health  resort.  The  country,  where  it  is  easy  to  get  constant  fresh 
air,  is  very  desirable;  a  quiet  country  house  with  a  large  garden  is 


Exophthalmic  Goitre.  57 

best.  The  patient  should  be  out  of  doors  all  day  but  never  get  tired 
from  exercise,  so  she  must  lie  down  and  sit  a  good  deal.  No  mental 
worries  should  be  allowed  to  bother  her.  Often  stopping  in  one 
place  too  long  bores  her.  Then  she  is  much  improved  by  moving 
to  some  other  quiet  place.  Few  patients  are  more  benefited  by 
change  of  scene  than  sufferers  from  exophthalmic  goitre.  There  is 
no  special  advantage  in  the  seaside,  but  high  altitudes  often  do 
harm. 

The  details  of  treatment  by  surgery,  e.g.,  excision  of  half  the 
gland,  ligature  of  some  of  the  thyroid  arteries,  do  not  fall  within 
the  scope  of  this  article,  but  when  considering  the  desirability  of 
operating  we  must  remember  that  very  severe  cases  are  unsuitable 
for  operation,  as  they  often  die  after  it.  Mild  cases  will  often  get 
well  without  any  operation.  Many  patients  have  died  as  a  direct 
result  of  the  operation,  and  very  quickly  after  it,  some  even  under 
the  anaesthetic,  and  even  including  mild  cases  it  is  the  experience 
of  many  that  the  mortality  after  operation  is  severe.  There  is  no 
doubt  that  an  operation,  which  is  very  rarely  desirable,  should  not 
be  undertaken  without  very  careful  consideration,  and  only  when 
prolonged  medical  treatment  has  had  a  fair  trial  and  has  failed. 

W.  HALE  WHITE. 


THE  SURGICAL  TREATMENT  OF 
EXOPHTHALMIC  GOfTRE. 

DURING  recent  years  exophthalmic  goitre  has  been  treated  by 
operative  measures,  and  though  different  surgeons  have  published 
large  numbers  of  cases  which  have  been  designated  as  genuine 
examples  of  this  affection,  it  is  by  no  means  certain  that  all  of 
them  should  have  been  classified  as  such.  And  thus  it  becomes 
very  difficult  to  estimate  how  much  benefit  may  be  expected  to 
follow  an  operation  for  this  disease.  Exophthalmic  goitre  may  be 
primary,  in  which  the  classical  signs  and  symptoms  are  present 
from  the  onset;  it  maybe  secondary  to  a  pre-c.i'istin<i  yoitre,  that 
is,  a  patient  may  have  had  a  goitre  for  a  long  or  a  short  period  and 
then  subsequently  develop  signs  of  exophthalmic  goitre ;  or  it  may 
be  atypical,  and  in  this  group  may  be  placed  a  large  number  of 
cases  where  the  patient  has  either  a  parenchyrnatous  or  adeno- 
matous  goitre,  with  a  rapid  pulse,  tremor,  and  perhaps  slight 
prominence  of  the  eyeballs.  These  latter  cases  are  not  really 
genuine  examples  of  the  disease  and  should  be  excluded  in  dis- 
cussing the  value  of  surgical  treatment.  In  them  the  gland  has 
neither  the  naked-eye  nor  the  microscopical  appearances  of  the 
exophthalmic  variety.  They  are  to  be  treated  by  unilateral  extir- 
pation or  an  enucleation  operation,  and  the  symptoms  then  rapidly 
disappear.  So  that  really  there  is  left  the  true  primary  form  and 
the  secondary  form  of  the  disease.  In  the  latter,  operation  should 
be  undertaken  at  once  before  the  signs  become  pronounced  ;  the 
prognosis  is  good  and  the  risks  of  the  operation  are  not  much 
greater  than  those  of  any  other  goitre  operation.  In  these  cases, 
too,  the  goitre  may  be  so  large  as  to  cause  pressure  on  the  trachea, 
giving  rise  to  dyspnoea,  and  this  will  be  a  most  important  indication 
for  operating.  Moreover,  in  these  patients  and  those  with  atypical 
signs  of  the  disease,  complete  rest  in  bed  will  often  cause  the 
symptoms  to  disappear  or  alleviate  them,  but  they  reappear  as 
soon  as  the  slightest  exercise  is  taken.  The  patient  thus  becomes 
a  chronic  invalid  and  operation  should  be  therefore  advised. 

It  may  be  insisted  upon  that  a  patient  with  primary  exoph- 
thalmic goitre  should  not  be  operated  upon  unless  medical  measures, 
including  absolute  rest  in  bed,  have  been  tried  and  found  to  be 
ineffective.  How  long  such  treatment  should  be  carried  out  must 


Surgical  Treatment  of  Exophthalmic  Goitre.     59 

be  determined  for  each  particular  case  by  the  stage  of  the  disease 
and  by  the  progress  which  is  made.  If  the  disease  is  steadily  or 
rapidly  becoming  worse  in  spite  of  medical  treatment,  operation 
should  not  be  too  long  delayed  and  it  should  be  done  before  there 
are  definite  organic  changes  in  the  heart  with  more  or  less  dilata- 
tion of  its  cavities  and  orifices,  because  the  greatest  risk  of  the 
operation  is  sudden  cardiac  failure.  It  must  not  be  forgotten  that 
these  patients,  apart  from  operation,  are  liable  to  die  suddenly  from 
this  cause. 

Operation. — Surgeons  are  not  agreed  as  to  the  best  ancesthetic  ; 
local  anaesthesia  is  advocated  by  some,  chloroform  or  A.C.E.  mixture 
is  advocated  by  others,  while  ether  by  the  open  method  is  recom- 
mended especially  by  American  surgeons.  If  a  general  anaesthetic 
is  used  the  patient  should  never  be  deeply  under  its  influence,  and 
whatever  method  is  employed  it  is  advisable  to  give  -J-  or  \  gr. 
morphia  a  short  time  before  the  operation,  with  the  double  object 
of  calming  the  patient's  mental  state  and  of  reducing  the  amount 
of  anaesthetic  which  will  be  required. 

The  primary  source  of  the  disease  being  the  thyroid  gland,  any 
operative  measures  undertaken  will  be  performed  upon  that  organ. 
At  the  present  time  extirpation  of  a  portion  of  it,  or  ligature  of 
some  of  the  vessels,  are  practically  the  only  operations  which  need 
be  considered. 

Ligature  of  the  thyroid  arteries  is  not  very  often  employed  except 
as  a  preliminary  to  extirpation.  The  ligation  of  these  vessels  does  not 
produce,  as  a  rule,  such  a  permanent  amelioration  of  the  symptoms 
as  a  partial  thyroidectomy,  and  it  may  be  as  difficult  an  operation, 
especially  the  ligation  of  the  inferior  thyroid  artery,  as  thyroid- 
ectomy. The  two  superior  thyroid  and  one  of  the  inferior  thyroid 
arteries  are  usually  ligatured.  It  was  hoped  that  by  ligaturing 
the  vessels  to  cut  off  the  blood  supply  the  gland  would  produce 
a  lessened  amount  of  secretion. 

Partial  thyroidectoiny  is  the  better  operation,  the  amount  of  the 
gland  removed  consisting  of  one  lobe  and  the  whole  or  part  of  the 
isthmus.  The  operation  is  carried  out  in  the  usual  manner. 
Especial  care  must  be  taken  to  ligature  or  otherwise  control  all 
vessels  before  they  are  divided  or  death  may  occur  on  the  operating 
table  from  haemorrhage  and  cardiac  failure,  as  these  patients  are  less 
able  to  stand  a  loss  of  blood  than  a  patient  with  an  ordinary  goitre. 
The  isthmus  or  other  line  of  division  should  never  be  crushed  with 
forceps.  Free  drainage  by  a  large  tube  should  be  provided  for 
thirty-six  or  forty-eight  hours. 

After  the  operation  the  great  danger  is  "  acute  thyroidism,"  which 


60      Surgical  Treatment  of  Exophthalmic  Goitre. 

may  follow  any  kind  of  operation  on  an  exophthalmic  goitre. 
There  is  a  sudden  rise  in  temperature  which  may  reach  105°  or 
more  in  a  short  time  ;  a  rapid  increase  in  the  pulse  rate  ;  great 
restlessness,  excitability,  severe  sweating  and  diarrhoea.  If  the 
heart  has  been  already  weakened  by  degenerative  changes  or  if  it 
is  dilated,  it  may  rapidly  or  suddenly  fail  and  death  quickly  follows. 
This  sudden  failure  of  the  heart  may  also  occur  unexpectedly 
in  a  patient  who  appears  otherwise  to  be  progressing  favourably. 
The  explanation  is  probably,  that  in  addition  to  the  influence  of  the 
exaggerated  sensibility  of  the  vascular  nervous  system,  there  is  a 
sudden  increase  of  intoxication  from  increased  resorption  of  the 
thyroid  secretion  following  the  manipulation  of  the  gland  during 
the  operation  (Kocher). 

After-treatment.  -  -  The  patient  is  put  back  to  bed  in  a 
semi-recumbent  position  with  the  head  well  supported  on  the 
pillows.  A  pint  or  a  couple  of  pints  of  saline  solution  should  be 
given  per  rectum  at  once  and  repeated  every  three  to  four  hours  in 
all  cases  where  there  has  been  any  bleeding  or  when  the  pulse  is  of 
low  tension.  If  it  is  not  retained  the  saline  should  be  given  sub- 
cutaneously  into  the  axilla  or  beneath  the  mammary  gland.  Plenty 
of  liquids  should  also  be  administered  by  the  mouth.  Restlessness  is 
controlled  by  hypodermic  injection  of  morphia  (J  to  J  gr.)  combined 
with  Y^J  gr.  of  atropine.  If  the  pulse  is  feeble  and  rapid,  digitaliu 
(TOO  to  ^o  8rO  mav  be  given  hypodermically,  but  saline  solution  is 
the  best  means  of  stimulating  the  heart.  If  the  temperature  rises 
to  a  great  height  there  is  practically  nothing  to  do  directly  to  bring 
it  down  ;  attention  must  be  directed  to  keeping  up  the  action  of  the 
heart  in  these  cases.  Sponging  and  cradling  the  patient  may 
however,  be  employed. 

The  immediate  effects  of  the  operation  having  been  recovered 
from,  the  patient  will  need  to  be  kept  in  bed  for  two  or  three  weeks 
or  longer,  and  when  convalescent,  should  be  kept  away  from  all 
excitement  and  lead  a  quiet,  restful  life,  for  some  months. 

Results. — As  to  the  ultimate  results  of  the  operation,  complete 
cure  is  by  no  means  certain  nor  is  it  always  permanent.  A  large 
proportion  of  cases  temporarily  improve,  especially  if  adequate  rest 
in  the  after-treatment  is  insisted  upon,  and  the  improvement  may 
be  rapid.  Thus  the  tremors  may  disappear,  the  tachycardia 
diminishes  ;  the  nervousness  and  restlessness  of  the  patient  are 
lost  and  the  general  health  may  be  greatly  improved.  The  exoph- 
thalmos  is  one  of  the  last  symptoms  to  disappear,  and  it  is  doubtful 
if  it  ever  entirely  disappears.  In  considering  the  value  of  the 
operation,  it  must  not  be  forgotten  that  there  is  a  tendency  to 


Surgical  Treatment  of  Exophthalmic  Goitre.       61 

spontaneous  improvement  in  a  fair  proportion  of  cases,  and  in  any 
case  many  months  must  elapse  before  the  full  benefit  derived  from 
the  operation  can  be  estimated.  The  most  unfavourable  cases,  both 
from  the  operative  point  of  view  and  as  to  ultimate  recovery,  are  bad 
acute  cases  of  typical  Graves'  disease,  whereas  the  more  chronic 
cases  are  much  more  favourable  and  benefit  considerably  from  the 
operation.  The  former  type  should  not  be  operated  on  except  after 
a  prolonged  course  of  medicinal  treatment.  In  the  present  state  of 
our  knowledge  much  discrimination  and  a  careful  consideration  of 
all  the  aspects  of  the  case  is  required  before  recommending  a  patient 
to  undergo  an  operation  for  this  disease. 

T.  P.  LEGG. 


62 


GOITRE. 

THE  treatment  of  goitre  is  either  non-operative  and  medicinal, 
or  operative.  In  order  to  select  the  appropriate  method  the 
diagnosis  of  the  kind  of  goitre  is  of  prime  importance.  A  goitre 
may  be  due  to :  (1)  A  general  or  parenchymatous  enlargement  of 
the  whole  gland  ;  (2)  the  development  of  adenomata  (including 
cysts)  in  the  gland;  (3)  exophthalmic  goitre  ;  (4)  malignant  disease. 
Combinations  of  these  forms  often  occur ;  thus  there  may  be 
adenomata  with  a  parenchymatous  enlargement  of  the  gland,  arid 
it  is  not  very  uncommon  for  malignant  disease  or  an  exophthalmic 
goitre  to  supervene  on  a  parenchymatous  or  adenomatous  goitre. 
The  treatment  of  exophthalmic  and  malignant  goitres  is  discussed 
in  separate  articles. 

NON-OPERATIVE   TREATMENT. 

General  Treatment. — It  is  well  known  that  goitre  is  prevalent 
in  certain  districts,  arid  therefore  if  possible  the  patient  should  be 
removed  to  a  district  where  the  disease  is  not  endemic,  especially  if 
the  goitre  is  a  small  parenchymatous  one,  and  if  the  patient  is 
young.  If  the  removal  of  the  patient  is  not  possible  and  inasmuch 
as  it  is  probable  that  the  cause  of  the  goitre  is  contained  in  the 
water,  it  is  advisable  that  all  water  should  be  boiled  and  filtered,  or  be 
distilled  before  being  drunk,  or  an  alteration  in  the  supply  may 
sometimes  be  effected.  Eain  water  which  has  been  filtered  and 
boiled  may  also  be  substituted  for  the  usual  supply.  Cysts  and 
adenomata,  which  have  undergone  secondary  changes,  will  not  be 
benefited  by  such  general  treatment.  When  the  goitre  is  of  the 
adeno-parenchymatous  variety,  some  improvement  may  follow  this 
line  of  treatment  from  diminution  of  the  size  of  the  parenchy- 
matous portion  of  the  enlargement. 

Medicinal  Treatment. — Iodine  and  its  preparations  are  the 
most  useful  drugs.  It  is  advisable  to  begin  with  small  doses ;  thus 
a  mixture  containing  5  min.  of  tincture  of  iodine  [U.S. P.  1£  min.] 
and  5  gr.  of  potassium  iodide  may  be  given  three  times  a  day,  the 
quantities  of  each  being  gradually  increased  to  three  or  four  times 
these  doses  if  the  patient  can  tolerate  so  much  and  symptoms  of 
iodism  are  not  produced. 

Thyroid  extract  is  another  very  useful  remedy  ;  at  first  it  should 


Goitre.  63 

be  given  in  small  doses,  1  or  2  gr.  daily,  and  the  amount 
may  be  increased  to  5  or  10  gr.  daily,  if  the  pulse  is  not 
unduly  augmented  in  frequency  and  no  other  untoward  symptoms 
occur.  Many  goitres  improve  more  rapidly  by  giving  the  iodine 
compounds  and  thyroid  extract  simultaneously.  If  the  goitre  is 
going  to  be  amenable  to  this  treatment,  diminution  in  its  size  will 
be  manifest  in  thre'e  or  four  weeks,  and  in  favourable  cases  it 
progresses  until  the  goitre  entirely  or  almost  entirely  disappears. 
The  parenchymatous  variety  which  occurs  in  young  people  is  the 
most  suitable  kind  for  medicinal  treatment.  Long  standing,  tough 
parenchymatous  goitres  as  well  as  adenomata  and  cysts  are  un- 
affected by  these  remedies.  When  adenomata  or  cysts  are  accom- 
panied by  a  general  enlargement  of  the  gland,  some  improvement 
may  result  owing  to  the  absorption  of  the  excess  of  gland  tissue, 
and  thus  operative  treatment  may  be  rendered  more  easy. 

Local  Treatment. — External  applications,  such  as  the  tincture 
or  liniment  of  iodine  or  a  mercurial  ointment,  are  often  applied  to 
the  neck  over  the  tumour.  It  is  only  occasionally  that  any  appre- 
ciable benefit  follows  the  application  of  such  remedies.  In  India, 
the  red  iodide  of  mercury  ointment  is  thickly  smeared  over  the 
tumour  and  the  neck  is  then  exposed  to  the  hot  sun  for  some  time. 
Such  a  method  is  not  usually  available  in  this  country. 

OPERATIVE   TREATMENT. 

The  treatment  of  a  goitre  by  operation  is  by  (1)  extirpation, 
(2)  enucleation.  The  methods  of  performing  these  operations  are 
quite  different,  therefore  it  is  essential  to  determine  the  nature  of 
the  goitre  before  proceeding  to  operate.  Parenchymatous  goitres 
cause  a  general  and  more  or  less  uniform  enlargement  of  the 
whole  gland,  and  the  tumour  maintains  the  general  shape  and 
contour  of  the  gland ;  the  trachea  retains  its  position  in  the  mid- 
line  of  the  neck  and  is  bilaterally  compressed.  Adenomata  are 
encapsuled  tumours  composed  of  thyroid  tissue;  they  may  be 
single  or  multiple  and  may  be  present  in  one  or  both  lobes.  They 
are  oval  or  globular  in  shape,  elastic  in  consistence,  and  when  large 
they  displace  the  trachea  to  the  opposite  side  of  the  neck. 

By  extirpation  (Fig.  1)  is  meant  the  removal  of  a  part,  generally 
one  lobe,  of  the  gland.  The  vessels  are  ligatured  and  divided 
outside  the  capsule  of  the  gland  ;  especial  care  should  be  taken  to 
secure  those  entering  the  lower  pole.  This  operation  is  performed 
in  cases  of  parenchymatous  and  adeno-parenchymatous  goitre, 
multiple  adenomata,  and  sometimes  for  malignant  disease  and  for 
exophthalmic  goitre.  It  is  never  necessary  to  remove  the.  whole  of 


64 


Goitre. 


both  lobes  for  an 'innocent  goitre,  and  only  occasionally  is  it  desirable 
or  possible  to  do  so  in  malignant  disease.  If  one  lobe  is  removed 
when  the  goitre  is  an  innocent  one,  the  other  generally  shrinks 
rapidly  and  may  almost  disappear.  When  the  isthmus  is  enlarged 
it  may  be  entirely  or  partially  removed  with  the  lobe.  An  impor- 
tant and  very  useful  modification  of  the  operation  of  extirpation  is 


I.T.A. 

i.r.v. 

Liny. 


FIG.  1. — Operations  on  thyroid  tumours.  Semidiagrammatic. 
In  the  right  lobe  of  the  thyroid  an  adenoma  and  its 
capsule  are  shown.  The  dark  line  represents  the  incision 
to  enucleate  the  tumour ;  it  is  made  where  there  are  not 
any  large  vessels  and  where  there  is  a  thick  layer  of  thyroid 
tissue  over  the  tumour.  On  the  left  lobe  of  the  gland  the 
operation  of  extirpation  for  a  parenchymatous  goitre  is 
illustrated.  All  the  vessels  are  ligatured  outside  the  capsule 
of  the  gland.  Ao.,  aorta  ;  C.A.,  carotid  avtery  ;  l.J.  F.,  inter- 
nal jugular  vein  ;  /.  T.A.,  inferior  thyroid  artery;  I.T.V.,  in- 
ferior thyroid  vein;  L.In.V.,  left  innominate  vein; 
L.T.V.,  lateral  thyroid  vein;  R.In.V.,  right  innominate 
vein;  S.1\A.,  superior  thyroid  artery;  S.T.V.,  superior 
thyroid  vein. 

called  resection-extirpation.  In  this  method  a  part  of  the  lobe  on 
its  inner  and  posterior  aspect  is  not  removed,  the  knife  being 
carried  through  the  gland  in  this  situation.  The  advantages  of  this 
operation  are  that  the  recurrent  laryngeal  nerve  is  not  endangered 
and  enough  of  the  gland  remains  to  carry  on  its  function,  if  it  ever 
becomes  necessary  to  remove  the  opposite  lobe. 

By  enucleation  (Fig.  1)  is  meant  the  removal  of  a  tumour  from 
inside  the  gland  ;  it  is  therefore  used  for  adenomata  and  cysts.     A 


Goitre.  65 

spot  over  the  tumour  where  there  are  few  vessels  is  chosen,  and  at 
this  place  an  incision  is  then  made  through  the  gland  substance  till 
the  capsule  of  the  tumour  is  reached.  This  is  opened  and  the 
tumour  rapidly  enucleated.  After  the  tumour  is  removed  a  cavity 
is  left,  and  in  it  there  will  he  vessels  requiring  to  be  ligatured.  The 
bleeding,  which  may  be  smart  for  the  moment,  should  be  controlled 
by  packing  the  cavity  with  gauze.  The  vessels  are  then  secured 
with  pressure  forceps  and  ligatured,  after  which  the  walls  of  the 
cavity  are  approximated  by  two  or  three  sutures.  Resection- 
?  u  ltd  i.' ttt  ion  is  a  useful  modification  of  enucleation  and  is  suitable  for 
large  adenomata,  when  there  is  only  a  thin  layer  of  normal  thyroid 
tissue  over  a  large  area  of  the  tumour.  In  performing  this 
operation  the  affected  lobe  is  displaced  forwards  and  an  incision  is 
made  through  it  till  the  tumour  is  exposed.  The  tumour  is  then 
enucleated  on  its  inner  and  posterior  aspect  and  in  the  latter 
situation  the  gland  tissue  is  again  divided ;  the  portion  of  gland 
over  the  tumour  is  removed  with  the  tumour.  All  the  vessels  in 
the  capsule  of  the  gland  must  be  clamped  before  being  divided  and 
will  be  subsequently  ligatured.  Care  must  also  be  exercised  not  to 
damage  the  recurrent  laryngeal  nerve  which  lies  on  the  inner  and 
deep  aspect  of  the  thyroid  gland. 

Details  of  the  above  Operations.— In  the  majority  of  cases  a 
general  anaesthetic  may  be  given  and  chloroform  for  preference. 
Ether  given  by  Clover's  inhaler  is  not  advisable.  Whatever 
anaesthetic  is  employed,  the  patient  should  not  be  placed  deeply 
under  its  influence,  and  throughout  the  whole  administration  a 
very  careful  watch  must  be  kept  over  the  breathing  and  pulse.  An 
operation  is  frequently  required  for  the  relief  of  dyspnoea  from 
pressure  on  the  trachea,  and  the  difficulty  in  breathing  may 
suddenly  increase  if  the  patient  is  deeply  anaesthetised.  Many 
deaths  during  the  operation  have  been  due  to  too  deep  anaesthesia. 
"When  dyspnoaa  is  extreme,  it  is  better  to  use  a  local  analgesic  such 
as  eucaine  and  adrenalin.  In  these  cases,  if  the  patient  is  very 
nervous  or  excitable  J  gr.  of  morphia  may  be  given  an  hour 
before  the  operation ;  a  general*  anaesthetic  may  be  administered 
after  the  removal  of  the  tumour,  as  the  danger  of  sudden  pressure 
on  the  trachea  is  then  over. 

A  curved  transverse  incision  placed  over  the  lower  part  of  the 
tumour  is  the  best  (Fig.  2).  Its  length  will  be  proportional  to  the 
size  of  the  tumour ;  if  necessary,  the  ends  of  the  incision  may 
be  carried  upwards.  Oblique  and  vertical  incisions  are  not  to  be 
recommended,  as  the  scar  often  hypertrophies  and  becomes  very 
prominent,  whereas  the  scar  left  from  a  transverse  incision  is 

S.T. — VOL.  ii.  5 


66  Goitre. 

usually  almost  imperceptible.  A  flap  consisting  of  the  skin,  deep 
fascia  and  platysma,  is  dissected  up  for  a  sufficient  extent  to  expose 
the  tumour  fully.  The  infra-hyoid  muscles  are  divided  as  high  as 
possible  and  turned  downwards,  and  to  obtain  a  complete  exposure 
of  the  tumour  it  is  usually  necessary  to  separate  these  muscles  of 
the  two  sides  by  a  vertical  incision.  When  the  tumour  is  large 
these  muscles  are  often  thinned  and  spread  out  over  its  surface  in 
a  thin  layer.  The  sterno-niastoid  is  firmly  retracted  if  it  overlaps 


•  -.:  "'' ' 


FIG.  2. — To  illustrate  the  situation  ot  the  transverse  curved 
incision  for  removal  of  a  thyroid  tumour.  The  scar  is 
almost  imperceptible. 

the  tumour,  which  is  then  gently  raised  into  the  wound  by  passing 
the  finger  all  round  it.  All  vessels  must  be  clamped  by  pressure 
forceps  before  being  divided,  and  special  attention  should  be  paid 
to  secure  the  inferior  thyroid  veins,  which  are  apt  to  retract  into  the 
loose  cellular  tissue  behind  the  sternum,  where  they  are  very 
difficult  to  pick  up  and  a  large  amount  of  blood  may  be  unneces- 
sarily lost.  Throughout  the  whole  operation  the  greatest  care 
should  be  taken  to  prevent  haemorrhage.  The  vessels  should  be 
tied  as  close  to  the  tumour  as  possible,  and  to  make  certain  that 


Goitre.  67 

none  have  been  unsecured  it  is  advisable  to  allow  the  patient  to 
come  round  partially  from  the  anaesthetic  and  make  him  strain. 
Any  unsecured  vessel  will  at  once  bleed,  and  can  be  picked  up  by 
pressure  forceps  and  ligatured.  A  drainage  tube  should  be  placed  in 
the  wound  for  twenty-four  hours,  as  there  is  often  a  good  deal  of 
oozing  of  blood  and  escape  of  colloid  material  from  the  gland  tissue. 
It  is  only  when  the  cavity  is  quite  small  after  the  removal  of  the 
tumour  that  drainage  should  be  dispensed  with,  and  these  cases  are 
the  exceptions.  The  infra-hyoid  muscles  should  be  replaced  in 
their  positions  and  their  cut  edges  united  by  sutures ;  in  young 
people  this  should  never  be  omitted.  The  platysma  and  deep  fascia 
are  united  by  three  or  four  interrupted  sutures ;  this  enables  the 
skin  edges  to  be  more  perfectly  apposed  and  permits  of  the  super- 
ficial stitches  being  removed  on  the  fourth  or  fifth  day  after  the 
operation. 

The  patient  on  being  put  back  to  bed  is  propped  up  with  pillows 
in  a  sitting  posture.  This  is  more  comfortable  than  the  recumbent 
one,  and  as  a  rule  the  majority  of  patients  may  be  allowed  to  get 
up  for  a  short  time  on  the  fourth  or  fifth  day. 

Indications  for  Operation. — Dyspnoea  is  the  most  frequent 
indication  for  operating  on  a  goitre,  and  the  more  urgent  it  is  the 
greater  is  the  need  for  an  operation.  In  children,  who  develop  a 
goitre  at  or  near  puberty,  respiratory  trouble  may  develop  very 
quickly  from  the  pressure  on  the  trachea.  A  goitre  in  a  child  is 
usually  of  the  parenchymatous  type,  and  if  medicinal  measures  do 
not  speedily  arrest  its  growth,  operation  should  not  be  delayed.  In 
cystic  adenomata,  rapid  increase  in  size  from  haemorrhage  into  the 
cyst  is  likely  to  cause  dyspnoea.  Any  long  standing  goitre  which 
begins  to  increase  should  be  removed.  Displacement,  or  compres- 
sion, of  the  trachea  is  a  frequent  indication  for  operation,  and  other 
reasons  for  advising  an  operation  are  the  size  of  the  tumour  and  the 
deformity  of  the  neck.  A  deep-seated  adenoma  should  always  be 
removed,  especially  if  it  is  low  down  in  the  neck  or  retro-sternal. 
Tumours  in  this  situation  are  liable  to  give  rise  to  serious  dyspnoea, 
either  from  a  rapid  increase  in  size  or  because  they  become 
impacted  behind  the  sternum.  Parenchymatous  goitres,  which  are 
not  improved  by  medicinal  measures,  should  be  operated  on. 

When  there  is  enlargement  of  the  whole  gland  it  is  not  always 
easy  to  decide  which  lobe  should  be  attacked.  As  a  general  rule, 
however,  that  which  extends  the  lower  and  the  deeper  in  the  neck 
is  the  one  to  remove.  When  the  operation  is  being  done  for 
adenomata,  the  lobe  causing  the  displacement  of  the  trachea 
should  be  dealt  with.  An  mtra-thoracic  goitre  may  be  present  at 

5—2 


68  Goitre. 

the  same  time  as  one  in  the  neck,  and  therefore  the  region  behind 
the  sternum  should  always  be  digitally  explored,  otherwise  only  the 
more  prominent  part  of  the  tumour  may  be  removed  and  the  relief 
of  the  symptoms  does  not  follow. 

Complications  during  the  Operation. — Haemorrhage  is  the 
most  frequent  and  important.  An  undue  or  excessive  loss  of  blood 
should  not  occur  if  care  is  taken  to  clamp  the  vessels  before  they 
are  divided.  The  near  proximity  of  the  internal  jugular  vein 
should  be  remembered ;  it  should  never  be  torn,  and  this  accident 
can  be  avoided  by  gentle  manipulations  of  the  tumour.  Owing  to 
the  thinness  of  the  walls  of  the  veins,  even  those  of  the  large  veins, 
they  may  be  easily  torn  unless  gentleness  is  employed  throughout 
the  whole  operation. 

Respiratory  trouble,  such  as  increase  in  the  dyspnoea  or  cessation 
of  respiration,  is  liable  to  occur  when  the  tumour  is  being  lifted  out 
of  the  wound  or  it  is  being  displaced  to  expose  the  vessels  at  the 
upper  and  lower  poles.  It  may  be  necessary  to  stop  the  operation 
temporarily  to  allow  the  respiration  to  be  re-established,  and  in 
every  case  the  operation  should  be  carried  out  as  quickly  as 
possible.  The  importance  of  having  the  patient  only  lightly 
ansethetised  has  already  been  pointed  out. 

The  air  passages,  more  especially  the  trachea,  may  be  wounded 
if  the  relation  of  this  structure  to  the  goitre  is  not  remembered, 
and  in  those  goitres  which  extend  around  the  oesophagus  or 
pharynx,  these  structures  may  also  be  damaged.  If  the  goitre  is 
closely  adherent  to  any  of  these  organs  it  is  better  to  leave 
a  portion  of  it  attached  to  them  rather  than  to  try  and  dissect  it  off 
completely,  if  by  so  doing,  a  wound  of  these  organs  is  likely  to  be 
produced.  Septic  infection  of  the  wound  is  almost  certain  to  follow 
injury  to  these  structures  and  is  a  very  dangerous  complication. 
The  recurrent  laryngeal  nerve  has  often  been  damaged  ;  it  ought 
not  to  be  injured,  and  can  be  avoided  by  dividing  all  the  tissues 
and  vessels  close  to  the  tumour. 

Complications  after  the  Operation. — Septic  infection  of  the 
whole  wound,  leading  to  cellulitis  of  the  fascial  planes  of  the  neck, 
is  the  most  serious.  The  infection,  of  course,  occurs  during  the 
operation  and  can  be  avoided  by  taking  the  same  antiseptic  pre- 
cautions as  in  any  other  operation.  During  the  whole  operation 
the  wound  should  be  covered  as  far  as  possible  with  gauze  wrung 
out  in  1  in  2,000  perchloride  or  biniodide  of  mercury.  Whenever 
infection  occurs,  free  drainage  must  be  provided  without  any  delay 
by  taking  out  the  stitches  ;  otherwise  septic  cellulitis  of  the  neck 
and  of  the  mediastinum  may  occur.  Wet  dressings  (1  in  2,000 


Goitre.  69 

perchloride  of  mercury)  must  be  applied  to  the  wound  and 
frequently  changed.  Large  quantities  of  saline  solution  per  rec- 
tum may  be  given  continuously  or  the  saline  may  be  injected 
subcutaneously,  a  pint  at  a  time,  and  repeated  every  three  or  four 
hours.  Cultures  should  be  made  from  the  wound,  and  a  vaccine, 
prepared  from  the  organism,  given,  or  the  appropriate  serum  may 
be  used. 

Hcematoma. — After  the  wound  has  been  sutured  the  deeper  parts 
may  be  distended  with  blood  derived  from  a  vessel  which  has 
escaped  being  ligatured,  or  from  a  vessel  from  which  the  ligature 
has  slipped  off  or  from  a  general  oozing.  Such  a  hsematoma  is 
a  source  of  danger,  (1)  because  it  may  cause  severe  dyspnoea  from 
pressure  on  the  trachea,  and  (2)  it  may  become  infected.  The  treat- 
ment of  such  a  hsematoma  is  in  the  first  place  prophylactic,  that  is, 
great  care  should  be  taken  to  ligature  securely  all  vessels,  and  to  see 
that  the  wound  is  dry  at  the  completion  of  the  operation.  In  the 
second  place,  a  drainage  tube  should  be  placed  in  the  wound  in 
all  cases  for  twenty-four  hours,  thereby  providing  an  escape  for 
any  blood  which  may  ooze  from  the  raw  surfaces  of  the  tissues  and 
of  the  gland.  If  the  haematoma  develops  soon  after  the  operation 
and  causes  dyspnoea,  then  the  wound  must  be  opened  up  and  an 
attempt  made  to  discover  and  secure  the  bleeding  points.  If 
it  is  impossible  to  find  them  the  wound  must  be  left  open  and 
packed.  Secondary  suture  of  the  skin  may  be  done  at  a  later 
period. 

A  haematoma  may  also  develop  slowly  at  a  later  period  after  the 
operation  ;  it  is  then  necessary  to  open  up  the  wound,  remove 
the  clot  and  provide  free  drainage. 

Pyrexia. — It  is  not  very  uncommon  to  find  the  temperature 
rising  to  100'5°  or  even  101°  during  the  day  following  or 
on  the  second  day  after  the  operation.  If  no  septic  element  is 
present  the  fever  subsides  in  the  course  of  a  few  hours  ;  if,  however, 
the  temperature  remains  persistently  high,  the  wound  should  be 
carefully  examined  and  opened  up  freely  if  there  is  any  sign  of 
inflammatory  mischief. 

Fistula. — At  a  later  period  a  sinus  or  fistula  occasionally 
develops  from  the  presence  of  an  infected  stitch.  They  are  often 
troublesome  to  get  to  close  and  may  persist  for  a  long  time. 

Thyroidism  (so-called),  which  is  supposed  to  be  due  to  the  pouring 
out  of  the  secretion  of  the  gland  into  the  wound  and  its  absorption 
therefrom,  very  rarely  occurs.  The  symptoms,  viz.,  persistent  high 
temperature,  rapid  pulse  and  delirium,  are  more  usually  due  to 
septic  infection,  and  it  is  exceedingly  rare  for  the  wound  to 


70  Goitre. 

become  distended  with  the  secretion  of  the  part  of  the  gland  which 
is  not  removed.  As  a  matter  of  fact,  the  remaining  portion  of  the 
gland  usually  rapidly  diminishes  in  size. 

Cachcxia  strumipriva  does  not  occur  unless  the  whole  gland 
is  removed  or  unless  that  portion  of  the  gland  left  behind  is  so 
diseased,  that  it  is  incapable  of  carrying  on  its  function.  In  such 
cases  it  is  necessary  to  give  thyroid  extract  after  the  operation. 
The  dose  should  be  1  or  2  gr.  daily  to  begin  with  and  increased 
to  5  gr.  or  more  if  necessary.  The  patient  will  have  to  continue 
taking  the  drug  for  the  rest  of  his  life. 

Occasionally  a  late  paralysis  of  the  recurrent  laryngeal  nerve 
occurs.  This  is  due  to  compression  of  the  nerve  by  scar  tissue  and 
may  be  completely  recovered  from. 

Other  Operations. — Many  operations  were  formerly  done  for 
goitres.  Tapping  of  cysts,  injections  of  iodine  into  the  tumour  and 
division  of  the  isthmus  for  the  relief  of  dyspnoea,  have  been 
performed.  These  operations  are  dangerous  and  not  efficacious, 
and  therefore  should  not  be  carried  out.  Tracheotomy  for  the 
relief  of  dyspnoea  of  an  innocent  goitre  should  never  be  performed ; 
the  proper  method  of  treating  such  dyspnoea  is  by  enucleation  or 
extirpation  of  the  goitre  ;  and  at  the  present  time  a  goitre  ought 
not  to  be  allowed  to  produce  such  urgent  dyspnoea. 

Results  of  Operative  Treatment. — Relief  from  dyspnoea  is 
complete  and  permanent.  In  very  few  cases  will  a  second  opera- 
tion be  necessary  ;  this  depends  to  some  extent  on  the  nature  of  the 
goitre  and  the  method  of  operating.  After  enucleation  of  an 
adenoma  or  the  enucleation  of  several  such  tumours,  any  left 
behind  may  continue  to  grow,  especially  if  the  patient  is  young. 
When  multiple  adenomata  are  present,  it  is  perhaps  therefore  better 
to  remove  one  lobe  by  extirpation  and  to  enucleate  accessible 
adenomata  from  the  opposite  lobe.  In  a  parenchymatous  goitre 
extirpation  of  one  lobe  is  followed  by  diminution  in  size  of  the 
remainder  of  the  gland.  Subsequently  some  increase  of  this 
remaining  lobe  may  occur,  but  rarely  to  such  an  extent  as  to 
necessitate  another  operation. 

When  the  general  health  has  been  affected  its  complete  restora- 
tion is  the  rule.  Sometimes  after  an  extensive  removal  of  the 
gland  it  may  be  advisable  to  give  small  doses  (1  or  2  gr.  daily) 
of  thyroid  extract,  combined  with  general  tonics,  such  as  arsenic 
and  iron,  for  a  few  months  till  the  general  health  of  the  patient 
has  been  restored  and  the  effects  of  the  operation  have  been 
recovered  from. 

If  the  recurrent  laryngeal  nerve  is  damaged  a  permanent  change 


Infantilism.  71 

in  the  voice  may  occur,  but  sometimes  perfect  compensation  may 
be  effected. 

When  properly  performed  with  the  assistance  of  a  careful  anaes- 
thetist, the  risks  of  the  operation  are  very  slight  and  the  mortality 
low.  If,  however,  the  operation  is  done  by  one  who  is  not  familiar 
with  it,  the  risks  are  very  much  increased. 

T.   P.   LEGG. 


INFANTILISM. 

SEVERAL  types  of  this  condition  are  described,  all  of  which  are 
dependent  upon  some  vice  or  deficiency  in  one  or  other  of  the 
principal  internal  secretory  glands.  That  which  is  most  often 
at  fault  is  certainly  the  thyroid,  and  inasmuch  as  there  is  little  or 
nothing  in  the  symptomatology  to  indicate  with  precision  where  the 
fault  lies,  it  is  always  well  to  begin  the  treatment  of  such  cases 
with  the  administration  of  thyroid  extract.  If  this  should  fail  to 
yield  satisfactory  results  it  would  be  wise  to  try  pancreatic  extract, 
as  recommended  by  Byrom  Bramwell.1  Failing  this,  a  trial  should 
be  made  of  pituitary  extract. 

In  addition  to  the  all-essential  specific  remedies  which  are 
demanded  by  myxoedema,  cretinism  and  infantilism,  the  physician 
should  not  forget  to  insist  upon  the  importance  of  fresh  air,  suitable 
clothing  and  good  plain  food.  So  far  as  the  latter  is  concerned, 
red  meats  and  alcohol  being  recognised  as  depressors  of  thyroid 
activity,  they  should  be  allowed  sparingly  if  at  all.  Having  .regard 
to  the  fact  that  such  patients  are  always  cold,  the  prescription  of 
a  warm  bath  (100° F.)  at  night  is  one  which  is  eagerly  followed, 
and  is  very  helpful  in  promoting  metabolism.  Physical  exercise, 
more  especially  of  a  vigorous  kind,  is  to  be  discouraged.  General 
massage,  on  the  other  hand,  skilfully  performed  for  an  hour  three 
times  a  week,  is  a  very  valuable  adjunct. 

LEONARD  WILLIAMS. 

REFERENCE. 
»  "Clinical  Studies,"  Edinb.,  1904,  II.,  p.  348, 


MYXCEDEMA  AND  CRETINISM. 

THESE  conditions  are  now  so  well  understood  that  it  is  not 
necessary  to  notice  anything  in  connection  with  them  except  their 
treatment,  which,  with  one  important  reservation,  resolves  itself 
into  the  judicious  administration  of  thyroid  extract — a  matter 
which  is  fully  discussed  in  a  special  article  (see  p.  48).  Inasmuch,  how- 
ever, as  some  writers  have  sought  to  draw  a  fundamental  but  highly 
fanciful  distinction  between  goitrous  cretins  and  those  who  are 
non-goitrous,  it  seems  necessary  to  insist  that  the  only  difference 
between  these  two  classes  is  provided  by  the  fact  that  in  the  former 
a  wholly  inadequate  thyroid  has  attempted  to  do  the  work  demanded 
of  it  and  has  become  hypertrophied  as  the  result  of  its  futile 
attempt;  whereas  in  the  other  there  never  has  been  a  thyroid  of 
any  sort  to  which  the  fruitless  appeal  could  be  made.  The  presence 
or  absence  of  the  goitre  makes  no  difference  in  the  essentials  of  the 
disease,  and  points  to  no  difference  in  the  line  of  treatment  to  be 
adopted,  except  in  so  far  as  the  goitre  itself  may  produce  mechanical 
complications.  It  is  needless  to  say  that  the  earlier  the  cretinoid 
condition  is  recognised  and  treated  the  less  likelihood  is  there  of 
the  development  of  a  goitre,  and  the  better  the  prospect  of  per- 
manent good  being  effected.  The  important  reservation  in  the 
treatment  of  myxcedema  and  cretinism  above  mentioned  refers  to 
trie  fact  recently  brought  to  light  that  inactivity  of  the  pituitary 
gland  not  infrequently  produces  conditions  very  closely  allied 
to  those  which  develop  as  the  result  of  thyroid  inactivity.  The 
matter  is  not  yet  ripe  for  dogmatic  statement,  but  it  is  safe  to  say 
that  where  cretinism  and  myxoedema  appear  to  be  intractable  to  the 
judicious  exhibition  of  thyroid  extract  or  where  the  extract  is  only 
partially  successful  in  ameliorating  the  condition,  the  probability 
becomes  great  that  some  dereliction  of  duty  on  the  part  of  the 
pitituary  gland  is  at  least  a  contributory  cause.  In  such  circum- 
stances the  extracts  of  the  two  glands  should  be  associated  in  the 
treatment  of  the  case.  Indeed,  if,  as  sometimes  occurs,  the  thyroid 
extract  seems  to  produce  only  unpleasant  symptoms,  it  is  well  to 
suspend  it  altogether  and  substitute  pituitary  extract.  The  latter 
is  best  given  by  intramuscular  injection  in  doses  of  1£  gr.  three 
times  daily,  care  being  taken  that  it  does  not  raise  the  blood 
pressure  to  the  point  of  danger.  Such,  however,  is  its  only  toxic 
effect. 

LEONARD    WILLIAMS. 


73 


MALIGNANT  DISEASE  OF  THE  THYROID  GLAND. 

Radical  Treatment. — The  only  form  of  radical  treatment 
for  this  affection,  when  any  is  possible,  is  a  free  removal  of  the 
whole  of  the  disease.  Successful  treatment  can  be  obtained  only 
by  making  the  diagnosis  in  the  early  stages  of  the  disease,  and 
therefore  special  attention  should  be  directed  to  this  point  and 
particularly  to  advise  patients  of  middle  age  with  a  goitre,  which  is 
beginning  to  increase  in  size  or  is  causing  pain,  or  which  has 
recently  developed,  to  undergo  an  operation  for  its  removal.  The 
method  of  performing  the  operation  is  to  expose  the  tumour  by 
a  free  incision,  and  to  ligature,  before  they  are  divided,  all  vessels 
entering  the  tumour  so  that  the  operator  may  see  exactly  what 
he  is  doing,  otherwise  severe  injury  may  be  inflicted  on  such 
important  structures  as  the  larynx,  trachea,  oesophagus,  and  the 
great  vessels  of  the  neck.  Unfortunately,  in  the  majority  of 
patients,  at  the  time  the  operation  is  performed,  the  tumour  will 
be  found  to  have  extended  through  the  capsule  of  the  gland  and  to 
have  infiltrated  the  surrounding  structures  and  lymphatic  glands, 
so  that  a  complete  extirpation  is  impossible  and  early  recurrence  is 
frequent.  If  both  lobes  are  involved  in  the  disease,  it  has  probably 
extended  outside  the  capsule,  and  therefore  cannot  be  completely 
eradicated,  so  that  only  rarely  is  removal  of  both  lobes  possible  or 
advisable.  Similarly,  operations  which  involve  the  resection  of  the 
trachea,  larynx  or  oesophagus  in  order  to  remove  the  tumour,  are 
of  very  little  value  to  the  patient. 

The  tumours  known  as  papilliferous  cysts  and  malignant 
adenoma  are  different  from  the  ordinary  carcinoma  and  sarcoma 
in  that  they  are  much  less  malignant  locally  and  are  less  liable  to 
recur  early  after  removal.  They  may  require  to  be  repeatedly 
operated  on,  and  the  patient  may  live  several  years. 

Palliative  Treatment. — 1.  Partial  removal  may  be  advisable 
sometimes  when  the  growth  presses  seriously  on  the  trachea  or  when 
the  pain  and  discomfort  are  very  severe.  It  should  not  be  done 
unless  it  is  probable  that  the  external  wound  can  be  closed  and  that  it 
will  heal ;  otherwise  a  fungating  mass  will  follow.  Owing  to  the 
vascularity  of  the  growth  there  may  be  much  haemorrhage,  and 
therefore  all  vessels  must  be  secured  before  being  divided.  As 
much  of  the  growth  should  be  removed  as  appears  necessary  to 


74    Malignant  Disease  of  the  Thyroid  Gland. 

produce  the  relief  of  the  symptoms.  It  must  be  remembered  that 
this  operation  is  likely  to  give  only  temporary  relief  and  therefore 
should  not  be  undertaken  too  early. 

2.  Tracheotomy  should  be  performed  when  the  dyspnosa  has 
become  pronounced  or  very  distressing  to  the  patient.  The  opera- 
tion may  be  very  difficult  on  account  of  the  enlargement  of  the 
veins  and  because  the  trachea  may  be  covered  by  the  growth,  so. 
that  the  latter  has  to  be  cut  through,  or  part  of  it  may  require  to 
be  removed  before  the  trachea  can  be  found.  Again,  the  trachea 
may  be  considerably  displaced  to  one  or  other  side  of  the  neck  and 
its  relation  to  the  great  vessels  altered.  Especial  care  must  be 
taken  to  make  the  incision  over  the  trachea  wherever  it  is  situated 
and  to  do  the  operation  as  high  as  possible. 

The  ordinary   form  of    tracheotomy  tube  is  not   long   enough 


FIG.   1. — Komig's  long  flexible   silver  tracheotomy   tube. 
It  has  no  inner  tube. 

and  therefore  a  special  form,  such  as  Kcenig's  long  flexible  tube 
(Fig.  1),  must  be  used.  If  it  is  not  available,  a  soft  catheter 
may  be  employed. 

Tracheotomy,  as  a  rule,  only  prolongs  the  patient's  life  for  a  few 
weeks,  but  it  may  give  much  relief  to  the  symptoms.  Bronchitis 
or  other  pulmonary  troubles,  which  are  frequently  septic  in  origin, 
are  the  usual  causes  of  death.  If  the  tumour  is  one  of  the  slow- 
growing  and  less  malignant  types,  the  duration  of  life  is  much 
longer,  especially  if  the  growth  has  not  been  cut  into  in  performing 
the  tracheotomy. 

3.  Morphia  and  other  sedatives  may  be  given  freely  when 
required.  On  account  of  the  dysphagia  food  may  be  required  to 
be  administered  by  a  nasal  or  oesophageal  tube.  It  is  doubtful 
if  gastrostomy  should  be  performed  in  these  cases.  The  writer  is 
unaware  whether  radium  has  been  employed  in  treating  this 
affection. 

T,   P.   LEGG, 


75 


NOCTURNAL    ENURESIS. 
NOCTURNAL    INCONTINENCE    BED- WETTING. 

THIS  affliction,  .when  it  occurs  apart  from  malformations  of  the 
genito-urinary  tract,  or  disease  in  the  central  nervous  system,  is 
commonly  regarded  as  a  functional  neurosis.  It  may  be  correct  so 
to  describe  it  in  some  cases ;  but  in  the  majority,  the  lines  along 
which  it  should  be  treated  become  much  more  clearly  defined  if  it 
is  considered  in  its  true  light,  namely,  as  one  of  the  stigmata  of 
degeneracy.  Most  children  who  are  the  subjects  of  nocturnal 
enuresis  will,  if  carefully  examined,  be  found  to  exhibit  some,  at 
any  rate,  of  the  other  recognised  stigmata,  such  as  facial  asymetry, 
ocular  defects,  rickets,  cutaneous  eruptions,  adenoids,  a  tendency  to 
cretinism,  infantilism,  gigantism  or  epilepsy.  As  a  general  rule, 
the  more  normal  the  child  in  other  respects,  the  more  intractable 
to  treatment  will  the  enuresis  prove  to  be. 

In  such,  otherwise  seemingly  normal,  children,  successful  treat- 
ment depends  upon  (a)  the  discovery  and  removal  of  any  source 
of  peripheral  irritation  to  the  nervous  system,  of  which  the  most 
common  are  intestinal  worms,  a  tight  prepuce,  chronic  constipation, 
dental  caries,  nasal  obstruction,  and  lastly,  the  most  important 
and  that  which  is  most  frequently  overlooked,  namely,  eye-strain, 
(ft)  Minute  supervision  of  the  general  mode  of  life,  such  as 
the  avoidance  of  overclothing,  sufficiency  of  exercise,  suitability  of 
food.  Fluids  should  be  strictly  limited  three  or  four  hours  before 
bedtime,  and  the  child  awakened  and  made  to  micturate,  if  possible, 
within  two  hours  of  retiring.  Tonics  should  be  administered  if 
they  seem  to  be  required.  The  most  efficacious  in  this  condition 
are  undoubtedly  Parrish's  food  and  cod-liver  oil.  (c)  The  adminis- 
tration of  belladonna  or  its  alkaloid,  atropine.  The  latter  is 
regarded  by  many  as  the  more  reliable  on  account  of  its  greater 
uniformity.  Professor  Emmett  Holt,  of  New  York,  extols  a 
solution  of  atropine  (£  gr.  to  the  ounce  of  water),  of  which 
one  drop  containing  ^(^  gr.  is  given  for  every  year  of  the 
child's  life.  This  dose  is  given  at  4  p.m.  and  at  10  p.m.  After 
a  week  an  extra  dose  is  interpolated  at  7  p.m.  The  dose  is  then 
gradually  increased  until  double  the  quantity  is  being  taken. 
When  the  physiological  effects  are  produced  the  dose  should  be 
gradually  diminished.  If  the  drug  has  been  successful  in  controlling 


j6  Nocturnal  Enuresis. 

the  enuresis  it  must  be  continued  for  at  least  two  months  after  the 
last  act  of  incontinence,  (d)  Simple  suggestion,  failing  which, 
hypnotic  suggestion.  If  the  child  is  old  enough  to  be  amenable 
to  simple  suggestion,  every  effort  should  be  made  to  encourage  it 
to  educate  and  exercise  the  necessary  control.  Punishment  of  any 
kind  is  wholly  inadmissible.  Hypnotic  suggestion  should  be  left 
to  experts. 

In  cases  where  nocturnal  enuresis  is  accompanied  by  other 
evidences  of  degeneracy  the  treatment  is  much  more  hopeful,  for 
the  degeneracy  itself  will  very  frequently  be  found  to  depend  upon 
defect  in  the  activities  of  one  of  the  internal  secretory  glands. 
That  which  is  most  commonly  in  fault  is  the  thyroid,  in  which 
case  the  enuresis  will  be  associated  with  evidence  of  defective 
development.  The  child  will  be  undersized  and  weigh  less  than 
the  average  for  its  age.  Its  temperature  will  be  subnormal  and 
its  pulse  rate  unduly  slow.  The  bones,  especially  those  of  the  jaws, 
are  unduly  soft,  giving  rise  to  the  open  bite  or  to  the  high-arched 
or  gothic  palate  so  often  falsely  attributed  to  adenoids.  Adenoids 
and  enlarged  tonsils  may  or  may  not  be  present.  The  mental 
processes  may  be  dull,  more  often  however,  except  in  extreme 
cases,  they  are  normal.  The  skin  is  generally  very  dry,  and  shows 
chronic  eruptions  which  are  obstinate  to  treatment.  The  hair  is 
lustreless  and  badly  developed.  The  eyebrows  have  a  '  decided 
tendency,  which  is  more  marked  in  fair  children,  to  fail  in  develop- 
ment in  their  outer  thirds.  In  older  children  puberty  is  delayed. 
Where  these  or  other  evidences  of  thyroid  inadequacy  co-exist  with 
the  nocturnal  enuresis  treatment  by  thyroid  extract  or  the  salts  of 
calcium  (which  stimulate  thyroid  activity),  or  both,  may  be  appealed 
to  with  considerable  confidence.  Thyroid  extract  should  be  given 
at  first  in  very  small  doses.  The  tabloids  sold  by  Messrs.  Burroughs 
Wellcome,  containing  £  gr.,  are  generally  very  reliable.  One 
such  tabloid  may  be  given  once  a  day  to  a  child  of  five  years, 
and  if  well  borne,  may  be  repeated  until  the  dose  is  being  taken 
three  times  a  day.  During  the  administration  a  careful  watch 
must  be  kept  upon  pulse  rate,  body  weight  and  temperature.  A 
rise  in  all  three,  while  of  hopeful  augury,  proclaims  that  the  dose 
is  sufficient,  and  all  that  is  necessary  is  patience  and  perseverance. 
If  the  weight  falls  the  dose  is  excessive.  As  soon  as  the  evening 
temperature  reaches  normal  caution  is  required,  and  in  any  case 
the  pulse  rate  must  not  be  allowed  to  become  unduly  quick  for  the 
child's  age.  It  is,  as  a  rule,  well  to  suspend  the  drug  for  one  week 
in  every  month  unless  the  patient  is  under  very  constant  super- 
vision. An  excess  of  thyroid  extract  is  almost  as  deleterious  as 


Nocturnal  Enuresis.  77 

an  insufficiency,  so  that  it  is  of  the  utmost  importance  that  the 
initial  dose  should  he  small,  more  especially  as  those  suffering  from 
thyroid  insufficiency  are  often  at  first  very  intolerant  of  thyroid 
extract.  During  the  period  in  which  thyroid  extract  is  being 
administered,  the  occurrence  of  a  nasal  catarrh  should  be  regarded 
as  an  indication  for  the  temporary  cessation  of  the  drug.  The 
thyroid  gland  is  stimulated  by  calcium,  arsenic  and  iodine.  The 
following  mixture  may  therefore  advantageously  be  given  along 
with  the  thyroid:  1^.  Calcii  lodid.,  gr.  2 ;  Liq.  Arsenicalis,  ni2; 
Tr.  Nucis  Vom.,  nil;  Syrup  Auranti,  5J ;  Aquam,  ad  388  [U.S.P. 
Iy.  Calcii  lodid.,  gr.  2 ;  Lig.  Potassii  Arsenitis,  iii2;  Tr.  Nucis 
Vom.,  ni 2 ;  Syr.  Aurantii,  5] ;  Aquam,  ad  jss]  ;  M.  Sig.  ter. 
die  post  cib.  The  above  doses  are  suitable  to  a  child  of  eight 
years.  Not  infrequently,  in  cases  of  minor  severity,  this  mixture 
alone  will  be  found  to  control  the  enuresis. 

It  must  be  admitted  that,  successful  as  the  thyroid  treatment  is 
in  the  vast  majority  of  cases  which  show  the  stigmata  of  degenera- 
tion, there  are  nevertheless  a  few  such  children  in  whom  the  enuresis 
proves  quite  as  intractable  to  this  treatment  as  the  otherwise 
normal  children  above  referred  to.  It  is  probable  that  in  these 
cases  some  internal  secretion  other  than  that  of  the  thyroid  is  at 
fault.  Zanoni  and  Ferrari  have  used  suprarenal  extract  with  very 
conspicuous  success  in  children  aged  from  four  to  fifteen  years. 
The  doses  employed  were  from  twenty  to  thirty  drops  a  day,  but 
the  preparation  is  not  specified.  Pituitary  gland  has  been  tried 
without  any  success.  The  experiments  with  thymus  gland,  on  the 
other  hand,  so  far  as  they  have  gone,  are  encouraging.  In  cases 
which  resist  thyroid  treatment  it  is  well  to  make  trials  of  extracts 
of  some  of  the  other  internal  secretory  glands  before  having 
recourse  to  atropine,  which  has  very  obvious  disadvantages. 

LEONARD    WILLIAMS. 


THYROID    INADEQUACY. 

THE  thyroid  gland  may  be  congenitally  wanting  in  vigour. 
Such  a  gland,  although  it  may  be  capable  of  supplying  to  the 
economy  enough  of  its  peculiar  essence  to  protect  the  individual 
from  cretinism  or  infantilism,  may  nevertheless  fail  to  supply  enough 
to  enable  a  child  to  develop  along  lines  which  are  quite  satisfactory. 
This  parsimony  of  tribute  is  a  very  strong  predisposing  cause,  even 
if  it  is  not  an  active  factor  in  the  production  of  rickets,  adenoids, 
nocturnal  enuresis,  and  similar  affections  of  backward  children,  and 
it  probably  accounts  for  the  readiness  with  which  some  of  these 
children  contract  mumps,  measles  and  other  infectious  diseases. 
Unsatisfactory  babies  are  usually  deficient  in  thyroid;  "delicate" 
boys  and  girls  are  not  infrequently  so,  and  when  the  age  of  puberty 
is  reached  the  difficulties  which  so  often  ensue  may  in  a  large 
number  of  cases  be  confidently  attributed  to  this  cause.  In  adults, 
bad  teeth,  premature  baldness  or  greyness,  mental  and  physical 
lethargy  and  certain  types  of  obesity  are  some  of  the  symptoms 
which  suggest  thyroid  inadequacy.  The  diagnosis  is  established  if, 
in  addition  to  the  so-called  stigmata  of  the  condition,  the  patient 
presents  an  unduly  slow  pulse  and  a  persistently  subnormal  tem- 
perature.1 The  treatment  is  by  administration  of  thyroid  extract 
(see  p.  48). 

LEONARD   WILLIAMS. 

EEFEREXCES. 

1  "Thyroid  Inadequacy,"  Folia  Therapeutica,  October,  1909,  and  "Thyroid 
Insufficiency,"  Clin.  Journ.  1909—10,  XXXV.,  p.  167. 


79 


INJURIES  AND  DISEASES  OF  THE  SPLEEN. 

INJURIES    OF    THE    SPLEEN. 

Two  types  of  injury  to  the  spleen  are  to  be  met  with  clinically : 
(1)  Contusion  of  the  spleen  ;  (2)  laceration  of  the  spleen  tissue. 

In  order  to  form  an  opinion,  and  to  be  in  a  position  to  treat 
a  case,  one  will  have  to  rely,  to  a  great  extent,  on  the  history  of  the 
case,  paying  special  attention  to  the  character  of  the  injury  and  to 
the  agent  which  determines  the  lesion.  These  two  sub-divisions, 
although  somewhat  arbitrary,  are  yet  extremely  important  clini- 
cally, because  in  the  first  instance,  rest,  combined  with  strapping 
the  lower  half  of  the  left  thorax,  will  very  rapidly  give  relief, 
whereas,  in  the  more  serious  lesion  of  laceration,  unless  recourse  is 
had  to  immediate  operation,  the  patient  will  inevitably  die. 

These  injuries  are  not  infrequently  due  to  compression  accidents, 
such  as  are  met  with  amongst  railway  employees  or  in  large  works, 
where  men  are  jammed  against  some  resisting  wall,  etc.,  by  a  moving 
object,  or  to  direct  blows  over  the  organ,  such,  for  example,  as  in 
kicks  or  stabs.  The  cardinal  points  to  be  noted  are  great  pain 
accompanied  by  shock.  To  make  a  differential  diagnosis  between 
contusion  and  laceration  it  is  essential  to  observe  very  carefully 
and  frequently  the  facial  characteristics  and  the  pulse  rate.  On 
the  other  hand,  it  is  absolutely  essential  to  exclude  left  renal  injury. 
This  latter  can  easily  be  accomplished  by  establishing  the  presence 
or  absence  of  haematuria.  In  the  case  of  the  lacerated  spleen 
increasing  dulness  in  the  left  hypochondrium  will  occur,  whereas 
if  the  lesion  is  renal  the  colon  note  persists  whilst  the  flank 
becomes  fuller  and  more  resistant. 

It  is  evident  from  the  foregoing  that  the  treatment  in  the  two 
conditions  must  vary  widely.  In  contusion,  rest  (both  general 
and  local)  is  all  that  is  required;  in  laceration,  on  the  other  hand, 
operative  interference  at  the  earliest  moment  is  imperative. 
Operative  procedure  consists  in  either  suturing  the  rents  or  com- 
plete removal  of  the  organ. 

In  case  the  practitioner  is  compelled  to  operate,  owing  to 
circumstances  from  which  he  has  no  escape,  the  following  method 
should  meet  his  requirements.  After  the  administration  of  a  general 
anaesthetic  the  skin  of  the  abdomen  is  prepared,  and  an  incision  is 


8o  Injuries  of  the  Spleen. 

made  in  the  left  semi-lunar  line,  commencing  well  above  the 
thoracic  border ;  the  peritoneum  is  quickly  reached  and  opened. 
Blood  and  blood  clots  will  readily  escape.  After  sponging  the 
region  in  order  to  locate  the  ruptured  parts  and  to  facilitate 
reaching  the  organ  it  is  advisable  to  turn  the  patient  towards  the 
right  side,  and  by  placing  a  sand-bag  along  the  back  to  maintain 
that  position  during  the  search  for  the  rents.  These  can  either  be 
sutured  with  catgut  or  be  packed  with  gauze,  after  which  the 
wound  is  quickly  closed  up  to  the  gauze,  which  is  allowed  to  pro- 
trude through  it.  Saline  injections  per  rectum  (1  pint  every  four 
hours)  will  aid  in  combating  shock. 

ARTHUR    CONNELL. 


8i 


SURGICAL   TREATMENT  OF   DISEASES   OF   THE 

SPLEEN. 

"Wandering  Spleen.— This  is  a  condition  which  causes  dragging 
pain  and  inconvenience,  and  if  allowed  to  exist  untreated,  not 
uncommonly  gives  rise  to  alarming  symptoms  of  acute  pain, 
accompanied  by  vomiting,  with  marked  tenderness  of  that  part  of 
the  abdomen  occupied  by  the  displaced  organ. 

This  train  of  symptoms  is  brought  about  by  torsion  of  the  pedicle. 
When  the  lesion  occurs  in  the  female  beware  of  tight-lacing  and 
see  to  it  that  the  corset  is  abandoned.  The  condition  yields  in 
some  early  cases  to  a  well-fitted  abdominal  support.  If,  however, 
this  does  not  answer,  then  it  is  necessary  either  to  fix  the  spleen 
(splenopexy)  or  to  remove  it,  especially  in  cases  where  torsion  of 
the  blood-vessels  has  taken  place,  as  this  condition  is  always 
accompanied  by  a  local  peritonitis. 

Cysts  of  the  Spleen. — These  are  uncommon;  they  may  be  in 
order  of  frequency,  hydatid,  haemorrhagic  or  lymphatic.  They  give 
rise  to  increase  in  the  size  of  the  organ  and  a  tense  swelling  in  the 
left  hypochondriac  region.  The  only  treatment  is  removal  of  the 
spleen. 

Abscess  of  the  Spleen. — This  condition  arises  in  connection 
with  some  infective  diseases,  e.g.,  endocarditis,  enteric  fever,  etc., 
and  is  most  frequently  due  to  an  embolus.  It  causes  painful 
enlargement  of  the  organ,  with  extreme  tenderness  in  the  left 
hypochondrium.  The  abscess  is  dealt  with  by  incision  and 
drainage,  rarely  by  excision,  as  the  patient  is  invariably  in  such  a 
critical  condition  from  general  toxemia  that  such  a  severe  operation 
'is  contra-indicated. 

Sarcoma  of  the  Spleen. — This  is  the  primary  neoplasm  met 
with ;  it  grows  very  rapidly  and  is  very  painful.  Treatment  is 
immediate  removal  if  the  condition  is  recognised  early. 

Splenomegaly  with  Leucopenia  and  Progressive  Anaemia. 
— The  operation  of  splenectomy  for  this  condition  would  appear  to 
be  strongly  indicated,  as  there  are  an  increasing  number  of  cases 
in  which  a  favourable  result  has  been  obtained  (sec  pp.  42  and  83). 

ARTHUR  CONNELL. 

S.T. — VOL.  II.  6 


82 


SPLENOMEGALY. 

UNDER  the  name  of  "  splenomegaly  "  there  are  generally  included 
a  group  of  diseases  in  which  primary  enlargement  of  the  spleen  is 
associated  with  anaemia.  The  exact  relationship  of  these  maladies 
to  each  other  has  not  as  yet  been  accurately  determined.  Primitive 
splenomegaly,  splenic  anaemia  and  Banti's  disease  are  often  used 
as  synonymous  terms. 

Sir  W.  Osier  describes  three  stages  of  Banti's  disease.  In  the  first 
there  is  simple  splenomegaly,  in  the  second  there  is  in  addition 
secondary  anaemia,  pigmentation  of  the  skin  and  a  tendency  to 
hsematemesis,  in  the  third  there  is  cirrhosis  of  the  liver  with 
ascites.  The  term  "  Banti's  disease  "  is  most  frequently  applied  to 
cases  in  this  third  stage,  in  which  cirrhosis  of  the  liver  and  ascites 
are  associated  with  the  splenomegaly  and  anaemia.  The  disease  is 
a  very  chronic  one  and  may  last  for  ten  or  even  twenty  years. 
We  know  nothing  as  to  the  cause  of  the  malady,  so  that  treatment 
is  directed  to  the  improvement  of  the  general  condition  of  the 
patient  and  the  relief  of  symptoms  as  they  arise. 

General  Treatment. — It  is  of  much  importance  in  this  disease 
to  maintain  the  general  condition  of  the  patient  at  as  high  a  level 
as  possible.  Rest  or  only  a  limited  amount  of  exercise  should 
be  advised.  Freedom  from  laborious  occupation  and  wrorry  should 
be  secured  as  far  as  possible  according  to  the  circumstances  of  the 
patient.  As  much  time  as  possible  should  be  spent  in  the  open-air, 
preferably  in  a  climate  where  the  sun  shines  frequently.  The  food 
should  be  good  but  plain  and  abundant.  If  the  spleen  is  much 
enlarged  and  causes  discomfort  in  walking  the  support  given  by 
a  suitable  belt  will  be  helpful. 

Medicinal  Treatment. — When  the  anaemia  is  well  marked 
arsenic  and  iron  may  be  given.  Liquor  arsenicalis  [U.S.P.  Liquor 
potassii  arsenitis]  may  be  prescribed  in  doses  of  5  min.  three  times 
a  day.  This  dose  may  be  gradually  increased  up  to  7  or  10  min. 
The  results  obtained  by  the  use  of  arsenic  are  however  not  nearly 
so  striking  as  in  spleno-medullary  leukaemia.  Haematemesis,  when 
it  occurs,  should  be  treated  by  rest  in  bed,  rectal  feeding  for  two  or 
three  days  and  the  administration  of  adrenalin  chloride  solution 
(1  in  1,000)  in  10-min.  doses  every  two  or  three  hours. 

X-rays  maybe  applied  to  the  spleen  in  just  the  same  manner  as 


Splenomegaly.  83 

in  spleno-medullary  leukaemia  (q.v.).  Beneficial  effects  have  been 
obtained  by  E inborn.  As  far  as  my  own  experience  goes,  however, 
the  diminution  in  the  size  of  the  spleen  is  only  slight  and  not  to  be 
compared  with  that  which  takes  place  in  spleno-medullary 
leukaemia. 

Surgical  Treatment  has  proved  to  be  of  great  value  in  this 
disease.  In  suitable  cases  the  enlarged  spleen  can  be  removed 
with  a  good  prospect  of  a  complete  recovery  taking  place.  In 
thirty-two  cases  of  operation  collected  by  Armstrong  there  were 
twenty-two  complete  recoveries  (69  per  cent.)  and  nine  died  after 
the  operation.  The  chief  risks  are  from  haemorrhage  and  shock. 
As  long  as  there  is  not  a  severe  anaemia  the  risks  of  the  operation 
are  probably  well  represented  by  the  above  series.  After  a 
successful  operation  the  anaemia  disappears,  the  haemorrhages  no 
longer  recur  and  the  liver,  if  enlarged,  decreases  in  size.  In  the 
later  stages  of  the  disease  when  ascites  has  developed,  it  may  be 
treated  by  repeated  tapping,  or  the  operation  introduced  by  Dr. 
Drummond  and  Professor  Morison,  for  the  relief  of  ascites,  may  be 
combined  with  splenectomy,  as  in  a  successful  case  recorded  by 
Tansini. 


GEORGE  R.  MURRAY. 


BEFEREXCES. 


Hutchison,  E.,  Allbutt  and  Rolleston's  "System  of  Medicine,"  1909,  Vol.  V., 
p.  777.  Osier,  Sir  W.  L.,  "  Principles  and  Practice  of  Medicine,"  7th  ed.,  New 
York  and  London,  1910,  p.  762. 


6—2 


84 


CHRONIC   POLYCYTHJEMIA  WITH  CYANOSIS  AND 
ENLARGED    SPLEEN. 

THIS  disease  is  characterised  by  an  increase  in  the  number  of 
the  red  corpuscles  up  to  as  many  as  7  or  even  12  millions  per  cubic 
millimetre  of  the  blood,  and  is  a  result  of  a  morbid  activity  of  the 
erythroblastic  function  of  the  bone  marrow.  The  blood  is  also 
increased  in  volume  and  is  more  viscous  than  in  health.  The 
spleen  is  enlarged  and  the  skin  and  mucous  membranes  are 
cyanosed. 

The  cause  of  the  disease  is  unknown  and  so  the  treatment  con- 
sists chiefly  in  the  avoidance  of  anything  which  may  tend  to 
aggravate  the  condition  and  in  the  relief  of  sj'mptoms  as  they  arise. 
Improvement  has  been  observed  to  follow  spontaneous  haemorrhages, 
and  Dr.  F.  P.  Weber  mentions  that  in  a  case  under  the  care  of  Dr.  T. 
D.  Acland  bleeding  was  followed  by  temporary  relief  of  symptoms. 
The  removal  of  (5  or  8  oz.  of  blood  from  time  to  time  will  there- 
fore give  some  relief,  but  it  is  doubtful  whether  the  course  of 
the  disease  can  be  materially  affected  by  this  treatment. 

The  amount  of  food,  and  more  especially  of  red  meats,  should  be 
limited  and  no  excessive  eating  permitted.  Over-exertion  must  be 
carefully  avoided.  No  alcohol  should  be  taken. 

Removal  of  the  spleen  is  not  advisable,  as  the  operation  is 
dangerous  and  of  doubtful  benefit.  X-ray  Treatment  has  on  the 
whole  yielded  the  most  satisfactory  results,  as  in  favourable  cases 
the  spleen  may  decrease  in  size  and  the  red  blood  corpuscles 
diminish  in  numbers.  The  treatment  is  carried  out  in  the  same 
manner  as  in  leukaemia  (q.v.). 

Herschfeld  advises  the  administration  of  iodides  in  these  cases. 
All  preparations  of  iron  or  arsenic  should  be  avoided.  The  head- 
aches which  are  sometimes  troublesome  may  be  relieved  by  the  use 
of  nitrites.  A  3-min.  capsule  of  amyl  nitrite  may  be  used  for 
inhalation  ;  a  tablet  containing  T^Q  gr.  of  trinitin  may  be  taken  or 
1  or  2  gr.  of  sodium  nitrite  may  be  given  in  an  ounce  of  pepper- 
mint water  when  the  headache  comes  on. 

GEORGE    R.    MURRAY. 

BEFEREXCE. 

Weber,  F.  P.,  Allbutt  and  Bolleston's  "  System  of  Medicine,"  2nd  ed.,  1909, 
Vol.  V.,  p.  836.  • 


DISEASES  OF  THE   LIPS. 
HARELIP. 

THE  only  treatment  is  by  operation,  the  edges  of  the  cleft  being 
pared  in  a  suitable  manner  and  united  by  means  of  sutures. 
Simple  as  the  operation  is,  there  are  many  points  of  detail  to  which 
attention  must  be  paid  if  a  really  good  result  is  to  be  obtained. 
The  chief  difficulties  to  be  encountered  are  those  connected  with  the 
prominence  of  the  premaxillary  bone  or  bones,  in  cases  in  which 
the  harelip  is  associated  with  cleft  in  the  palate. 

Preliminary  Considerations. — Age  at  which  the  operation  should 
be  jH'i-formed.  Provided  that  the  infant  is  otherwise  healthy  and 
in  good  condition,  the  sooner  the  operation  is  performed  the  better. 
It  should  certainly  be  performed  within  the  first  few  weeks  of 
life,  and  there  is  no  objection  to  its  performance  within  the  first 
few  days. 

Owing  to  the  inability  of  the  infant  to  take  the  breast  (except  in 
slight  cases),  it  often  happens  that  the  subject  of  this  deformity 
wastes  rapidly  unless  great  care  is  exercised  in  feeding  by  artificial 
means.  A  very  early  operation  may  prevent  this  if  it  enables  the 
child  to  be  breast  fed  instead  of  hand  fed.  On  the  great  advantage  of 
breast  feeding  whenever  possible  it  is  unnecessary  to  dwell.  Many 
a  harelip  infant  is  not  seen  by  the  surgeon  until  it  is  already  in  an 
emaciated  condition.  Such  children  should  not  be  operated  on  at 
once.  They  should  be  carefully  and  judiciously  fed  with  milk 
(administered  best  by  means  of  a  spoon  and  very  slowly),  until  a 
better  condition  of  nutrition  is  attained.  Even  a  week  or  two  of 
careful  preliminary  feeding  by  a  skilled  nurse  will  often  make  all 
the  difference  between  success  and  failure  of  the  subsequent  opera- 
tion. If  an  infant  is  so  wasted  and  feeble  that  it  is  likely  to  die  of 
marasmus,  the  performance  of  any  surgical  operation  will  not 
improve  its  chance  of  life.  But  careful  feeding  will  do  so,  and  will 
frequently  effect  so  much  improvement  in  the  general  condition 
that  the  operation  may  then  be  performed  with  every  prospect  of 
success.  Similarly,  if  the  child  is  suffering  from  catarrh,  diarrhoea, 
or  other  infantile  ailment,  treatment  should  be  directed  to  the  cure 
of  these  before  operation  is  undertaken. 

The  main  object  of  a  harelip  operation  should  be,  not  merely  to 


86 


Harelip. 


restore  the  lip  to  its  normal  condition  as  regards  both  height  and 
thickness,  but  also  to  insure  that  no  notch  is  left  either  in  the  free 
edge  of  the  lip  or,  much  more  important,  in  the  lower  border  of  the 
skin  area. 

But  in  most  cases  of  harelip  the  deformity  to  be  remedied  involves 
not  only  the  lip  but  also  the  nostril.  In  cases  of  harelip  associated 
with  complete  cleft  palate,  and  in  a  few  others,  the  treatment  of  the 
premaxillary  bones  also  requires  consideration.  We  will  deal  with 
each  of  these  three  parts  separately. 

THE  LIP. 

Single  Harelip. — The  edges  of  the  cleft  should  be  pared  with  a 
very  sharp  knife  in  such  a  manner  that  the  raw  surfaces  involve 

the  whole  thickness  of  the  lip. 
If  this  is  not  done  the  lip  will 
afterwards  be  thin  and  unsightly 
along  the  line  of  union. 

In  cases  of  incomplete  harelip 
it  is  rarely  sufficient  to  pare 
merely  the  edges  of  the  actual 
cleft.  The  incisions  should  be 
prolonged  upwards  to  the  nostril 
in  the  form  of  an  inverted  V,  the 
apex  of  which  should  be  at  the 
margin  of  the  nostril.  The  thin 
and  sometimes  discoloured  tissues 
which  often  exist  between  the 
nostril  and  the  apex  of  the  actual 
cleft,  should  always  be  cut  freely 
away  (Figs.  1,  2  and  3).  An  opera- 
tion sometimes  advised  for  incomplete  harelip  consists  in  making  an 
inverted  V  incision  close  to  the  margin  of  the  cleft.  This  V  is 
thus  converted  into  a  diamond-shaped  space  by  simply  drawing 
downwards  the  tissues  below  the  incision.  This  operation  affords 
but  a  poor  result,  and  is  not  to  be  recommended.  "When  the  sides 
of  the  diamond  are  sutured  laterally  an  ugly  prominence  will  be 
found  at  the  upper  end  of  the  line  of  union.  The  only  cases  in 
which  such  an  operation  may  be  permissible  are  the  very  slight  ones 
in  which  just  the  edge  only  of  the  lip  is  cleft,  and  some  few  cases  of 
secondary  operation  in  which,  after  a  harelip  has  been  sutured,  a 
small  triangle  of  mucous  membrane  has  been  left  by  error  projecting 
upwards  into  the  area  of  white  skin.  But  even  in  these  last  com- 
plete excision  of  the  red  triangle  generally  yields  a  better  result. 


FIG.  1. — Single  incomplete  harelip. 
Note  the  thinness  of  the  tissues 
below  the  right  nostril. 


Harelip.  87 

Mere  paring  of  the  actual  edge  of  a  harelip  is  not  enough.  If 
nothing  more  is  done  it  will  be  found  that  after  suture  a  notch  has 
been  left  in  the  lower  margin  of  the  lip.  There  are  several  methods 
by  which  the  occurrence  of  this  notch  may  be  avoided. 

(1)  The  incision  may  be  carried  for  some  little  distance  downwards 
and  outwards  beyond  the  actual  cleft  along  the  line  of  junction  of 
skin  and  mucous  membrane.     The  incision  is  then  turned  sharply 
inwards  at  an  acute  angle,  cutting  nearly  transversely  through  the 
red  margin  of  the  lip.     By  this  means  little  triangles  of  red  lip  are 
formed  which  when  sutured  together  fill  up  the  notch  that  otherwise 
would  be  left. 

(2)  If  these  triangles  of  red  tissue  are  not  sufficient  the  lower  part 
of  the  incision  should  be  carried  for  a  short  distance  into  the  white 


FIG.  2. — Lines  of  incision. 


FIG.  3. — Single  incomplete  harelip, 
showing  bridge  of  normal  tissues 
above  the  cleft  and  lines  of  incision. 


portion  of  the  lip,  before  being  turned  inwards.  The  flap  thus 
formed  is  covered  partly  by  skin  and  partly  by  mucous  membrane. 
In  each  case  the  longer  limb  of  the  incision  should  be  equal  to  the 
height  of  the  normal  skin-covered  lip  and  mucous  membrane. 

(3)  A  similar  object  is  attained  by  paring  the  sides  of  the  cleft  in 
a  curved  direction.     The  incision  in  this  case  is  carried  with  its 
convexity  outwards,  with  the  substance  of  the  lip  well  outside  the 
mucous  margin  of  the  cleft.     The  curved  surfaces  thus  produced, 
when  straightened  out,  equal  the  vertical  height  of  the  normal  lip. 

By  each  of  the  above  methods,  two  symmetrical  flaps  are  formed, 
one  on  each  side  of  the  cleft. 

(4)  Another  method  consists  in  cutting  a  single  and  somewhat 
larger  flap  from  one  side  only  (Figs.  2 — 5).     On  the  inner  side  of  the 
cleft  the  incision  is  made  from  the  nostril  downwards  along  the  line 
of  junction  of  skin  and  mucous  membrane,  and  thus  carried  in  a 


88 


Harelip. 


sloping  direction  towards  the  middle  line  at  the  free  margin  of  the 
lip.  The  whole  of  the  paring  is  then  removed.  On  the  other 
(outer)  side  of  the  cleft,  the  incision  beginning  at  the  nostril,  is 


FIG.  4. — Single  complete  harelip. 


FIG.  5. — Lines  of  incision. 


carried  at  first  vertically  downwards.  It  then  slopes  gradually 
downwards  arid  outwards  into  the  substance  of  the  lip.  At  a  point 
some  little  distance  above  the  lower  margin  of  the  skin  it  is  turned 
abruptly  inwards  and  downwards  to  the  free  margin  of  the  lip.  A 


FIG.  6. — Double  incomplete  harelip. 


FIG.  7. — Lines  of  incision. 


triangular  flap  covered  partly  by  skin  and  partly  by  mucous 
membrane  is  thus  formed.  The  angular  raw  surface  is  then  sutured 
to  the  raw  surface  on  the  opposite  side  of  the  cleft.  Whatever 
method  of  incision  is  adopted,  care  must  be  taken  to  insure  that 


Harelip. 


after    suture  the  lower  edge  of  the  skin-covered  area  forms   an 
unhroken  line. 

Various  other  more  complicated  methods  have  been  described  by 
which  Z-shaped  and  other  incisions  have  been  used  in  the  paring 
of  the  edges.  The  sup- 
posed object  of  most  of 
them  is  to  enable  the 
edges  of  a  wide  cleft  to 
be  brought  together. 
They  are  unnecessary, 
and  they  leave  irregular 
unsightly  scars. 

It  cannot  be  too 
strongly  insisted  upon 
that,  if  the  cleft  is  wide, 
it  is  by  free  undercutting 
of  the  outer  portions  of 


FIG.  8. — Double  complete  harelip. 


the  lip  and  nostril  that 
relief  of  tension  is  to  be 
obtained,  not  by  ingenious  and  complicated  methods  of  paring  the 
edges.  The  curved  incisions  sometimes  made  through  the  skin  and 
round  the  lower  margin  of  the  aia  of  the  nostril  are  never  necessary. 
Double  Harelip. — The  incisions  in  this  case  have  to  be  planned 
so  that  the  outer  edges  of  the  clefts  can  be  united  partly  to  each 
other  and  partly  to  the  central  portion  of  the  lip  which  remains 

attached  to  the  septum  of  the  nostril. 
This  portion  can  generally  be  utilised 
to  form  the  upper  part  of  the  centre  of 
the  new  lip.  If  it  is  drawn  too  far  down- 
wards, the  tip  of  the  nose  becomes  de- 
pressed in  an  unsightly  manner  (Figs. 
G — 9).  Occasionally  it  is  advisable  to 
dissect  up  this  little  flap  of  skin  and 
utilise  it  in  the  formation  of  a  better 
columna  nasi.  The  outer  sides  of  the 

cleft  are  then  united  directly  to  each  other.  The  paring  of  the  outer 
margins  of  the  cleft  is  a  little  more  complicated  than  in  single  harelip. 
The  best  procedure  is  that  of  paring  vertically  downwards  along 
the  skin  margin  until  the  red  mucous  lower  border  of  the  lip  has 
been  reached.  The  upper  twcvthirds  of  the  flap  thus  formed  is 
then  cut  completely  away.  The  lower  third  is  turned  downwards 
and  joined  with  its  fellow  of  the  opposite  side  to  form  the  central 
prominence  of  the  lip. 


FIG.  9. — Lines  of  incision. 


9o 


Harelip. 


THE    NOSTRIL. 

In  all  cases  of  complete  and  in  many  of  incomplete  harelip  the 
nostril  of  the  affected  side  is  widened  and  flattened.     In  remedying 


Right  nostril 


Bony  edge  of  [ 
left  nostril   J 


R.  Maxilla 


/"Inner  surface 

-  •      of     splayed 
^    left  nostril 

~  Lip  everted 

-  Incision  for  re- 

flection of  lip 
and  cheek 


Premaxilla      j        \       L.  Maxilla 
Septum  nasi        L.  turbinate  bones 

FIG.  10. — Single  complete  harelip  and  cleft  palate,  showing  on  the  left  side  the  incision 
for  reflection  of  the  lip  and  cheek.     Cheek  compressor  shown  on  the  left  side  only. 

the  deformity  care  must  be  taken  to  round  up  the  nostril  and  so  to 
make  it  of  the  same  shape  as  its  fellow.      To  do  this  it  is  necessary 


Raw  surface  of 
pared  lip 

Intra-nasal  suture 


Raw  surface  of 
pared  lip 


FIG.  11. — Single  complete  harelip,  showing  pared  edges  and  insertion  of  intra-nasal 

suture. 

• 

to  undercut  the  ala  of  the  nostril  and  the  neighbouring  portion  of 
lip  where  it  is  attached  to  the  gum. 

The  wider  the  cleft  the  more  undercutting  is  necessary  to  enable 


Harelip.  91 

the  parts  to  be  brought  together  without  undue  tension.  On  the 
inner  (median)  side  of  the  cleft  very  little  undercutting  is  desirable 
or  possible,  since  the  soft  tissues  are  thin  and  division  of  the  artery 
of  the  septum  is  apt  to  cause  troublesome  haemorrhage.  The  outer 
margin  of  the  cleft  being  everted,  an  incision  is  made  in  the 
direction  shown  in  Fig.  10.  The  edge  of  the  knife  must  be  kept 
quite  close  to  the  bone  to  prevent  undue  haemorrhage,  and  the  soft 
parts  of  the  lip,  nostril  and  cheek  dissected  up  as  far  as  may  be 
necessary.  Haemorrhage  is  checked  by  sponge  pressure. 

The  point  of  the  needle  is  first  inserted  on  the  inner  aspect  of  the 
ala  and  passed  deeply  into  its  substance  (Fig.  11).  The  needle  is  then 
carried  across  the  cleft  and  passes  in  a  similar  manner  through  the 
inner  margin  of  the  nostril.  The  soft  tissue  in  this  situation  being 
thin,  it  is  often  advisable  to  pass  the  suture  deeply  so  as  to  include 
part  of  the  cartilaginous  septum.  When  this  suture  has  been  tied, 
the  knot  will  lie  wholly  within  the  nostril.  The  ends  should  be  cut 
long  so  as  to  facilitate  subsequent  withdrawal.  This  suture  should 
be  left  in  situ  for  several  days,  as  it  is  very  important  that  the 
tissues  which  it  unites  should  adhere  firmly.  Premature  with- 
drawal is  likely  to  be  followed  by  gaping  of  the  wound.  This 
means  an  unsightly  red  area  near  the  nostril  and  a  permanent 
widening  of  the  nostril  itself.  The  scar  left  by  the  suture,  being 
within  the  nostril,  is  not  visible  and  is  of  no  importance. 

THE    PREMAXILLARY    BONES. 

Single  Harelip. — In  those  cases  in  which  the  harelip  is 
associated  with  complete  cleft  plate  the  premaxillary  bones  project 
forward,  carrying  with  them  the  central  portion  of  the  lip.  As  a 
rule,  it  is  not  necessary  to  do  anything  to  replace  these  bones 
(Figs.  12 — 14).  Provided  that  the  soft  tissues  on  the  outer 
side  of  the  fissure  be  undercut  sufficiently,  it  will  be  possible  to 
bring  the  edge  of  the  harelip  together  without  undue  tension. 

But  in  some  few  cases  of  very  marked  projection  of  the  bones  and 
unusually  wide  cleft  it  is  desirable  to  attempt  some  reposition  of 
the  bones.  This  is  best  done  with  a  pair  of  bone  forceps,  the  blades 
of  which  are  inserted  between  the  maxillary  and  the  premaxillary 
of  the  unaffected  side.  By  closing  the  blades  very  slowly  the 
tissues  are  partly  cut  and  partly  crushed,  and  the  united  pre- 
maxillary bones  are  forced  backwards  towards  the  cleft  in  the 
palate  by  a  rotary  movement  of  the  forceps. 

The  chief  objection  to  this  proceeding  is  the  damage  which 
is  likely  to  be  inflicted  on  the  teeth  and  the  consequent  irregularity 
in  their  subsequent  eruption. 


Harelip. 


If  the  margins  of  the  cleft  in  the  alveolar  margin  can  be  closely 
approximated  it  is  sometimes  advisable  to  pare  them  and  to  fasten 

them  together  by  means  of 
a  stout,  silver  wire  passed 
through  the  bones.  But 
this  proceeding  is  rarely 
necessary,  and  is  also  open 
to  the  objection  above 
mentioned,  that  of  causing 
damage  to  the  teeth. 

Double  Harelip.—  The 
bony  deformity  in  these 
cases  is  much  more  serious 
and  usually  demands  some 
operative  interference  be- 
fore the  soft  tissues  of  the 
lip  can  be  sutured  (Fig.  15). 
It  may  be  dealt  with  by 
operation  (1)  upon  the  pre- 
maxillary  bones  themselves ; 
(2)  upon  the  septum. 

(1)  The  easiest  method 
is  that  of  removal  of  the 
premaxillary  bones.  This, 
although  often  performed, 
is  open  to  very  serious  ob- 
jection. The  loss  of  the  bones  leads  to  the  falling  together  of  the 
neighbouring  maxillaries,  and  a  contracted,  pointed  arch  ensues. 
The  unsupported  upper  lip  falls  in  and 
produces  a  most  unsightly  prominence  of 
the  lower  lip.  A  somewhat  less  unsatis- 
factory result  is  produced  by  scooping  out 
the  incisor  teeth  and  leaving  the  rest  of 
the  bones  in  situ.  But  here,  too,  the  loss 
of  the  teeth  leads  to  more  or  less  faulty 
development  of  the  alveolar  arch. 

(2)  A  better  method  is  that  of  operat- 
ing upon  the  septum,  by  removing  a  V- 
shaped  portion.  The  projecting  pre- 
maxillary bones  can  then  be  pushed  back- 
wards into  the  normal  position.  It  is  not  necessary  to  remove  any 
of  the  soft  tissues  of  the  septum. 

A    straight   incision    about   1   inch  long  (see  Fig.   16)  is  made 


FIG.  12. — Single  complete  harelip  with  marked 
prominence  of  the  premaxillary  bones. 
(From  a  photograph  taken  just  before  the 
operation  on  the  lip  at  the  age  of  three 
months.  No  attempt  was  made  to  replace 
the  projecting  bones  or  to  interfere  with 
them  in  any  way.) 


FIG.  13. — Lines  of  incision. 


Harelip. 


93 


*****  , 

l 


FIG.  14.  —  The  same  patient  nine 
years  later,  showing  that  the  pre- 
maxillary  bones  have  spontane- 
ously returned  to  the  normal  posi- 
tion and  that  there  is  no  undue 
falling  in  of  the  upper  lip.  (The 
irregularity  near  the  right  nostril 
is  merely  an  accidental  patch  of 
Herpes.) 


along    the    anterior    part    of    the 

free  lower  margin  of  the  septum. 

With    a    raspatory     the     perios- 
teum and   the  other   soft  tissues 

are  detached  on  each  side.     With 

a     pair    of     sharp-pointed     bone 

scissors  a  triangular  piece  of  the 

cartilaginous     septum     is     then 

removed.     The    piece   of    septum 

removed  must    be    large    enough 

to  allow  of  the  premaxillary  bones 

being    pushed    back    into    place. 

This    method   is,    on    the   whole, 

the    best    for     most     really    bad 

cases  of  double  harelip.     The  chief 

objection   to   it  is  that  owing  to 

the    rotation    of    the    bones    the 

incisor   teeth   when   erupted  tend 

to  project  backwards  towards  the 

cavity  of  the  mouth.     This  irregularity  must  be  corrected  later  by 

ordinary  dental  means. 

A  method  that  I  have   of    late    years    adopted    in  a  few  cases 

with  considerable  success  is  that  of 
preserving  the  septum  and  pre- 
maxillaries  intact  and  uniting  the 
lip  in  front  of  them.  But  to  do  this 
without  producing  undue  tension 
requires  very  free  undercutting  on 
both  sides,  and  the  operation  is  not 
always  possible.  It  is  generally  best 
when  attempting  this  operation  to 
unite  one  side  only  of  the  lip  at  first 
to  the  central  portion.  After  a  delay 
of  a  few  weeks  it  is  usually  possible 
to  close  the  remainder  of  the  cleft 
without  causing  too  much  tension. 
The  result  obtained  by  this  method 
when  it  is  successful  is  superior  to 
that  of  any  other,  as  the  falling  in 
of  the  upper  lip  is  wholly  avoided. 

After  -  treatment.  --  The  best 
dressing  for  a  harelip  operation  is  a 
layer  of  flexible  collodion.  Over  this 


FlG.  15. — Side  view  of  a  case  of 
double  complete  harelip  and  cleft 
palate  showing  the  usual  projec- 
tion of  the  premaxrllary  bones, 
and  of  the  central  portion  of  the 
Up. 


94  Harelip. 

a  dumbbell-shaped  piece  of  strapping  may  be  applied  to  relieve 
tension.  This  should  have  broad  ends  which  are  applied  to  the 
cheeks.  The  soft  tissues  of  the  lips  and  cheeks  should  be  approxi- 
mated with  finger  and  thumb  before  the  strapping  is  applied.  The 
strapping  is  apt  to  become  sodden  by  secretions  from  the  nose  and 
mouth,  and  may  become  a  source  of  infection.  For  this  reason, 
especially  in  cases  where  there  is  not  much  tension,  it  is  often 
better  to  dispense  altogether  with  its  use. 

The  child  should  be  fed  with  milk  administered  slowly  and 
carefully  by  means  of  a  spoon. 

One  or  more  of  the  stitches  should  be  removed  on  the  third  or 


FIG.  16. — The  same  case  as  Fig.  15  seen  from  below.  The  dotted 
line  shows  incision  for  removal  of  a  wedge  of  septum.  Note  the 
usual  deviation  of  the  septum  to  one  side.  The  mouth  is  held 
open  by  a  Smith's  gag. 

fourth  day  and  the  remainder  of  those  in  the  skin  a  day  or 
two  later.  The  stitch  in  the  nostril  and  any  that  have  been 
inserted  on  the  mucous  surface  may  be  left  in  situ  for  several  days 
longer.  It  should  be  remembered  that  stitches  in  the  white  skin 
surface,  if  left  more  than  three  days,  are  likely  to  leave  visible 
scars.  On  the  other  hand,  if  they  are  removed  prematurely  the 
edges  of  the  wound  are  apt  to  separate. 

SECONDARY  OPERATIONS. 

If  within  a  few  days  of  the  operation  separation  of  the  line  of 
union  has  occurred  in  part  or  the  whole  of  the  wound,  it  may  still 
be  possible  at  once  to  repair  the  mischief,  at  any  rate  partially. 


Harelip.  95 

One  or  more  stitches  should  be  passed  through  the  lip  and  the 
granulating  surface  again  brought  into  apposition. 

If  the  separation  has  been  caused,  however,  as  it  usually  has,  by 
marked  septic  infection  of  the  raw  areas,  it  is  better  to  clean  the 
wound  by  means  of  some  simple  dressing,  and  to  postpone  further 
operative  measures  until  the  parts  have  healed. 

Most  secondary  operations  for  harelip  are  done  at  a  later  stage 
for  the  improvement  of  a  badly  united  harelip.  The  common 
faults  that  most  often  require  remedy  are  undue  flattening  of  the 
nostril,  the  occurrence  of  a  notch  or  of  a  red  triangle  at  the  upper 
or  lower  border  of  the  lip,  or  an  undue  thinness  of  the  lip  along  the 
whole  line  of  union. 

In  really  bad  cases  where  much  deformity  exists  it  is  best  to  cut 
right  through  the  whole  lip,  excise  the  scar,  and  do  the  whole 
operation  over  again.  If  the  fault  is  merely  the  existence  of  a 
small  red  triangle  in  the  cutaneous  area,  it  may  suffice  to  excise 
this,  and  to  treat  by  one  of  the  methods  already  described  under 
incomplete  harelip. 

Faulty  union  in  the  neighbourhood  of  the  nostril  usually  requires 
considerable  reconstruction  of  the  lip,  with  free  undercutting  of  the 
lip  and  nostril. 

JAMES    BERRY. 


%*  The  Illustrations  in  this  article  are  taken  from  Berry  and  Legg's  "Hare- 
Lip  and  Cleft- Palate." 


OTHER  AFFECTIONS  OF  THE  LIPS. 

AFFECTIONS  of  the  lips  other  than  congenital  malformations  may 
conveniently  be  considered  under  three  divisions  :  (1)  Acquired 
deformities ;  (2)  inflammatory  affections  ;  (3)  new  growths  (innocent 
and  malignant). 

(1)  Acquired  Deformities  demanding  surgical  treatment  are 
those  due  to  (a)  injuries  of  various  kinds,  including  burns  and  those 
produced  by  surgical  operations  for  the  removal  of  tumours  ;  (/>)  in- 
flammatory diseases,  such  as  cancrum  oris,  tuberculosis,  syphilis, 
etc.,  which  have  led  to  actual  destruction  of  the  tissues  of  the  lips. 

Lacerated  and  incised  wounds  which  have  been  allowed  to 
heal  with  faulty  approximation  of  the  surfaces  are  best  treated  by 
reopening  freely  along  the  line  of  scar,  cutting  away  if  necessary 
redundant  scar  tissue,  replacing  the  parts  in  correct  position,  and 
accurately  uniting  the  freshly  made  raw  surfaces.  The  same 
principles  that  guide  us  in  the  treatment  of  harelip  apply  here 
also,  care  being  taken  to  undercut  if  necessary  the  parts  that  are 
attached  to  the  bone  so  as  to  allow  of  accurate  suturing  without 
undue  tension.  As  in  harelip,  the  line  of  junction  between  skin 
and  mucous  membrane  should  be  restored  as  accurately  as  possible 
if  a  good  result  from  an  artistic  point  of  view  is  to  be  obtained.  If 
actual  loss  of  substance  has  occurred,  very  free  undercutting  will 
be  required,  and  it  will  often  be  necessary  to  carry  incisions  far 
beyond  the  originally  wounded  area,  so  as  to  obtain  one  or  more 
flaps  of  tissue  with  which  to  fill  up  the  gap  in  the  lip. 

For  an  extensive  reconstruction  of  the  lower  lip  it  will  be  neces- 
sary to  carry  curved  incisions  below  the  chin  on  one  or  both  sides, 
and  to  dissect  up  freely  on  either  side  of  the  chin. 

Deformities  due  to  loss  of  substance  from  infective  diseases 
(tubercle,  syphilis,  etc.)  should  not  be  treated  by  operation  until 
the  primary  disease  has  been  thoroughly  cured  and  the  parts  are 
in  a  healthy  condition.  They  may  then  be  dealt  with  on*  the 
principles  already  described. 

(2)  Inflammatory  Affections  of  the  lips  do  not  differ  in  their 
treatment  from  similar  affections  elsewhere  and  do  not  require 
special  mention  here.  The  treatment  of  tuberculous,  syphilitic 
and  other  innocent  forms  of  ulceration  is  the  treatment  (local  and 
general)  of  the  primary  disease  (see  under  Tubercle,  Syphilis,  etc.). 


Affections  of  the  Lips.  97 

(3)  New  Growths. — Imior,'nt  tumours  such  as  adenomata, 
papillomata  and  mucous  cysts,  rarely  attain  a  large  size  and  may 
be  treated  easily  by  free  excision.  Care  should  be  taken  that  in 
the  healing  of  the  wounds  so  made  contraction  and  deformity  do 
not  occur. 

In  the  case  of  tumours,  such  as  adenomata  and  cysts,  which 
project  on  the  mucous  surface  of  the  lips,  as  much  as  possible  of 
the  mucous  membrane  should  be  preserved  to  form  a  covering  for 
the  raw  surface  produced  by  the  operation. 

Large  nsevi  (including  the  so-called  aneurysm  by  anastomosis) 
not  uncommonly  affect  the  lips  and  often  require  formidable 
operations  for  their  removal. 

If  not  suitable  for  electrolysis,  which  is  the  best  treatment  in 
most  cases,  they  must  be  excised.  Haemorrhage  is  the  main 
danger  of  such  operations,  and  is  especially  to  be  feared  if  the 
tumour  extends,  as  it  so  often  does  into  the  neighbouring  parts  of 
the  face.  Whenever  possible,  flaps  of  mucous  membrane  should  be 
turned  back  from  the  surface  of  the  tumour.  One  or  more 
incisions  may  have  to  be  made  in  the  skin  to  obtain  free  access  to 
the  growth,  and  the  surgeon  should  aim  as  far  as  possible  at 
cutting  through  the  healthy  tissue  in  the  neighbourhood  of  the 
tumour  rather  than  through  the  very  vascular  tumour  itself. 
Ligature  of  masses  of  nrevoid  tissue  that  cannot  be  removed  with 
the  knife  may  have  to  be  combined  with  excision  of  the  more 
accessible  portions. 

Maliijnant  tumours  that  are  especially  prone  to  affect  the  lips 
are  rodent  ulcer  and  carcinoma  (epithelioma).  Rodent  ulcer  is 
generally  best  treated  nowadays  by  X-rays  or  radium,  but  if  these 
forms  of  treatment  are  not  available,  free  excision  is  required.  It 
is  important  to  bear  in  mind  that  rodent  carcinoma  spreads  beneath 
the  skin  for  some  little  distance  beyond  the  visible  area  of  ulcerating 
disease.  The  lines  of  incision  for  its  removal  should,  therefore, 
always  be  at  least  £  inch  away  from  the  apparent  margin  of  the 
disease.  It  is  essentially  a  local  disease,  capable  of  complete 
eradication  by  a  sufficiently  thorough  operation.  Recurrence  after 
removal  would  not  be  nearly  as  common  as  it  is  were  the  surgeon 
to  pay  more  attention  in  the  first  instance  to  the  complete  removal 
of  the  disease  and  less  to  the  deformity  he  is  causing  by  his 
operation.  The  deformity  can  subsequently  be  remedied  if 
necessary  by  a  plastic  operation. 

Incomplete  removal  leads  to  further  operations  which  often,  in 
the  end,  lead  to  far  more  deformity  than  would  originally  have 
been  produced  by  a  really  thorough  operation. 

S.T. — VOL.  n.  7 


98  Affections  of  the  Lips. 

In  the  treatment  of  epithelioma  of  the  lips  similar  principles 
apply.  The  disease  is  essentially  a  local  one,  and  in  its  early 
stages  at  least  it  is  readily  curable,  and  completely  curable,  if  only 
it  is  thoroughly  removed  with  a  sufficiency  of  surrounding  parts, 
together  with  the  neighbouring  lymphatic  glands. 

When  the  disease  is  confined  to  the  free  margins  of  the  lip  it 
can  readily  be  removed,  although  some  undercutting  of  the  soft 
parts  from  the  neighbouring  bone  will  often  be  necessary  to 
minimise  the  resulting  deformity. 

When  the  disease  is  close  to,  or  is  involving,  the  jaw  a  much  more 
extensive  operation  is  required,  and  it  may  even  in  some  cases  be 
necessary  to  leave  a  large  open  wound  to  be  closed  subsequently  by 
a  secondary  plastic  operation. 

In  the  planning  of  an  operation  for  the  removal  of  a  carcinoma 
of  the  lip  the  path  of  infection  pursued  by  the  disease  should  not 
be  forgotten,  and  the  excision  of  neighbouring  tissues  should  be 
much  more  free  in  this  direction  than  in  any  other. 

In  order  to  fill  up  the  gap  left  after  an  extensive  excision  it  is 
often  necessary  to  carry  curved  incisions  well  below  the  chin  and 
to  dissect  up  extensive  flaps  of  soft  tissues,  in  order  to  effect  a  good 
restoration  of  the  lip. 

Thorough  removal  of  the  neighbouring  lymphatic  glands  should 
always  be  performed  either  at  the  time  of  the  primary  operation  or 
a  few  weeks  later. 

JAMES  BERRY. 


99 


DISEASES  AND  AFFECTIONS  OF  THE  JAWS. 

FRACTURES  OF  THE  JAWS. 

The  Upper  Jaw. — The  upper  jaw  is  comparatively  rarely  the 
seat  of  fracture  and  then  usually  as  the  result  of  direct  violence 
by  some  smashing  or  crushing  blow.  The  fracture  may  merely 
implicate  one  of  the  processes  of  the  maxilla,  the  nasal  or  alveolar 
processes  or  the  orbital  plate  being  the  most  likely  to  suffer  in  this 
way  ;  or  the  whole  body  of  the  bone  may  be  smashed  in  towards 
the  antrum,  and  in  this  case  the  fracture  will  probably  extend  to 
the  ethmoid  and  sphenoid  bones  and  thus  involve  the  base  of  the 
skull.  Certain  complications  may  attend  these  fractures  owing  to 
the  anatomical  relations  of  the  maxilla  to  blood-vessels,  air  spaces 
and  nerves.  These  are:  (1)  Epiphora  from  injury  of  the  nasal  duct ; 
(2)  surgical  emphysema  from  a  communication  of  the  cavity  of  the 
antrum  with  the  subcutaneous  tissues ;  (3)  severe  haemorrhage  from 
branches  of  the  internal  maxillary  artery  ;  this  may  occur  into 
the  nose  or  pharynx,  or  more  commonly  as  a  large  subcutaneous 
hfematoma  ;  (4)  anaesthesia  of  the  cheek,  teeth  and  lips  from  sever- 
ance of  the  infra-orbital  nerve.  Owing  to  the  abundant  blood  supply, 
suppuration  or  necrosis  is  very  rare,  whilst  union  is  firm  and  rapid. 

The  chief  indications  for  treatment  are  :  (1)  The  prevention  of 
facial  deformity ;  (2)  correction  of  dental  displacement ;  and  (3)  cure 
of  epiphora. 

(1)  The    Prevention    of  Facial    Deformity. — If   the    injury  has 
been  the  result  of  a  penetrating  wound,  e.g.,  that  of  a  bullet  or  a 
spike,  it  is  best  to  deal  with  the  resulting  deformity  by  enlargement 
of  the  external  wound  and  a  replacement  or  removal  of  displaced 
bony  splinters.     If  the  malar  process  has  been  violently  impacted 
into  the  antrum,  it  will  be  necessary  to  turn  up  the  upper  lip,  incise 
the  mucous  membrane  at  the  junction  of  the  cheek  and  gums  and 
by  careful  leverage  attempt  to  prise  out  the  impacted  fragments. 
A  gauze  drain  is  left  in  the  antrum  and  brought  into  the  mouth. 

(2)  Correction  of  Dental   Displacement. — If  the  alveolar  border 
is  broken   off  from  the  body  of  the  jaw  the  utmost  care  will  be 
necessary  to  prevent  the  loss  of  the  teeth  or  their  displacement. 
The  deformity  should  be  corrected  by  digital  pressure  under  an 
anaesthetic  and  when  the  teeth  of  the  two  jaws  have  been  brought 

7—2 


ioo  Fractures  of  the  Jaws. 

into  correct  apposition,  a  firm  jaw  bandage  is  applied  and  kept  in 
position  for  a  week  or  ten  days,  the  patient  being  fed  by  a  tube 
placed  between  tbe  cheek  and  the  teeth. 

(3)  Cure  of  Epiphora. — Epiphora  which  results  from  an  injury 
of  the  nasal  duct  usually  subsides  spontaneously  within  a  few  days, 
being  due  then  merely  to  laceration  and  congestion  of  the  mucous 
membrane  lining  its  interior.  If,  however,  it  persists  the  lachrymal 
sac  must  be  opened  and  metal  sounds  passed  down  into  the 
nose  in  order  to  re-establish  its  patency. 

The  other  complications  of  fractured  upper  jaw,  e.g.,  ecchymosis, 
anaesthesia  and  emphysema,  do  not,  as  a  rule,  require  any  special 
treatment. 

Separation  of  the  Upper  Jaws  from  the  Skull. — This  rare 
accident,  which  results  from  severe  crushing  injuries,  is  known  as 
Guerin's  fracture.  Both  superior  maxillae,  together  with  the  palate 
bones,  are  displaced  from  their  attachments  to  the  cranium.  This 
involves  fracturing  of  the  pterygoid  plates  of  the  sphenoid  and  of  the 
malar  bones. 

The  treatment  consists  in  an  attempt  at  reduction  of  the 
deformity  under  an  anaesthetic.  If  this  can  be  successfully 
accomplished  there  is  not  much  liability  to  recurrence  provided  that 
the  jaws  are  kept  at  rest  by  firm  bandaging. 

Fracture  of  the  Lower  Jaw. — This  fracture  is  comparatively 
common  and  the  innumerable  devices  which  have  been  and  still  are 
suggested  for  its  treatment  show  how  difficult  it  has  been  for 
successful  cure.  It  is  necessary  to  classify  the  cases  according  to 
the  locality  and  nature  of  the  fracture  as  follows :  (1)  Fractures  of 
the  body,  i.e.,  the  tooth-bearing  region  of  the  jaw :  these  are 
always  compound  :  (a)  Unilateral :  the  bone  is  usually  broken  in 
front  of  the  mental  foramen  in  the  socket  of  the  canine  tooth. 

(b)  Bilateral :    the    symphysis   and  anterior  part  of  the  jaw  are 
separated  from  the  remaining  portions  and  are  displaced  downwards 
by  the  attachment  of  the  geniohyoid  and  geniohyoglossi  muscles. 

(c)  Median :    this  is  the  rarest  of  the  varieties  because  the  sym- 
physis is  the  strongest  part  of  the  jaw.     It  results  from  indirect 
violence,  as,  for  example,  when  the  head  is  run  over  and  the  two 
sides  of  the  jaw  are  forcibly  compressed. 

(2)  Fractures  of  the  ramus  and  its  condylar  or  coronoid  pro- 
cesses :  these  may  be  simple  or  compound,  the  latter  usually 
resulting  from  gunshot  injuries. 

From  the  point  of  view  of  treatment,  however,  all  cases  may  be 
divided  into  :  (1)  Those  without  displacement ;  (2)  those  with  dis- 
placement ;  (3)  those  involving  the  neighbourhood  of  the  joint. 


Fractures  of  the  Jaws.  101 

Fractures  of  the  Lower  Jaw  without  Displacement.  —  These 
are  decidedly  uncommon  or  else  they  are  overlooked.  Painful 
mastication,  local  tenderness  on  pressure  over  the  fractured  spot 
and  blood-stained  discharge  from  the  mouth  are  the  chief  indica- 
tions. The  treatment  is  simple  and  consists  in  the  application  of 
an  ordinary  jaw  bandage  in  the  first  instance  and  then  of  a  well- 
moulded  leather  or  gutta-percha  splint  provided  with  straps  to  go 
over  the  upper  part  of  the  head.  This  should  be  worn  continuously 
for  six  days,  feeding  being  by  a  tube  between  the  teeth  and  gums. 
Then,  for  a  further  period  of  about  a  fortnight,  the  splint  may  be 
removed  during  meals,  the  patient  being  fed  with  soft  spoon  food. 

Fractures  of  the  Lower  Jaw  with  Displacement. — This  con- 
stitutes the  really  important  and  disputable  part  of  the  subject. 
The  jaw  is  broken  through  a  tooth  socket  on  one  or  both  sides,  the 
mucous  membrane  is  torn  so  that  the  injured  bone  is  in  communica- 
tion with  the  septic  cavity  of  the  mouth,  and  the  anterior  fragment 
is  displaced  downwards  so  that  it  puts  a  number  of  teeth  out  of  action 
with  their  opponents.  Usually  there  is  no  difficulty  in  reducing 
the  displacement,  but  it  recurs  almost  immediately.  In  many  cases 
the  alveolar  border  of  the  jaw  necroses  and  sinuses  may  remain 
for  many  months  opening  into  the  mouth.  For  all  these  reasons 
this  type  of  fracture  is  rightly  regarded  as  one  which  requires  great 
care  in  its  treatment.  But  inasmuch  as  many  of  the  splints  and 
contrivances  designed  for  this  object  were  invented  in  the  old  days 
when  pugilism  and  sepsis  were  both  much  commoner  than  they  are 
at  present,  the  majority  of  them  may  be  regarded  as  having  only  a 
historical  interest.  There  are  three  forms  of  treatment  which  may 
be  applied  to  these  cases,  viz. :  (1)  Simple  bandages  and  splints ; 
(2)  complicated  splints  ;  (3)  direct  fixation  of  the  bone. 

SIMPLE  BANDAGES  AND  SPLINTS. — In  those  cases  in  which  the 
displacement  is  slight  and  easily  kept  in  a  rectified  position,  the 
method  described  for  cases  without  displacement  may  be  adopted. 
But  in  this  case  it  is  wise  to  allow  a  fortnight  to  elapse  before 
removing  the  splint  even  temporarily.  The  disadvantage  of  the 
method,  besides  the  deprival  of  solid  food  for  so  long  a  time,  is 
that  it  is  difficult  to  keep  the  mouth  clean,  but  a  tooth  brush  and 
mouth  washes,  if  used  before  and  after  each  feeding,  may  remedy 
this. 

When  the  anterior  fragment  is  much  displaced  it  may  be  easier 
to  adapt  the  fragments  when  the  jaw  is  open.  Under  these  cir- 
cumstances an  internal  gutta-percha  splint  (Gunning's)  may  be 
applied  if  the  patient  will  not  consent  to  direct  suture  of  the  bones. 
An  anaesthetic  is  administered,  the  mouth  opened,  and  the 


IO2  Fractures  of  the  Jaws. 

fragments  replaced  in  good  position.  A  mass  of  soft  gutta-percha  is 
then  moulded  so  as  to  fit  inside  both  jaws  and  embrace  the  crowns 
of  all  the  teeth.  A  hole  is  made  in  this  splint  between  the  incisor 
teeth  for  feeding  and  cleansing  the  mouth.  The  jaws  are  then 
firmly  bandaged  together,  and  the  apparatus  retained  without 
moving  the  splint  for  three  weeks.  This  method  will  only  succeed 
if  the  reposition  of  the  fragments  is  very  accurately  carried  out, 
and  the  splint  well  made  by  a  dental  surgeon  (see  Dental  Surgery, 
Vol.  III.). 

COMPLICATED  SPLINTS. — There  are  many  of  these,  but  it  is  high 
time  they  were  relegated  to  oblivion.  Some,  the  wire  dental 
splints,  act  by  encircling  the  crowns  of  all  the  lower  teeth  by  stout 
wire,  with  fine  wire  between  the  teeth.  Others  form  more  or  less 
complicated  moulds  of  the  dental  margin  of  the  jaw,  which  are 
fastened  by  steel  bands,  bars  or  screws  to  other  splints  on  the 
outer  surface  of  the  mandible.  There  are  many  reasons  why 
all  such  contrivances  should  be  abandoned.  They  are  difficult  of 
manufacture,  uncertain  in  action,  uncomfortable  to  the  patient,  and 
make  efficient  cleansing  of  the  mouth  impossible.  The  wire  inter- 
dental varieties  tend  to  loosen  the  teeth  whose  function  it  is  their 
main  object  to  preserve,  and  they  render  the  septic  state  of  the 
jaw  much  worse  by  the  inevitable  retention  of  food  debris. 

DIRECT  UNION  OF  THE  BONE. — This  undoubtedly  should  be  the 
method  of  choice  in  all  fractures  of  the  lower  jaw  with  much 
displacement.  In  carrying  it  out  the  following  principles  should 
be  observed  :  To  remove  any  carious  teeth  or  tooth  fragments  from 
the  proximity  of  the  fracture ;  to  perform  the  bone  fixation  through 
a  clean  incision  made  externally  below  the  body  of  the  jaw,  wiring 
or  screwing  the  dense  bone  along  its  lower  margin,  and  avoiding  the 
fragmented  and  friable  alveolar  margin.  An  incision,  3  centimetres 
long,  is  made  well  within  the  line  of  the  edge  of  the  mandible. 
This  leaves  a  very  inconspicuous  scar,  and  does  not  divide  the 
facial  nerve  filaments  to  the  angle  of  the  mouth.  The  periosteum 
is  divided  along  the  margin  of  the  bone  and  a  suitable  metal  plate 
placed  over  the  fractured  area,  and  the  drill  holes  marked  when 
the  bone  is  being  held  in  accurate  position  by  an  assistant.  Any 
adult  jaw  will  readily  take  screws  1  centimetre  long  and  3  millimetres 
in  diameter.  The  holes  for  the  screws  ought  to  be  drilled  by  a  dental 
engine,  or,  if  this  is  not  available,  by  an  Archimedean  screw.  When 
the  plate  is  in  position  the  periosteum  is  sewn  over  it  and  skin 
united  by  fine  sutures  or  clips.  If  the  fracture  is  double  the  same 
procedure  is  adopted  on  the  other  side.  The  direction  of  the  screw 
holes  should  be  upwards  and  inwards,  as  this  gives  the  longest 


Fractures  of  the  Jaws.  103 

thickness  of  dense  bone,  without  risk  of  perforating  the  canal  of 
the  dental  nerve  or  the  tooth  sockets.  There  ought  to  be  no 
difficulty  in  getting  the  metal  plate,  screws  and  drills  even  in  the 
most  remote  places,  and  it  is  well  worth  waiting  for  two  or  three 
days  to  obtain  them.  Wiring  is  not  nearly  so  easy  or  satisfactory, 
because  the  holes  must  be  made  right  through  the  bone,  and  it  is 
rather  troublesome  to  get  the  wire  from  the  deep  surface  through 
the  second  hole.  After  direct  union  of  fracture  of  the  jaw, 
bandages  are  only  necessary  for  one  week  or  ten  days,  and  they 


FIG.  1. — Union  of  a  fracture  of  the  mandible  through  an  external 
incision,  by  means  of  a  steel  plate  and  screws. 

should  be  removed  frequently  during  this  time  for  spoon  feeding 
and  for  cleansing  the  mouth. 

Fnn-tures  of  the  Ram  us  an<\  its  Processes. — No  general  rule  can 
be  laid  down  for  these  cases,  but  usually  no  special  apparatus  or 
operation  is  necessary  for  their  treatment.  In  gunshot  injuries 
with  comminution  of  the  condyle  and  coronoid  process  the 
wound  should  be  enlarged  and  cleansed,  loose  fragments  of 
bone  removed,  and  movements  of  the  jaw  carefully  begun  within 
one  week  of  the  accident.  Ankylosis  of  the  joint  is  the  danger 
to  be  guarded  against  in  these  cases,  rather  than  want  of  union 
or  displacement. 


io4  Dislocation  of  the  Jaw. 

INJURIES  AND  DISEASES  OF  THE  TEMPORO- 
MAXILLARY  JOINT. 

Dislocation  of  the  Jaw. — Between  the  condyle  of  the  jaw  and 
the  glenoid  fossa  on  each  side  there  are  two  joints  within  a  single 
capsule,  separated  from  one  another  by  a  disc  of  nbro-cartilage. 
The  lower  joint  between  the  jaw  and  the  disc  is  a  hinge,  whilst 
that  between  the  disc  and  the  skull  is  a  gliding  joint.  In  dislo- 
cation of  the  jaw  the  condyle,  with  the  disc,  slips  forward  over  the 
eminentia  articularis.  In  the  majority  of  cases  it  is  only  a  sub- 
luxation,  being  wholly  within  the  capsule  of  the  joint.  Reduction 
is  rendered  difficult  by  the  facts  that  the  condyle  lies  in  front  of 
the  line  of  action  of  the  masseter  and  internal  pterygoid  muscles, 
the  spasm  of  which  tends  further  to  push  it  forwards,  and  that 
there  is  no  muscle  to  oppose  the  forward  drag  of  the  external 
pterygoid.  In  some  cases,  too,  the  coronoid  process  becomes 
hitched  in  front  of  the  malar  bone.  It  is,  therefore,  clear  that  the 
main  factor  in  the  reduction  of  the  deformity  must  be  the  abolition 
of  muscular  spasm. 

The  dislocation,  which  is  usually  the  result  of  extreme  yawning 
or  of  the  injudicious  use  of  the  gag  in  mouth  operations,  is  almost 
always  bilateral,  but  occasionally  is  one-sided.  It  is  much 
commoner  in  women  than  in  men. 

Treatment  of  Recent  Cases. — The  patient  is  seated  in  a  high- 
backed  chair  or  one  provided  with  a  firm  head  rest.  The  operator 
wraps  his  thumbs  with  thick  gauze  and  places  them  over  the  last 
lower  molar  teeth,  the  fingers  lying  underneath  the  chin.  The 
thumbs  are  pressed  firmly  downwards  and  the  jaw  opened  more 
widely  than  ever.  This  serves  to  overcome  the  muscular  spasm  ; 
the  coronoid  process  is  unhooked,  and  then,  whilst  firm  pressure  is 
maintained  downwards  on  the  molar  teeth,  the  chin  is  raised  and 
pushed  backwards.  In  some  cases,  especially  when  the  accident 
has  happened  more  than  once,  this  manoeuvre  may  succeed,  even 
without  an  anaesthetic,  but  in  the  majority  of  cases  an  anaesthetic 
will  be  necessary.  The  method  of  placing  a  wooden  cylinder 
between  the  back  molars  on  both  sides,  and  using  this  as  a  fulcrum, 
whilst  upward  leverage  is  made  on  the  chin,  is  much  inferior  to 
that  already  described,  because  there  is  great  difficulty  in  keeping 
the  wood  in  position  unless  it  is  hitched  behind  the  teeth,  in  which 
case  it  prevents  the  backward  movement  of  the  ramus  of  the  jaw. 
No  special  after-treatment,  except  ordinary  caution  in  yawning,  is 
required. 

Treatment  of  Old  Unreduced  Cases. — It  is  very  rare  to  meet  with 
these  nowadays,  but  at  all  costs  and  after  any  lapse  of  time,  such 


Ankylosis  of  the  Jaw.  105 

a  case  should  be  submitted  to  treatment,  because  the  condition  so 
seriously  interferes  with  both  feeding  and  speaking.  Up  to  a 
period  of  six  weeks  from  the  accident  simple  manipulation 
under  an  anaesthetic  may  still  be  successful,  but  in  any  case  it 
is  wise  to  be  prepared  before  the  anaesthetic  is  administered 
to  go  on  to  operative  measures.  Before  resorting  to  the  final 
expedient  of  excision  of  the  condyle,  it  is  worth  while  to  try  to  lever 
down  the  neck  of  the  jaw  through  a  small  incision  below  the 
zygoma  on  both  sides.  Through  this  incision  a  blunt-pointed 
periosteal  elevator  is  pushed  until  it  engages  in  the  sigmoid  notch. 
When  this  has  been  done  on  both  sides  a  simultaneous  raising  of 
the  elevators  will  serve  to  disengage  the  condyle  from  the  temporal 
fossa  and  the  coronoid  process  from  the  malar.  If  this  fails,  then 
the  neck  of  the  jaw  must  be  sawn  through  and  the  condyle  removed 
on  both  sides. 

Inflammatory  Diseases  of  the  Temporo-maxillary  Joint, — 
Considering  the  proximity  of  the  jaw  joint  to  that  common  seat 
of  suppuration,  the  ear,  it  is  somewhat  remarkable  how  seldom  it 
becomes  affected  by  acute  arthritis.  This  immunity  is  probably  due 
to  the  interposition  of  a  lobe  of  the  parotid  gland  between  the 
tympanic  plate  and  the  capsule  of  the  joint ;  but  acute  septic 
arthritis  of  this  joint  does  rarely  occur  in  connection  with  wounds, 
suppurative  parotitis  and  otitis,  or  in  infancy  probably  under  con- 
ditions similar  to  those  causing  the  acute  arthritis  of  infancy  in 
other  joints.  In  all  these  conditions  the  diagnosis  is  liable  to  be 
confused  with  that  of  inflammatory  disease  of  the  parotid  gland, 
which  causes  similar  pain  and  difficulty  in  mastication,  and  the  need 
for  special  treatment  may  only  be  recognised  at  a  late  date  when 
ankylosis  has  resulted. 

Subacute  or  chronic  inflammatory  disease  may  result  from 
rheumatism,  osteo-arthritis  or  gonorrhoea,  but  in  such  cases  there 
is  seldom  any  special  indication  for  treatment  beyond  that  appro- 
priate for  the  causative  disease.  In  osteo-artliritis  a  painful  grating 
and  clicking  of  the  joint  may  be  caused  by  the  fibrillation  and 
degeneration  of  the  inter-articular  fibro-cartilage.  Usually  this  is 
not  so  severe  as  to  call  for  surgical  intervention,  and  the  pain  can 
be  temporarily  relieved  by  counter-irritation  by  iodine  or  blisters 
applied  over  the  joint.  In  the  more  inveterate  cases  in  which 
mastication  is  seriously  interfered  with,  however,  the  joint  should 
be  opened  through  a  horizontal  incision  below  the  zygoma  and  the 
degenerated  remains  of  the  cartilage  removed. 

Ankylosis  of  the  Jaw. — Fixation  of  the  jaw  may  result  from  a 
true  intra-articular  bony  or  fibrous  union  resulting  from  any  of 


io6 


Ankylosis  of  the   Ja\v. 


FIG.  2. — Boxwood  wedge  for  the  treatment  of  fibrous 
ankylosis  of  the  jaw. 


the  above  inflammatory  diseases,  or  from  a  false  or  extra-articular 
fibrosis  resulting  from  scars  or  septic  processes  in  the  neighbour- 
hood. Temporary  inability  to  open  the  mouth  is  often  caused  by 
inflammatory  diseases  of  the  tonsils,  pharynx,  or  molar  teeth,  but 
the  nature  and  treatment  of  this  are  usually  so  obvious  as  to  need 
no  separate  description. 

The  Treatment  of  True  Bony  Ankylosis. — If  it  is  quite  clear  that 
the  jaw  fixation  is  due  to  bony  union  of  the  joint  surfaces  the  best 

treatment  is  excision  of 
the  condvle.  An  inci- 
sion about  4  centimetres 
long  is  made  along  the 
lower  border  of  the 
zygoma,  beginning  just 
in  front  of  the  ear,  down 
to  the  deep  fascia  covering  the  parotid.  This  is  cautiously  divided 
by  blunt  dissection  so  as  to  avoid  branches  of  the  facial  nerve. 
The  parotid  gland  is  retracted  downwards  and  backwards,  and  the 
origin  of  the  masseter  muscle  divided  in  the  posterior  part  of  the 
wound.  The  neck  of  the  jaw  is  now  exposed,  and  it  is  divided  by  a 
sharp  chisel  and  bone  forceps  (there  is  not  room  for  the  employ- 
ment of  a  rigid  saw,  and  if  Gigli's  wire  saw  is  used  it  is  liable 
to  break  owing  to  the  sharp  flexion  necessary).  The  capsule 
of  the  joint  is  opened  and  the  condyle  removed  after  chiselling 
through  the  adhesions  to  the 
temporal  bone.  The  cut  neck 
of  the  jaw  is  rounded  off  and 
the  cut  fibres  of  the  masseter 
muscle  united  to  the  internal 
pterygoid  so  as  to  interpose  a 
barrier  of  soft  parts  between 
the  bone  surfaces.  Usually  only 
one  side  requires  operation. 

The  Treatment  of  Fibrous  Ankylosis. — When  the  fixation  of  the 
jaw  is  not  absolute,  but  permits  of  slight  movement,  the  first  method 
to  be  adopted  is  that  by  wedges  and  gags.  In  the  first  instance,  these 
should  be  employed  under  full  anesthesia  so  as  to  abolish  muscular 
spasm  and  allow  of  a  forcible  stretching  of  fibrous  adhesions.  A 
sharp  wooden  wedge  (Fig.  2)  is  first  used  to  lever  open  the  front 
teeth,  then  a  powerful  screw  wedge  (Fig.  4)  is  inserted  and  opened 
as  far  as  possible  without  injury  to  the  teeth.  Subsequently  the 
patient  is  instructed  to  apply  some  form  of  wedge  gag  daily,  the 
boxwood  screw  (Fig.  3)  probably  being  the  most  convenient.  This 


FIG.  3. — Boxwood  screw  wedges.  The 
patient  places  the  small  end  between 
his  incisor  teeth,  and  rotates  it  as  far  as 
possible.  This  proceeding  is  repeated 
daily. 


Inflammatory  Diseases  of  the  Jaws.        107 

after-treatment  must  be  continued  for  many  months  if  any  per- 
manent results  are  to  be  obtained. 

Treatment  of  Severe  Grades  of  Extra-articular  Adhesions. — In 
those  cases  where  the  last-mentioned  treatment  has  failed,  a  new 
joint  must  be  made  on  both  sides  of  the  jaw  in  the  region  of  the 
angle.  A  curved  incision  is  made  outside  the  margin  of  the  angle, 
beginning  below  the  lower  margin  of  the  lobule  of  the  ear  and 
ending  in  front  of  the  insertion  of  the  masseter.  The  soft  parts  are 
all  turned  upwards,  the  facial  vessels  being  retracted  in  front.  The 
masseter  is  separated  from  its  attachment  to  the  outer  surface  of  the 
jaw,  the  periosteum  being  raised  with  the  muscle,  and  a  V-shaped 
piece  of  the  bone  at  the  junction  of  the  ramus  and  body  sawn 
through.  Smart  haemorrhage  will  result  from  the  division  of  the 


FIG.  4. — Powerful  screw  gag.  It  can  only  be  used  if  the  front  teeth 
are  firm  and  strong,  and  the  tips  should  be  protected  by  rubber 
tubing  to  prevent  chipping  the  enamel. 

inferior  dental  artery  in  the  substance  of  the  bone,  and  this  must 
be  stopped  by  plugging  with  aseptic  wax  or  a  wooden  splinter  which 
has  been  boiled.  In  the  bed  from  which  the  bone  has  been 
removed  lies  the  deep  surface  of  the  internal  pterygoid  muscle.  The 
masseter  and  pterygoid  muscles  should  be  sewn  together  over  as  wide 
an  area  as  possible  so  as  to  prevent  union  of  the  adjacent  bony  sur- 
faces. The  same  procedure  must  be  adopted  on  the  opposite  side. 
It  is  not  to  be  expected  that  any  powerful  mastication  will  be  possible 
after  this  operation.  Its  main  object  will  be  to  enable  the  mouth  to 
be  opened  so  that  soft  food  can  be  taken. 

INFLAMMATORY  DISEASES  OF  THE  JAWS. 

The  inflammatory  conditions  of  the  jaws  may  be  classified  as 
follows :    (1)   Acute    pyogenic   infection,  (a)  localised,  from    teeth 


io8  Necrosis  of  the  Jaw. 

or  antrum ;  (i)  diffuse  osteomyelitis ;  (2)  chronic  pyogenic  infec- 
tion, pyorrho?a  alveolaris,  phosphorous  necrosis ;  (3)  chronic 
specific  disease,  syphilis,  tubercle,  actinomycosis.  Diseases 
associated  with  the  teeth  and  the  antrum  and  pyorrhoea  are 
dealt  with  elsewhere  (see  Dental  Surgery,  and  Diseases  of  the 
Antrum,  Vol.  III.). 

Necrosis  of  the  Jaw. — In  its  simple  form  associated  with  dental 
periostitis  and  in  its  acute  infective  form  the  treatment  of  necrosis 
of  the  jaws  does  not  require  any  special  discussion  ;  but  the  chronic 
diffuse  inflammation  which  leads  to  very  extensive  necrosis  in  phos- 
phorus workers  is  peculiar,  and  its  treatment  requires  careful 
consideration. 

Prophylactic  Treatment  is,  of  course,  of  the  first  importance. 
Working  with  yellow  phosphorus  should  be  restricted  as  far  as 
possible,  as  the  red  phosphorus,  from  which  safety  matches  are 
made,  appears  to  be  harmless.  All  the  teeth  should  be  period- 
ically inspected  and  carious  teeth  removed  or  efficiently  stopped, 
because  the  disease  always  begins  as  an  osteitis  round  a  carious 
tooth.  The  hands  should  be  thoroughly  washed  between  work  and 
meals,  as  it  is  probable  that  food  contamination  is  even  more 
deleterious  than  inhalation  of  fumes ;  and,  lastly,  cleanliness, 
sunlight  and  ventilation  should  be  secured  in  the  factories  and 
the  home  life  of  the  workers. 

Curative  Treatment. — On  the  first  appearance  of  the  disease  the 
gum  becomes  retracted  from  the  teeth  and  pus  exudes  from  its 
margin.  The  tissues  over  the  jaw  swell  and  break  in  various 
positions,  both  internal  and  external,  and  through  these  openings  a 
quantity  of  foul  pus  is  constantly  discharged.  The  originally  sound 
teeth  become  loosened  and  fall  out  and  mastication  is  rendered 
impossible.  In  the  bone  itself,  especially  along  the  dental  margin, 
large  areas  become  soft  and  carious,  new  spongy  bone  forms  a 
periosteal  involucrum,  and  the  dense  parts  of  the  body  and  rarnus 
undergo  necrosis.  The  whole  process  is  very  slow  and  many  months 
elapse  before  separation  of  sequestra  take  place.  It  is  very  impor- 
tant, therefore,  to  recognise  and  treat  the  condition  in  its  earliest 
stages.  The  teeth  in  the  affected  area  should  be  removed  and  the 
whole  of  the  alveolar  border  freely  chiselled  and  scraped  away,  the 
patient  being,  of  course,  absolutely  removed  from  contact  with 
phosphorus  or  its  fumes.  In  the  advanced  condition  it  is  far 
better  boldly  to  attack  the  disease  through  an  external  incision  than 
to  wait  in  the  hope  of  being  able  to  remove  sequestra  through  the 
mouth.  The  jaw  is  quite  useless  for  mastication  and  forms  a 
serious  menace  to  life.  In  extreme  cases  the  greater  part  of  the 


Benign  Growths  of  the  Jaw.  109 

mandible  may  require  to  be  removed,  but  it  is  usually  possible  to 
preserve  the  rami,  and  by  connecting  these  at  the  time  by  one  of 
the  varieties  of  artificial  jaw  (see  section  on  Tumours  of  the  Jaw), 
the  facial  appearance  may  be  preserved  and  a  useful  member 
eventually  obtained. 

The  Specific  Infective  Diseases  of  the  jaws  must  be  treated 
on  similar  lines  to  those  of  such  affections  of  other  bones.  Tuber- 
culous disease  may  affect  the  orbital  margin,  the  angle  of  the 
mandible  or  the  malar  process,  and  it  will  necessitate  local  incision 
and  scraping.  Actinomycotu  is  particularly  liable  to  affect  the 
angle  or  any  part  of  the  body  of  the  lower  jaw,  when  it  may  readily 
be  mistaken  for  a  recurrent  dental  abscess.  Free  erasion  of  the 
disease  with  administration  of  large  doses  of  iodides  is  the  treat- 
ment required,  and  it  should  be  energetically  carried  out  before 
extension  to  the  lungs  or  digestive  organs  has  occurred  (see 
Actinomycosis,  Vol.  I). 

BENIGN  GROWTHS  OF  THE  JAW. 

Simple  tumours  of  the  jaw  are  usually  cysts  connected  with  the 
teeth,  but  the  ordinary  varieties  of  benign  bony  outgrowths,  osteoma, 
fibroma,  also  occur  with  some  rarety.  Osteoma  usually  grow  with 
extreme  slowness  from  the  angle  of  the  mandible,  and  are  of  the 
dense  ivory  variety.  They  may  cause  some  distortion  of  the  face, 
for  which  their  removal  will  be  necessary.  This  is  best  effected 
with  the  aid  of  a  surgical  motor  or,  if  the  growth  is  pedunculated, 
by  a  Gigli's  saw.  The  bone  is  so  dense  that  an  attempt  to  remove 
it  by  the  chisel  and  mallet  may  result  in  fracture  of  the  jaw. 

Fibromata. — These  vary  much  in  appearance  and  clinical  course. 
In  the  simplest  form  it  grows  from  the  margins  of  the  dental  sockets 
as  a  fibrous  cpulis  which  is  comparatively  soft  and  covered  by 
vascular  mucous  membrane.  Such  a  growth  should  be  freely 
removed  with  the  margin  of  alveolus  that  it  grows  from  directly  it 
is  observed.  There  is  no  reliable  means  of  determining  whether  a 
given  epulis  is  fibrous  or  myeloid,  except  microscopical  examination, 
and  it  is  almost  as  easy  to  remove  the  growth  thoroughly  as  to  take 
a  part  of  it  for  section.  Other  varieties  of  fibromata  are  much  rarer. 
In  physical  signs  and  locality  of  occurrence  they  exactly  resemble 
the  sarcomata,  but  the  rate  of  their  growth  is  very  slow.  Clinically 
it  is  certain,  and  pathologically  it  is  probable,  that  there  is  no  sharp 
differentiation  between  the  benign  fibroma  and  the  malignant 
sarcoma.  It  is  therefore  necessary  to  remove  these  tumours  as 
soon  as  they  are  recognised.  If  they  occur  as  well-defined 
periosteal  growths  the  local  complete  removal  will  present  no 


iio  Benign  Growths  of  the  Jaw. 

difficulty.  If  they  involve  the  upper  jaw,  then  it  would  be  wise 
first  to  remove  a  portion  for  microscopical  examination  before 
deciding  between  a  local  tumour  removal  or  an  extensive  resection 
of  the  jaw.  It  is  probable  that  the  few  cases  of  so-called  sarcoma 
of  the  jaw  who  have  survived  for  long  periods  after  excision  are  in 
reality  instances  of  fibroma. 

Solid  tumours  of  the  jaw  may  arise  from  the  tooth  roots.  These 
are  termed  Radicular  Odontomes  and  are  in  reality  merely 
ivory  exostoses  of  dental  origin.  They  are  only  likely  to  simulate 
jaw  tumours  when  occurring  in  the  teeth  of  the  upper  set,  the 
canine  and  premolars  being  those  most  often  affected.  The  tumour 
may  practically  fill  the  maxillary  antrum  and  bulge  forward 
upon  the  cheek.  The  clue  to  diagnosis  is  given  by  the  shape  of 
one  of  the  teeth  whose  root  is  larger  than  the  crown.  These 
dental  growths  must  be  removed  by  cutting  through  the  mucous 
membrane  and  thin  bony  shell  which  overlies  them,  and  then 
pulling  the  mass  outwards  by  the  crown  of  the  tooth. 

Simple  Cysts  of  the  Jaw. — Cysts  of  the  jaws  are  of  common 
occurrence,  and  it  is  probable  that  they  are  chiefly  of  dental 
origin,  though  in  the  upper  jaw  the  mucocele  of  the  antrum  arises 
from  the  mucous  membrane  lining  that  cavity.  Some  grow  at  the 
root  of  a  mature  tooth,  others  (follicular  odontomes)  consist  of 
the  tooth  follicle  itself  with  the  unerupted  crown  in  its  cavity. 
All  these  simple  cysts  are  of  slow  growth  and  are  not  associated 
with  much  pain.  They  expand  the  overlying  bone  so  that  at 
length  it  can  be  indented  like  the  shell  of  a  ping-pong  ball.  Their 
treatment  is  simple  and  satisfactory  and  consists  in  the  removal 
of  as  much  of  the  outer  bony  wall  as  possible  after  incision  of  the 
mucous  membrane.  The  cavity  is  then  laid  freely  open  and  its 
lining,  together  with  any  dental  rudiments,  thoroughly  removed  by 
scraping.  It  is  packed  tightly  to  stop  the  oozing,  and  when  the 
packing  is  removed  on  the  second  day  it  is  syringed  out  with  a 
solution  of  Condy's  fluid  or  of  glycothymoline  after  every  meal. 

Myeloid  Growths  of  the  Jaw. — These  used  to  be  termed  "  mye- 
loid  sarcomata"  and  "malignant  epulis"  but  it  is  better  to  place 
them  in  a  class  by  themselves  and  call  them  "  myelomata,"  because 
whilst  locally  malignant  in  the  sense  of  destroying  and  replacing 
all  the  tissues  with  which  they  come  in  contact,  they  cause  no 
metastases  and  do  not  affect  the  lymph  glands. 

Myeloid  Epulis  occurs  as  a  fungating  polypoid  mass  from 
the  gums  round  the  socket  of  a  tooth.  It  bleeds  freely  and  it 
slowly  invades  the  adjacent  part  of  the  alveolus.  Its  substance 
is  replete  with  large  multi-nucleated  cells  which  makes  its 


Benign  Growths  of  the  Jaw. 


1 1 1 


microscopical  diagnosis  easy.  The  treatment  consists  in  removal 
by  the  chisel  and  sharp  spoon  of  the  alveolar  border  of  the  jaw 
from  which  it  is  growing. 

Central  Myelomata. — These  occur  chiefly  in  the  lower  jaw  as 
medullary  tumours,  which,  growing  slowly  and  causing  an  absorp- 
tion of  the  overlying  bone,  closely  resemble  cysts ;  in  fact,  their 


FIG.  5. — An  operation  for  the  removal  of  a  tumour  of  the  lower  jaw 
without  destroying  the  continuity  of  the  latter.  M,  masseter  muscle 
turned  up  ;  F,  facial  artery  tied  and  cut. 

vascular  stroma  does  often  become  the  seat  of  spurious  blood  cysts, 
which  makes  this  resemblance  closer.  The  treatment  is  a  matter 
which,  in  principle,  is  the  same  as  that  of  the  epulis,  but  com- 
plicated in  practice  by  the  desirability  of  preserving  the  continuity 
of  the  lower  jaw.  In  the  old  days  when  the  limited  malignancy  of 
a  myeloma  was  not  recognised  the  affected  half  of  the  jaw  would  be 
resected,  but  this  is  quite  unjustifiable  in  the  light  of  our  present 
knowledge.  Two  operations  are  necessary.  At  the  first  the  growth 


ii2  Malignant  Disease  of  the  Jaws. 

is  merely  explored.  If  it  proves  to  be  a  simple  cyst  the  treatment 
can  then  and  there  be  completed.  But  if  it  is  a  solid  haemorrhagic 
mass,  then  a  part  of  this  must  be  microscoped  before  deciding 
upon  the  ultimate  operative  scope.  The  microscopical  diagnosis 
of  a  myeloma  is  so  easy  that  a  section  taken  immediately, 
whilst  the  patient  is  under  the  anaesthetic,  may  be  relied  upon.  If 
the  growth  has  converted  the  whole  of  the  jaw  into  a  friable,  egg- 
shell-like mass,  it  may  be  inevitable  to  remove  a  part  of  the  jaw 
in  its  whole  thickness,  but  nowadays  this  is  rarely  necessary, 
and  it  is  possible  to  preserve  a  bridge  of  the  dense  bone  along  the 
lower  margin  of  the  body.  In  the  case  of  a  small  growth  about  the 
size  of  a  plum  the  operation  can  be  conducted  inside  the  mouth  by 
means  of  a  chisel  and  sharp  spoon.  After  drying  out  the  cavity 
left  by  scraping,  a  solution  of  zinc  chloride  (40  gr.  to  the  ounce) 
is  thoroughly  rubbed  in  and  the  cavity  is  then  packed  with 
iodoform  gauze.  If  the  tumour  is  too  large  to  attack  from  the 
mouth,  the  cheek  is  turned  up  by  an  incision  round  the  angle 
of  the  jaw  the  facial  vessels  being  tied  and  cut.  Then  with  a 
fine  keyhole  saw  the  whole  tumour  may  be  cut  away  without 
opening  it,  the  lower  margin  of  bone  being  preserved.  It  is 
necessary  to  protect  the  tongue  from  the  point  of  the  saw  by  gauze 
pads. 

Epithelial  Odontomes  ;  Fibrocystic  Disease. — This  is  a  very 
rare  disease  and  so  far  has  only  been  observed  in  the  lower  jaw.  It 
consists  in  an  irregular  epithelial  proliferation  from  the  embryonic 
tooth  germs.  It  grows  comparatively  slowly,  and  the  epithelial 
tubules  become  dilated  to  form  numerous  small  cysts  separated 
by  dense  fibrous  tissue.  It  is  quite  uncertain  at  what  period  in  its 
history  it  becomes  truly  malignant,  but  in  those  cases  treated  by 
conservative  methods  of  chiselling  and  scraping,  recurrence  with 
epitheliornatous  disease  of  the  glands  has  usually  taken  place. 
When,  therefore,  the  diagnosis  has  been  established  a  free  primary 
resection  of  the  jaw  should  be  carried  out,  the  bone  being 
divided  well  beyond  the  disease  on  either  side.  It  will  in  this  way 
usually  be  possible  to  retain  enough  of  the  ascending  ramus  to 
afford  attachment  to  an  artificial  jaw  in  the  manner  described 
below. 

MALIGNANT  DISEASE  OF  THE  JAWS* 

Sarcoma  is  unfortunately  by  no  means  a  rare  disease  of  the  jaws, 
occurring  at  any  age  and  usually  developing  with  great  rapidity. 
Carcinoma  occurs  in  the  upper  jaw  of  elderly  people,  starting  no 
doubt  in  the  mucous  membrane  of  the  antrum.  In  the  early 


Malignant  Disease  of  the  Jaws.  113 

stages  malignant  disease  may  readily  be  mistaken  for  some 
inflammatory  affection,  this  being  especially  tbe  case  with  the 
superior  maxilla,  where  antral  suppuration  produces  an  exactly 
similar  appearance  to  that  of  a  rapidly  growing  sarcoma.  The  fact 
that  in  its  early  stages  malignant  disease  is  painless  should  be 
the  safeguard  against  this  error,  which  often  costs  the  patient  his 
life. 

In  the  case  of  the  Lower  Jaw  the  limitations  and  connection 


|'K;.  6. — Showing  the  best  method  of  division  and  union  ot  the  jaw  by  a 
V-shaped  saw  cut.  This  prevents  all  tendency  of  the  two  halves  of  the 
jaw  moving  upon  one  another. 

of  the  new  growth  can  usually  be  explored  without  difficulty, 
and  provided  that  the  diagnosis  has  been  made  certain,  the  treat- 
ment admits  of  no  doubt.  In  cases  where  the  disease  is  clearly 
unilateral,  the  half  jaw  should  be  removed,  with  its  adjacent 
muscles  and  periosteum.  The  genial  tubercles  may  be  spared  on 
the  side  of  the  excision,  as  they  afford  such  important  attachments 
to  the  tongue  and  larynx.  But  the  masseter  on  the  outside, 
and  the  pterygoid,  mylohyoid  and  buccinator  muscles  on  the  inner 
side  should  be  freely  removed.  As  a  preliminary  to  this  extensive 
S.T. — VOL.  u.  8 


ii4  Malignant  Disease  of  the  Jaws. 


resection  the  glands  in  the  submaxillary  triangle,  including  the 
salivary,  should  be  removed  and  the  external  carotid  artery  tied. 
If  the  growth  encroaches  upon  the  region  of  the  symphysis  menti 
the  greater  part  of  the  body  of  the  jaw  should  be  removed,  leaving 
the  rami  if  possible  for  the  attachment  of  an  artificial  jaw. 

The  Restoration  of  Continuity  of  the  Lower  Jaw. — In  some 
operations,  e.g.,  Symes'  method  of  tongue  excision,  the  symphysis 
menti  is  cut  through,  and  unless  special  means  are  taken  to 
prevent  it,  the  two  halves  of  the  jaw  remain  ununited  and  the 
patient's  troubles,  which  are  great  enough  already,  increased  by 
a  disability  to  masticate.  The  ordinary  wiring  of  the  fragments  is 

not  enough,  because 
the  region  of  the  sym- 
physis, being  very 
hard  and  avascular, 
is  slow  to  unite,  and 
the  part  is  usually 
in  a  septic  condition. 
There  are  two  methods 
by  which  this  can  be 
prevented.  The  best 
is  to  make  the  saw 
cut  through  the  sym- 
physis angular  instead 
of  linear,  using  a  fine 
keyhole  saw.  The 
muscles  attached  to 
the  genial  tubercles 

must  be  separated  first  and  held  out  of  the  way.  The  lines  of  saw 
cut  should  be  planned  and  holes  drilled  for  wire,  screws  or  pegs 
before  the  bone  is  divided. 

When  a  part  of  the  jaw  has  been  removed  for  malignant  disease 
it  is  a  matter  of  great  importance  to  provide  a  temporary  sub- 
stitute for  the  part  removed  at  the  time  of  the  operation.  This 
acts  as  a  splint,  and  if  it  is  not  used  the  two  halves  of  the  jaw 
become  pulled  inwards  by  muscular  action  and  mastication  is 
rendered  impossible.  It  is,  moreover,  very  difficult  to  fit  a  dental 
plate  for  such  a  patient  later  on,  because  fibrous  contraction 
has  distorted  the  mandible  beyond  rectification. 

Various  splints  have  been  devised,  e.g.,  Martin's,  which  consists 
of  gutta-percha  with  metal  attachments  to  the  jaw  stumps; 
Partsch's,  which  is  a  simple  metal  band,  and  Stoppany's,  which  is 
a  moulded  and  perforated  aluminium  plate  shaped  like  the  chin. 


FIG.  7. — Showing  an  aluminium  plate  formed  into 
an  artificial  jaw  and  fixed  in  place  by  steel  screws. 


Malignant  Disease  of  the  Jaws.  115 

These  no  doubt  are  all  excellent,  but  they  have  this  great  draw- 
back, that  they  have  to  be  made  before  the  operation,  and  it  is 
usually  impossible  to  accurately  foresee  how  much  of  the  jaw  is 
going  to  be  removed.  Under  these  circumstances  it  is  best  to  be 
provided  with  a  suitable  metal  splint  considerably  larger  than 
will  be  required  and  be  prepared  to  cut  it  to  the  necessary  length 
after  the  excision  is  completed.  It  is  then  attached  by  screws  to 
the  ends  of  the  jaw  and  the  soft  parts  sewn  over  it.  In  some 
cases  it  will  remain  permanently  in  position,  becoming  embedded 
in  the  soft  tissues.  In  others  it  will  have  to  be  removed  at  the  end 
of  about  a  month  or  six  weeks,  by  which  time  a  permanent 
dental  plate  will  have  been  prepared. 

The  condition  may  also  be  treated  by  bone  grafting,  a  piece 
of  the  patient's  own  rib  being  the  most  convenient  material  to 
employ.  The  rib  is  removed  with  its  periosteum  and  fastened  in 
position  by  wiring.  It  is  seldom  that  this  method  can  be 
employed  at  the  time  of  resection  of  the  jaw,  because  the  patient's 
condition  will  not  allow  of  the  further  operation  and  because 
the  bone  will  have  to  be  transplanted  into  a  septic  cavity  (the 
mouth).  But  it  has  been  successfully  employed  after  the  mouth 
has  healed,  by  making  a  bed  for  the  new  bone  through  an  external 
incision. 

In  the  case  of  the  Upper  Jaw  the  matter  is  much  more 
difficult,  because  it  is  impossible  to  ascertain  what  are  the  limits  of 
the  growth  before  operation.  The  ethmoidal  and  sphenoidal  air 
cells  or  the  interior  of  the  nose,  or  the  pterygoid  fossa,  may  be 
invaded  by  malignant  growth  at  a  time  when,  from  the  outward 
appearance,  the  disease  is  early.  However,  as  in  general  terms  it 
may  be  definitely  stated  that  malignant  disease  of  the  upper  jaw 
must  be  treated  by  excision,  it  may  make  for  simplicity  if  we  begin 
with  the  proposition  and  proceed  to  discuss  certain  limitations  and 
conditions  which  affect  it. 

(1)  Diagnostic  Operations. — In  every  case  in  which  a  swelling  of 
the  upper  jaw  occurs  and  is  not  speedily  relieved  by  the  removal  of 
a  tooth  or  evacuation   of  the  antrum,  no  time  should  be  lost  in 
exploring  this  swelling  and  freely  removing  a  portion  for  micro- 
scopical diagnosis.     It  is  the  utmost  folly  in  such  cases  to  wait  for 
further  signs  to  develop,  and  if  the  condition  is  benign  or  inflam- 
matory this  early  operation  will  bring  about  its  cure,  whereas  if 
it  is  malignant,  it  wTill  be  dealt  with  at  the  only  stage  at  which  any 
radical  cure  can  be  expected. 

(2)  Limitations. — Extensive   fungation   into   the  nasal   cavities, 
displacement  of  the  eyeball,  swelling  at  the  back  of  the  pharynx  or 

8—2 


u6  Malignant  Disease  of  the  Jaws. 

in  the  temporal  fossa,  are  signs  which  indicate  that  the  disease  has 
already  spread  beyond  the  limits  of  the  maxilla  and  make  any 
radical  removal  impossible.  Involvement  of  the  skin  either  by 
actual  fungation  or  by  adherence  to  the  growth  will  be  a  contra- 
indication when  it  is  associated  with  evidence  of  a  large  and 
extensive  growth.  In  children,  when  the  growth  has  rapidly 
assumed  a  large  size,  it  is  useless  to  operate,  as  such  patients 
usually  die  after  the  operation  or  suffer  a  speedy  recurrence. 

(3)  Partial  or  Modified  Operations. — If  the  lower  border  of  the 
jaw  is  the  seat  of  the  growth  it  is  wise  to  preserve   the   orbital 
plate  of   the    maxilla    in    order    to    maintain    the    position    and 
functions  of  the  eye.     If  the  disease  is  early  and  situated  on  the 
upper  part  of  the  jaw  the  muco-periosteum  of  the  hard  palate  may 
be  preserved  and  stitched  to   the  cheek    so    as    to    shut   off   the 
cavity  of  the  mouth  from  that  left  by  the  removal  of  the  growth. 
If  the   growth  extends  back  into  the  orbit  it  is  better  to  remove 
the  eyeball  at  the  time  and  clear  out  the  bony  socket,    scraping 
and  treating  with  zinc  chloride  the  ethmoid  and  sphenoid  cells. 
If  the  skin  is  adherent  to  or  involved  by  the  growth  it  must  be 
freely  removed  and  the  defect  remedied  by  a  plastic  operation. 

(4)  The  Removal  of  Lymph  Glands. — If  the  submaxillary   and 
cervical  lymph  glands  are  affected  their  removal  will  naturally 
be  undertaken  either  before  or  after  the  jaw  is  removed.     But  it 
is  wise  to   make   a    routine   procedure    of    clearing    out   all    the 
lymph  gland  tissue  in  every  case,  and  if  this  is  done  at  the  first 
stage  of  the  operation  (through  a  curved  incision  running  from  the 
angle    of    the    jaw   to    the   hyoid   bone    and   thence    up   to    the 
symphysis)    the   external   carotid  can   be   ligatured   at   the   same 
time. 

(5)  Control    of   Hemorrhage. — As     ordinarily     practised,     the 
excision  of  the  maxilla  is  an  avulsion  in  which  many  branches  of 
the  internal  maxillary  artery  are  torn,   and  this  tearing,  together 
with  hot  water  and  gauze  pressure,  is  the  only  means  relied  upon 
for  the  arrest  of  haemorrhage.     For  this  reason  the  operation  is 
one  with  a  very  high  mortality.     In  any  case  the  nerve  shock  is 
extreme  and  if  there  are  added  to  this  great  loss  of  blood  and  the 
liability   for   the  blood    to  be  inspired  into  the  air  passages,  the 
danger    is    greatly    increased  ;    we    hold,    therefore,     that    some 
preliminary  method  of  haemostasia  ought  always  to  be  undertaken. 
The  easiest  is  by  ligature  of  the   external    carotid   artery    above 
the  superior  thyroid.     This  may  be  combined  with  the  removal  of 
the   lymph  glands.      The   temporary   clamping    of    the   common 
carotid  has  also  been  adopted,  but  it  involves  the  risk  of  severe 


Malignant  Disease  of  the  Jaws.  117 

bleeding  after  the  removal  of  the  clamp,  because  the  torn  vessels 
cannot  be  individually  ligatured. 

(6)  The  Method  of  Ancesthesia. — There  is  always  a  great  liability 
for  blood  to  collect  in  the  pharynx  and  run  into  the  air  passages. 
This  may  be  minimised  by  ligature  of  the  carotid   and  by  placing 
the  patient  in  a  head-down  position.     But  though  the  latter  pre- 
vents blood  trickling  down  into  the  trachea,  it  greatly  increases  the 
venous  oozing.     On  the  Continent  a  method  has  been  adopted  by 
choice  which  is  often  enforced  by  necessity,  viz.,  the  cessation  of  the 
anaesthesia  after  the  blood  begins  to  collect  in  the  throat.     As  the 
result,  the  larynx  regains  its  reflex  sensibility  and  blood  is  coughed 
up.     Kronlein  practises  what  is  termed  "  suggestive  anaesthesia  "  by 
morphia  (£  gr.)  before  the  operation,  and  "  a  few  whiffs  "  of  ether  at 
the  time.     To  us  this  appears   to   be   sheer   barbarism    under   a 
euphemistic  title.     A    preliminary  laryngotomy  prevents  all  this 
trouble  and  danger.     It  is  performed  in  about  two  minutes  and  the 
pharynx  can  then  be  firmly  packed,  and  the  anaesthetist  has  his  own 
field  to  himself,  whilst  the  patient  is  afforded  complete  oblivion  to 
what  is  one  of  the  most  terrible  operations  in  surgical  practice. 
When  this  is  done  the  patient  can  be  elevated  so  that  the  body  is 
at  an  angle  of  45  degrees  with  the  horizon,  and  the  venous  oozing 
will  then  be  reduced  to  a  minimum. 

(7)  Results  of  the  Operation. — According  to  most  authors  and  as  a 
matter  of  common  experience,  the  operation  is  one  with  a  very  high 
death   rate  and  very  poor  ultimate  results.     Professor  Schlatter 
quotes  the  following  figures  to  show  the  influence  of  anaesthesia  in 
causing  the  mortality : 

Xo.  of  Case.  Period.  Mortality, 

percent. 
Rahe,  606  .         .     1827  to  1873,  pre-ansesthetic  period     .         .     18'4 

Kronlein,  158     .     1870  to  1897 21'5 

Konig 30-0 

Kronlein    .         .     By  method  of  "  suggestive  anaesthesia "       .       2*8 

Sir  H.  T.  Butlin  considers  that  30  per  cent,  represents  the  opera- 
tive mortality,  but,  in  marked  contrast  to  every  other  writer,  Cheyne 
and  Burghard,  without  giving  details,  say  they  have  had  no  mortality. 
If  the  above  described  methods  are  adopted  as  a  routine,  i.e.,  ligation 
of  the  carotid  and  preliminary  laryngotomy,  there  seems  no  reason 
why  the  mortality  should  be  any  greater  than  5  per  cent. 

As  regards  permanent  results,  the  question  turns  chiefly  on  the 
pathological  nature  of  the  growth  and  the  period  at  which  it  is 
attacked.  The  soft  round-celled  sarcoma  which  has  already  filled 
the  whole  jaw  at  the  time  of  operation  is  probably  absolutely  hope- 


n8  Malignant  Disease  of  the  Jaws. 

less.  The  hard  fibro-sarcoma  limited  to  the  anterior  face  of  the 
bone  gives  a  good  prospect  of  cure.  Unfortunately  such  cases  are 
the  exception.  Schlatter  has  collected  133  cases  of  this  operation 
with  only  19  three-year  survivals.  Butlin  reports  only  4  out  of  64. 
There  does  not  seem  to  be  any  definite  difference  either  in  prognosis 
or  treatment  between  sarcoma  and  carcinoma  of  the  maxilla. 

Konig  has  recently  recorded  8  cases  (out  of  48)  of  carcinoma  of  the 
upper  maxilla  which  survived  operation  for  periods  varying  between 
ten  and  twenty-six  years.  These  results  are  attributed  by  the  author 
to  the  method  of  removing  the  jaw  with  a  very  wide  margin  of 
surrounding  tissues.1 

(8)  The  Routine  Operation. — Incisions  are  made  in  the  soft  parts 
from  a  point  just  below  the  inner  canthus  of  the  eye  outwards  to 
the  external  angular  process  of  the  frontal  and  downwards  in  the 
margin  between  the  nose  and  cheek,  round  the  ala  and  through  the 
mid-line  of  the  lip. 

The  skin  flap  thus  marked  out  is  turned  outwards,  the  muscles 
and  fat  being  left  on  the  bone.  The  orbital  periosteum  is  separated 
from  the  maxilla.  The  muco-periosteum  of  the  hard  palate  is 
incised  in  the  mid-line  after  extraction  of  the  central  incisor 
tooth,  the  junction  of  hard  and  soft  palates  is  cut  through  by  curved 
scissors.  The  malar  bone  is  cut  through  to  the  spheno-maxillary 
fissure  by  a  Gigli's  saw ;  in  the  same  manner  the  nasal  process  of 
the  maxilla  is  cut  between  the  lachrymal  groove  and  the  anterior 
nares,  after  separating  the  cartilage  from  the  latter.  The  hard 
palate  is  divided  by  a  keyhole  saw  in  the  mid-line.  The  bone  is 
then  wrenched  out  by  lion  forceps. 

The  part  is  thoroughly  irrigated  with  water  at  110°  F.  and  packed 
with  iodoform  gauze.  The  skin  flap  is  accurately  sutured  in  position. 
The  gauze  is  removed  on  the  second  day  and  the  cavity  irrigated 
with  glycothymoline  or  Condy's  fluid  and  repacked.  About  a 
month  after  the  operation  a  false  jaw  should  be  made  by  a  dentist, 
to  preserve  the  outline  of  the  cheek  and  to  shut  off  as  far  as  possible 
the  cavity  from  the  mouth. 

(9)  Treatment  other  than  Operative. — Apart  from  operation,  the 
injection  of  Coley's  fluid  is  the  only  method  at  present  which  is 
available  for  trial  ;   and  that  it  has  only  a  remote  chance  of  success 
is  shown  by  the  fact  that  Dr.  Coley  himself,  out  of  a  total  of  500 
cases  of  malignant  disease  of  all  kinds,  chiefly  sarcoma,  has  only 
had  success  in  52,  and  only  one  of  these  was  a  sarcoma  of  the  upper 
jaw.2     The  first  dose  is  £  min.   of  the   mixed   toxins  of  bacillus 
prodigiosus  and  erysipelas.     This  is  repeated  daily,  increasing  by 
\  min.  each  day,  until  a  reaction  occurs,  and  then  repeated  only 


Malignant  Disease  of  the  Jaws.  119 

after  the  temperature  has  been  normal  for  three  days.  The  one 
successful  case  had  103  injections  in  all,  lasting  from  August, 
1901,  to  January,  1902. 

ERNEST   W.  HEY  GROVES. 

REFERENCES. 

1  "  Archiv  f.  klinchir  Berlin,"  1910,  XCIL,  p.  918. 

2  Wiiiberg,  O.  K.,  Med.  Record,  New  York,  1902,  LXL,  p.  681,  andProc.  Roy, 
Soc.  Med.,  1910,  III.  (Surg.  Sect.),  p.  32. 


120 


DISEASES  AND  AFFECTIONS  OF  THE  MOUTH. 

STOMATITIS. 

CATARRHAL   STOMATITIS. 

THIS,  the  most  simple  form  of  stomatitis,  may  occur  at  any  age ; 
either  in  infancy,  associated  with  dentition  or  gastro-intestinal  dis- 
orders, or  at  other  times,  as  the  result  of  irritation  or  indigestion. 
It  does  not  produce  constitutional  disturbance.  Treatment  consists 
in  the  local  application  of  glycerine  of  borax  and  the  administration 
of  bland  non-irritating  foods.  Any  gastro-intestinal  disorder  will 
require  appropriate  treatment. 

APHTHOUS   STOMATITIS. 

This  usually  occurs  during  the  first  four  years  of  life,  though  it 
may  occasionally  be  seen  in  rather  older  children.  Constitutional 
symptoms  are  well  marked  and  sometimes  precede  the  local  by  a 
day  or  two.  It  usually  lasts  from  seven  to  ten  days  in  spite  of 
vigorous  local  and  general  treatment. 

Prophylaxis. — This  consists  in  scrupulous  cleanliness  on  the 
part  of  the  mother,  or  nurse,  as  regards  everything  that  comes  in 
contact  witti  the  child's  mouth.  The  food  itself,  together  with  all 
utensils  for  preparing  the  food  or  conveying  it  to  the  mouth,  must 
receive  careful  attention.  The  use  of  dirty  "  soothers  "  should  be 
avoided.  Prophylaxis,  indeed,  means  constant  care  as  to  the 
general  hygiene  of  the  child.  As  the  disease  sometimes  attacks 
more  than  one  member  of  a  household,  it  is  well  to  isolate  a  suffer- 
ing child  from  its  companions  as  regards  spoons,  cups,  kissing,  etc. 

Local  Treatment. — In  most  cases  this  should  be  simple  but 
thorough.  Cleansing  the  mouth  with  lint  or  absorbent  wool 
soaked  in  boiled  water,  or  in  a  saturated  solution  of  boric  acid,  is 
both  preventive  and  curative.  Kerley  gives  the  following  directions 
for  washing  a  baby's  mouth :  "  The  child  is  placed  on  its  side  or 
stomach,  the  index  finger  of  the  mother,  or  nurse,  being  thoroughly 
wrapped  in  absorbent  cotton.  The  finger  is  then  dipped  into  the  solu- 
tion and,  without  expressing  the  fluid,  is  placed  in  the  child's  mouth. 
By  gentle  pressure  upon  the  gums  and  cheeks  a  sufficient  amount 
of  the  fluid  will  be  expressed  to  run  out  of  the  mouth  and  effectually 
cleanse  it.  The  washing  is  assisted  by  the  opposition  offered  by 
the  child  to  the  manipulation  of  the  tongue,  cheeks  and  jaw." 


Stomatitis.  121 

The  use  of  stronger  astringents  is  unnecessary  except  in  severe 
cases.  Of  these  may  be  mentioned  :  Alum,  either  as  powder  with 
equal  parts  of  bismuth,  or  as  solution  (10  gr.  to  the  fluid  ounce) 
applied  on  a  swab  or  brush ;  or  silver  nitrate,  applied  to  individual 
aphthae  in  solid  stick  form,  or  in  solution  (10  gr.  to  the  fluid  ounce) 
on  a  fine  brush  point  once  or  twice  daily. 

General  Treatment. — As  a  rule  this  is  unnecessary  and  has  no 
direct  effect  on  the  stomatitis.  Some  writers  recommend  the 
administration  of  chlorate  of  potassium  internally.  Attention  must 
be  paid  to  the  condition  of  the  bowels,  and  any  tendency  to  consti- 
pation or  diarrhoea  must  be  suitably  dealt  with.  Mercury,  in  the 
form  of  grey  powder  or  calomel,  is  recommended  by  some,  whilst 
others  consider  that  in  any  form  its  use  is  contra-indicated  in 
stomatitis  of  all  sorts. 

Food. — So  long  as  the  mouth  is  sore  the  administration  of  food 
will  be  more  or  less  interfered  with,  and  it  may  be  necessary  to  feed, 
for  a  time,  with  the  spoon.  It  should  be  given  cool.  Ice  to  suck 
will  be  grateful  and  comforting.  If  breast-fed,  the  milk  should  be 
withdrawn  by  a  breast  pump  for  this  purpose. 

ULCERATIVE   STOMATITIS. 

This  condition  is  essentially  associated  with  fully-developed 
teeth,  and  usually  occurs  from  the  age  of  four  to  twelve  years.  It 
is  more  common  in  the  lower  classes,  probably  due  to  dirt  and  bad 
nutrition.  It  not  uncommonly  follows  various  specific  fevers, 
particularly  measles  and  typhoid  fever,  or  some  other  general 
disease  producing  a  cachectic  state.  It  may  occur  in  adults,  par- 
ticularly in  crowded  institutions  of  an  insanitary  character. 

Prophylaxis. — This  includes  general  hygiene,  cleanliness  of  the 
mouth  and  teeth,  especially  during  any  specific  fever,  proper  atten- 
tion to  dental  caries,  suitable  and  varied  food,  and  fresh  air. 

Chlorate  of  potash,  given  internally,  is,  practically,  a  specific ;  it  is 
important  that  a  sufficient  quantity  of  the  drug  be  given.  Two  grains 
every  three  or  four  hours,  making  not  more  than  a  total  of  15  gr. 
in  the  twenty -four  hours,  may  be  given  to  a  child  of  three  years  old. 
In  adults  20  gr.  may  be  given  thrice  daily.  The  possible  dangers 
from  the  use  of  chlorate  of  potash  in  this  condition  seem  to  be 
almost  nil  and  are  quite  outweighed  by  its  advantages. 

Local  Treatment. — Hydrogen  peroxide  (2  to  10  per  cent.)  solu- 
tion in  water  is  a  useful  mouth  wash.  It  should  be  used  several 
times  daily  and  the  mouth  then  frequently  rinsed  with  water. 
Potassium  permanganate  in  a  fairly  strong  solution  may  be  used 


122  Stomatitis. 

for  sponging  or  flushing  the  gums.  In  severe  or  obstinate  cases 
Pfaundler  and  Schlossmann  recommend  the  direct  application  of 
iodoform  gauze  soaked  with  aluminium  acetate  or  pencilling  the 
gums  -with  zinc  chloride  (5  per  cent.)  twice  daily.  The  latter  has 
the  advantage  of  not  attacking  the  healthy  mucosa.  Powdered 
alum,  chloride  of  lime,  or  iodoform,  applied  dry,  have  also  been 
found  useful. 

Diet  and  General  Hygiene. — Attention  to  these  is  of  the 
highest  importance  in  promoting  recovery.  A  plentiful  supply  of 
fresh  air  will  often  act  in  a  surprisingly  beneficial  manner.  If 
possible,  the  child  should  be  out  of  doors  altogether.  If  this  is  not 
possible,  the  window  should  be  kept  wide  open  and  the  child  close 
to  it.  Exceptional  cleanliness  is  called  for  to  counteract  the  fcetor 
of  the  mouth.  Food  must  be  sufficient  in  amount  and  varied  in 
kind.  The  difficulty  of  mastication  will  necessitate  liquid  food  only, 
and  the  natural  tendency  to  resist  taking  even  liquids,  owing  to  the 
discomfort  caused,  must  be  firmly  overcome.  If  necessary,  forcible 
feeding  must  be  resorted  to.  In  addition  to  milk,  beef-tea,  eggs, 
etc.,  fruit  juices  and  fresh  vegetable  purges,  etc.,  may  be  given  with 
advantage.  Stimulants  may  also  be  required  both  during  the 
disease  and  in  convalescence.  When  the  mouth  condition  is  im- 
proving, astringent  tonics,  iron,  cinchona,  etc.,  are  useful. 

If  the  teeth  become  loosened  it  is  desirable,  if  possible,  to  leave 
them  alone  in  the  hope  that,  with  recovery,  they  may  become  firm 
again.  If,  however,  necrosis  sets  in,  it  will  be  necessary  to  extract 
the  affected  teeth. 

RECURRENT   STOMATITIS. 

In  this  condition  there  are  frequent  outbreaks  of  small  painful 
ulcers  about  the  tongue  and  lips. 

Treatment  consists  of  the  use  of  soothing  and  antiseptic  mouth 
washes,  touching  the  ulcers  with  chromic  acid  solution  or  silver 
nitrate,  and  the  avoidance  of  irritating  foods  or  tobacco.  The 
disease,  however,  runs  its  course  in  spite  of  treatment,  and 
recurrences  take  place  without  any  apparent  cause. 

PARASITIC   STOMATITIS   (THRUSH). 

Prophylaxis.— Except  when  the  condition  occurs  as  a  compli- 
cation in  the  course  of  wasting  diseases  or  inflammation  in  the 
alimentary  canal,  it  is  practically  limited  to  the  first  month  of  life, 
and  owing  to  the  ease  and  certainty  with  which  it  may  be  pre- 
vented every  expectant  mother  and  monthly  nurse  should  be  fully 


Stomatitis.  123 

instructed.  The  infant's  mouth  should  be  carefully  wiped  out  with 
a  small  clean  piece  of  linen,  moistened  in  water,  after  each  feed. 
Neglect  of  this  simple  precaution  sometimes  leads  to  a  train  of 
gastro-intestinal  symptoms  which  may  seriously  prejudice  its  future 
health. 

Local  Treatment. — In  the  uncomplicated  cases  the  disease  is 
usually  soon  got  rid  of  by  the  frequent  application  of  borax  in 
glycerine,  and  strict  cleanliness,  though  the  question  of  diet  should 
be  carefully  inquired  into  and  controlled.  Escherich's  boric  acid 
teat  is  sometimes  used.  It  consists  of  a  compress  of  sterilised  cotton 
dipped  in  finely-powdered  boric  acid  and  wrapped  in  gauze  to  form 
a  small  ball,  from  a  strawberry  to  a  hazel  nut  in  size.  It  may  be 
dipped  in  a  weak  saccharine  solution  to  make  it  palatable.  It  is 
important  that  it  should  be  the  proper  size  and  shape  ;  it  should 
be  kept  free  from  contamination. 

In  severe  cases  a  more  radical  local  treatment  may  be  necessary, 
such  as  pencilling  the  affected  areas  with  1  per  cent,  formalin 
solution  or  the  addition  of  sulphate  of  zinc  (10  gr.  to  the  ounce)  to 
the  mouth  wash,  and  in  still  more  severe  cases  the  application  of 
papain  (3  or  4  gr.  with  glycerine,  and  painted  over  with  a  thick 
brush)  in  order  to  soften  and  remove  the  fungus,  has  been  recom- 
mended. 

General  Treatment. — All  cases  of  thrush,  however  mild,  require, 
in  addition  to  local  measures,  careful  attention  to  the  general 
health  and  to  details  of  personal  hygiene ;  fresh  air,  cleanliness,  a 
diet  carefully  regulated  both  as  to  quantity  and  quality,  and  the 
correction  of  any  gastro-intestinal  errors.  The  more  severe  the 
case  the  more  does  this  general  treatment  increase  in  relative 
importance.  The  very  presence  of  a  severe  or  intractable  thrush 
connotes  an  ill  child.  Under  such  circumstances  it  may  require 
the  utmost  skill  and  care  in  dieting  and  treatment  to  effect  an 
improvement ;  for  with  increased  severity  of  the  mouth  condition 
comes  corresponding  difficulty  in  taking  food,  and  consequently  a 
distaste  for  food.  Spoon  or  even  nasal  feeding  may  be  necessary. 
The  exact  arrangement  of  the  diet  will  vary  with  each  individual 
case,  but  it  must  be  remembered  that  the  condition  is  an  asthenic 
one,  and  stimulants,  such  as  white  wine  whey,  etc.,  are  often  of 
great  benefit.  In  certain  cases  the  elimination  of  starchy  food  is 
efficacious. 

Internal  Treatment  must  depend  upon  the  individual  conditions 
found  ;  gastro-intestinal  derangements,  such  as  constipation, 
diarrhoea,  etc.,  or  general  nutritional  diseases,  such  as  anaemia, 
rickets,  etc.,  will  each  require  appropriate  treatment. 


124  Stomatitis. 

When  thrush  occurs  as  a  sequela  of  exhausting  diseases  the  treat- 
ment is  mainly  that  of  the  original  disease,  but  local  treatment  is 
still  important.  Chlorate  of  potassium  given  internally  is  sometimes 
of  service  in  these  cases. 

Thrush  in  adults  is  usually  limited  to  persons  suffering  from  the 
more  advanced  stages  of  tuberculosis,  typhoid  and  other  specific 
fevers  or  various  cachectic  states.  Local  treatment  must  be  on 
similar  lines  to  that  recommended  for  the  same  condition  in 
childhood.  General  treatment  must  be  directed  to  the  primary 
disease. 


GANGRENOUS  STOMATITIS   (CANCRUM   ORIS;  NOMA). 

The  very  high  mortality  of  this  specific  bacterial  infection  (80  to 
90  per  cent.)  makes  its  preventive  treatment  of  the  greatest  im- 
portance. In  general  this  consists  of  hygienic  measures,  particularly 
as  regards  the  supply  of  sufficient  nutritious  food  and  fresh  air. 
As,  however,  the  disease  is  particularly  liable  to  occur  in  children 
debilitated  by  one  of  the  specific  fevers,  special  attention  should  be 
given  to  the  thorough  cleansing  of  the  mouth  throughout  such  an 
illness. 

When  the  process  has  once  begun  heroic  methods  are  imperative. 
The  organism  in  the  whole  of  the  infected  area  (if  possible)  must  be 
absolutely  destroyed.  The  most  simple  and  effective  method  is  free 
excision.  This  must  be  done  under  anaesthesia.  The  apparently 
healthy  tissues,  for  a  considerable  margin  beyond  the  visible  disease, 
must  be  removed,  and  the  cut  surface  cauterised  by  Paquelin's 
cautery.  Some  prefer  free  destruction  by  Paquelin's  cautery  alone, 
without  excision,  or  by  pure  nitric  acid,  acid  nitrate  of  mercury, 
sulphuric  acid,  etc.  Whichever  of  these  methods  is  used  it 
must  be  done  thoroughly  and  effectually ;  there  must  be  no  half 
measures. 

In  addition  to  our  attempts  to  destroy  the  parasite  it  is  im- 
portant: (1)  To  isolate  the  patient ;  (2)  to  destroy  everything  that 
has  been  in  contact  with  the  mouth ;  (3)  to  keep  the  parts  as  sweet 
as  possible  by  means  of  free  irrigation,  with  hydrogen  peroxide 
lotion,  carbolic  acid  (1  per  cent.)  or  other  antiseptic  solution; 
(4)  to  keep  the  window  wide  open,  or  better  still,  keep  the  child 
out  of  doors  altogether ;  (5)  to  give  plenty  of  stimulating  food. 
Alcohol  is  well  tolerated  and  may  be  given  freely. 

If  recovery  takes  place  at  all,  convalescence  will  be  tedious,  and 
will  require  the  usual  tonic  treatment.  No  plastic  operation  should 


Stomatitis. 


125 


be  attempted  until  some  time  after  complete  recovery  has  taken 
place. 

The  disease  is  one  in  which  vaccine  treatment  (see  Vaccine 
Therapy,  Vol.  III.)  seems  to  hold  out  a  promise  of  success.  If  this 
hope  is  realised  the  older  heroic  methods  may  become  unnecessary. 

MERCURIAL    STOMATITIS. 

Prophylaxis. — As  this  condition  is  solely  due  to  the  absorption 
of  mercury  by  the  system,  it  is  desirable  that  in  all  cases  where 
persons  are  exposed  to  the  action  of  this  metal,  either  in  the  course 
of  their  work,  or  as  a  drug,  whether  internal  or  external,  they 
should  be  clearly  warned  of  the  possibility  of  its  occurrence  and 
informed  as  to  its  earliest  symptoms.  This  is  specially  important 
because  of  the  marked  susceptibility  of  some  persons  to  even  small 
doses  of  the  drug.  Before  beginning  a  course  of  mercury  it  is 
advisable  that  special  attention  be  given  to  the  state  of  the  mouth. 
Carious  teeth  should  be  filled  or  removed,  deposits  of  tartar  scraped 
away,  and  daily  brushing  of  the  teeth  insisted  upon.  Frequent 
rinsing  of  the  month  with  an  antiseptic  solution  is  most  important. 
A  solution  of  hydrogen  peroxide  in  water  (2  to  10  per  cent.)  is  useful. 
Kraus  recommends  sublimate  solution  (1  in  4,000  to  1  in  2,000), 
which,  although  it  contains  mercury,  is  found  in  practice  to 
prevent  stomatitis. 

Local  Treatment. — Antiseptic  and  deodorant  mouth  washes 
must  be  used  frequently.  Those  mentioned  under  Prophylaxis  will 
be  found  useful.  Potassium  permanganate  in  fairly  strong  solution 
may  be  used  as  a  deodorant.  If  ulcers  are  present  they  should  be 
painted  with  chromic  acid  (10  gr.  to  the  fluid  ounce)  or  silver 
nitrate  (solid).  If  very  painful  a  previous  application  of  cocaine 
solution  may  be  necessary. 

General  Treatment. — Internally,  especially  in  cases  of  syphilis, 
the  following  mixture  may  be  given :  1^ .  Potassii  Chloratis,  gr.  10 ; 
Dec.  Sarsas  Co.,  sij,  t.d.s.  Bland  liquid  foods  without  seasoning 
will  alone  be  tolerated. 

There  are  certain  somewhat  rare  cases  of  mercurial  stomatitis, 
not  usually  referred  to  in  the  text-books,  in  which,  in  addition  to 
great  swelling  of  the  tongue,  gums  and  fauces,  with  more  or  less 
hypersecretion  of  saliva,  practically  the  whole  of  the  buccal  and 
pharyngeal  mucosa  is  covered  with  a  thick  yellowish  membrane, 
simulating  diphtheria.  Such  cases  are  more  likely  to  occur  where 
there  is  defective  elimination  owing  to  kidney  disease,  and  unless 
recognised  early  may  prove  disastrous. 


126  Leukoplakia  Buccalis. 


LEUKOPLAKIA   BUCCALIS. 

The  treatment  in  all  stages  of  severity  of  this  condition  consists 
in  the  prohibition  of  what  has  been  the  original  cause.  In  most 
cases  this  is  tobacco,  either  smoked  or  chewed.  This  should  be 
given  up  entirely.  If  the  condition,  however,  is  only  slight  it  may 
be  sufficient  to  diminish  the  quantity  of  tobacco  daily  or  to  vary  the 
manner  of  smoking,  by  changing  the  position  of  the  pipe  or 
changing  from  one  kind  of  "  smoke  "  to  another.  In  a  certain 
number  of  cases  this  is  all  that  will  be  tolerated,  but  seeing  that  the 
condition  is  one  which  tends  to  advance,  and  that  the  restricted 
smoker  is  always  tending  to  exceed  his  irksome  limit,  it  is  more 
satisfactory  to  get  him  to  break  the  habit  entirely.  The  chewing  of 
tobacco  should,  in  all  cases,  be  absolutely  forbidden.  The  diet 
should  be  plain  and  simple,  avoiding  all  things  which  give  dis- 
comfort to  the  tongue,  particularly  hot  or  highly  seasoned  articles, 
acids  or  salted  foods.  Alcohol  should  be  limited  in  quantity  and 
spirits  avoided. 

Local  Treatment. — In  mild  cases  the  occasional  painting  with 
solution  of  chromic  acid  (5  to  10  gr.  to  the  ounce  (Butlin))  or  tannic 
acid  solution,  mel-boracis  or  alum  is  sufficient.  Chlorate  of  potash 
lozenges  may  also  be  sucked  frequently. 

In  severer  cases  frequent  applications  will  be  required.  In  such 
cases  Butlin  and  Spencer  recommend  preparations  with  a  greasy 
basis.  Their  basis  may  be  either  of  ordinary  cold  cream  or  of 
lanoline  (6  parts)  and  vaseline  (2  parts) ;  to  this  may  be  added  such 
active  drugs  as  the  prescriber  desires,  which  should  be  rather 
sedatives  than  irritants.  All  irritation  is  harmful  and  any  form  of 
caustic  must  be  avoided.  The  applications  should  be  repeated 
frequently  during  the  day,  for  it  must  be  remembered  that,  just  as 
in  diseases  of  the  skin,  the  applications  quickly  become  absorbed  by 
the  clothes  or  rubbed  off,  so  the  movements  of  the  tongue  and  the 
flooding  of  the  mouth  with  saliva  tend  quickly  to  remove  any 
application. 

General  Treatment  must  be  directed  to  any  known  defect,  such 
as  gout,  constipation,  syphilis,  etc.,  details  of  which  will  be  found 
under  corresponding  articles.  In  certain  cases  leukoplakia-like 
conditions  of  the  mouth  are  associated  with,  and  form  part  of, 
certain  skin  diseases,  lichen  planus,  psoriasis,  syphilis,  etc.  Treat- 
ment of  these  is  merely  that  of  the  skin  disease  of  which  they  form 
a  part. 


Oral  Sepsis.  127 


FCETOR   ORIS. 

The  causes  of  offensive  breath  are  numerous  and  varied.  In  each 
case  it  is  imperative  to  ascertain  the  cause,  and  to  direct  treatment 
to  that.  Thus  acute  or  chronic  diseases  of  the  nose,  naso-pharynx, 
mouth,  teeth,  gums,  jaws,  resophagus,  stomach,  intestines,  or  air 
passages  may  each  be  the  starting  point. 

Chronic  fcetor  of  the  breath  is  commonly  due  to  carious  teeth  or 
ozcena,  and  in  spite  of  careful  treatment  may  be  difficult  to  remove. 
It  must  not  be  forgotten  that,  in  some  cases,  the  condition  is  a  sub- 
jective one ;  the  patient  complains  of  the  breath  being  offensive 
when  to  the  observer  it  is  not  so.  Such  cases  belong  to  the  category 
of  imaginary  affections,  and  treatment  must  be  directed  to  the 
general  mental  condition  rather  than  the  mouth.  In  all  such  cases 
a  very  thorough  examination  of  the  mouth  and  nose  should  be 
made,  not  merely  to  confirm  the  diagnosis,  but  also  to  satisfy  the 
patient's  anxieties. 


ORAL   SEPSIS. 

This  term  should  be  limited  to  the  more  severe  septic  conditions, 
such  as  pyorrhoaa  alveolar  is,  or  to  an  indurated  septic  inflammation 
of  the  gums  with  septic  discharge  from  chronic  sinuses,  associated 
with  necrosis  of  the  teeth.  Treatment,  whether  preventive  or 
therapeutic,  lies  rather  with  the  dental  surgeon  than  with  the 
physician.  But  it  is  the  physician  to  whom  the  patient  first 
appeals,  and  he  must  be  the  adviser  on  many  points  of  difficulty 
that  may  arise  in  treatment.  Thus,  in  a  severe  case  of  pernicious 
anaemia  associated  with  oral  sepsis,  the  question  of  how  far  the 
patient  is  in  a  fit  condition  to  undergo  radical  treatment  at  the 
hands  of  the  dental  surgeon  will  be  one  for  the  medical  man  to 
answer,  and  may  prove  a  delicate  and  difficult  one. 

Prophylaxis. — It  is  desirable  that  proper  attention  should  be 
given  to  cleansing  the  mouth  and  teeth  from  early  childhood.  The 
regular  daily  use  of  a  toothbrush,  especially  before  going  to  rest,  with 
soap  and  water,  either  as  a  simple  curd  soap,  or  in  the  form  of  a 
reliable  prepared  tooth  soap,  is  essential ;  the  child  should  be  taught 
to  do  this  thoroughly,  not  perfunctorily,  and  clean  teeth  should  be 
insisted  upon.  The  toothbrush  alone,  however,  does  not  effectively 
cleanse  those  places  where  caries-producing  organisms  are  chiefly 
located,  namely,  in  the  clefts  between  adjoining  teeth.  These  places 


128 


Oral  Sepsis. 


may  be  best  kept  clean  by  the  regular  "  silking  of  the  teeth  "  ;  for 
this  purpose  a  prepared  silk,  thin  rubber  tissue,  or  even  the  edge  of 
a  handkerchief,  should  be  passed  between  adjacent  teeth  once  or 
twice  a  week,  or  even  daily  at  bedtime.  The  value  of  such  a  pro- 
cedure in  preventing 
caries  is  very  great1 
(Fig.  1).  When  caries 
first  appears,  it  should 
be  dealt  with  at  once  by 
the  dental  surgeon,  and, 
seeing  that  the  earlier 
stages  are  easily  over- 
looked, it  is  well  that 
regular  routine  visits 
should  be  made  to  him 
every  three  months, 
even  where,  apparently, 
there  is  nothing  wrong. 
To  wait  until  pain 
announces  the  caries  is 
to  wait  much  too  long. 

After  brushing,  the 
mouth  should  be 
thoroughly  rinsed  with 
clean  water  or  a  suitable 
mouth  wash.  The  fol- 
lowing is  a  useful  for- 
mula, which  has  the 
advantage  of  being 
pleasant  to  use,  slightly 
astringent,  and  leaving 
an  agreeable  odour  be- 
hind :  Borax,  5j ;  Eau- 
de  -  Cologne,  jj  ;  Kose 

If  such  simple  daily  hygiene  of     the  mouth   is 
all    caries,    whenever    it    occurs,    promptly 


FIG    1. — Rubber    tooth    cleaner   (Harrison's    Reg. 

No.  569,430). 

The  instrument  consists  of  a  simple  holding 
device  (A.),  between  the  jaws  of  which  (D.  and  B.) 
a  strip  of  rubber  (C.),  for  cleaning  between  the  teeth, 
can  be  kept  stretched.  Nos.  1,2,3  show  the  method 
of  fixing  the  rubber  strip  in  position. 


Water,  ad  jviij. 

persevered    in    and 

dealt  with,  oral  sepsis  except  as  an  accidental   infection  will  be 

very  rare. 

If,  however,  sepsis  has  occurred,  it  will  require  prompt  and  radical 
treatment  at  the  dentist's   hands ;    stumps    must    be   extracted, 


1  A  simple  and  effective  instrument  for  this  purpose  has  recently  been  devised 
by  Mr.  Frank  Harrison,  L.D.S.,  and  is  shown  in  the  figure. 


Ptyalisrn.  129 

cavities  cleansed  and  filled,  accumulations  of  tartar  removed  and 
antiseptic  mouth  washes,  or  antiseptic  ointments  freely  applied.  The 
patient  should  use  the  mouth  wash  every  two,  three  or  four  hours ; 
each  mouthful  should  be  retained  for  half  a  minute;  this  should 
be  repeated  ten  times  at  each  sitting.  It  is  surprising  how  willingly 
most  patients  will  follow  out  such  definite  instructions,  and  how 
much  better  are  the  results  so  obtained  than  when  vague  indefinite 
directions  are  alone  given.  Where  artificial  tooth-plates  are  worn 
they  should  be  kept  scrupulously  clean.  When  possible,  they 
should  be  removed  and  rinsed,  or  brushed,  after  each  meal ;  they 
should  always  be  removed  on  going  to  bed,  brushed  with  soap  and 
water,  and  placed  in  a  tumbler  of  water  or  some  simple  deodorant 
antiseptic  solution.  It  is  important  that  no  roots  of  teeth  should  be 
retained  under  or  covered  by  a  denture. 

In  all  febrile  cases  particular  attention  should  be  given  to  the 
mouth  ;  if  artificial  teeth  are  worn  they  should  be  removed  entirely 
or  only  put  in  during  meals,  or  occasionally.  Mouth  washes  such 
as  the  formula  given  above  should  be  freely  used  for  rinsing  or 
wiping  out  the  mouth  after  every  meal.  Brushing  of  the  teeth  with 
some  antiseptic  tooth  soap  of  known  value  should  be  performed 
even  more  frequently  than  in  health,  and  the  tongue  carefully 
scraped  and  wiped  regularly. 

If  a  radical  operation  in  the  form  of  an  extraction  of  many  teeth 
is  performed  great  care  must  be  taken  at  the  operation  to  prevent 
the  aspiration  of  stumps  into  the  air  passages ;  whilst  for  many  days 
afterwards  the  mouth  should  be  thoroughly  and  frequently  washed 
out  with  antiseptics  to  prevent  general  infection. 

To  what  extent  vaccine  therapy  may  in  the  near  future  be 
utilised  in  the  early  treatment  of  caries  or  septic  conditions  of  the 
gums  is  at  present  hardly  ripe  for  dogmatic  statement,  but  its 
importance  cannot  be  overlooked  in  considering  the  question  of 
oral  sepsis.  (See  Vaccine  Therapy  and  Pyorrhoaa  Alveolaris.) 


SUPERSECRETION    (INCREASED    SALIVATION,    PTYALISM). 

The  commonest  causes  of  supersecretion  are  :  (1)  The  presence 
of  some  disease  of  the  mouth  ;  (2)  mercurialism.  For  their  suit- 
able treatment  see  the  preceding  paragraphs  of  this  article. 
Other  occasional  causes  to  which  treatment  must  be  directed 
are  :  Reflex  irritations  from  affections  of  distal  organs,  e.g.,  the 
pancreas,  stomach,  and  uterus  (including  gestation)  ;  toxins  of 
certain  specific  fevers,  variola,  typhus,  etc. ;  various  drugs,  gold, 

S.T. — VOL.  n.  y 


130 


Xerostomia. 


copper,   iodides,    tobacco,    jaborandi,    musCarin,    rabies;    certain 
mental  diseases. 

Occasionally  the  condition  seems  to  be  idiopathic  ;  in  such  cases 
extr.  belladonna  (±  to  £  gr.)  may  be  given  as  a  pill,  three  times 
daily,  or  atropine  sulphate  (^  gr.).  These  cases  usually  occur  in 
neurotic  subjects,  and  it  is  important  to  attend  carefully  to  the 
general  hygiene,  change  of  scene,  removal  from  all  sources  of 
worry,  bracing  climate,  regular  hours,  plenty  of  good  plain  food. 
Arsenic  and  preparations  of  iron  are  useful. 


XEROSTOMIA    (DRY    MOUTH). 

This  disease  is  fortunately  very  rare  as,  when  present,  it  is  a 
source  of  much  discomfort.  The  extreme  dryness  of  the  buccal 
mucous  membrane,  owing  to  the  absence  of  saliva,  interferes 
greatly  with  the  mastication  of  food. 

It  occurs  most  commonly  in  females  of  middle  or  old  age,   and  is 
often   associated  with    some   nervous    disorder    or   follows    some 
nervous  shock.     A  sudden  and  acute  form  occurs  in  fright.     It  is 
occasionally  produced  by  a  rapid  progressive  atrophy  of  the  salivary 
glands.     As  a  secondary  affection   it  may  be  an  acute  symptom 
accompanying  or  preceding  secondary  parotitis  and  consequently  may 
be  of  service  in  the  differential  diagnosis  between  this  affection  and 
mumps.     Carious  teeth  and  other  forms  of  irritation  should  receive 
attention.     Jaborandi  or  -pilocarpine  have  been  given  on  physio- 
logical grounds,  and  are  said  to  have  been  beneficial  in  some  cases ; 
in   others,  however,  they  have  proved  useless.     These  drugs  are 
given,  as   a   rule,  hypodermically,   but   Fraser   recommends  that 
5  minims  of  a  2  per  cent,  solution  of  pilocarpine  should  be  given  to 
the  patient  to  hold  in  his  mouth  for  a  few  minutes  from  time  to 
time,  or  that  a  £  gr.  tabloid  of  this  drug  should   be   allowed   to 
dissolve  on  the  tongue.     Osier  mentions  a  case  in  which  improve- 
ment followed  the  local  use  of  a  galvanic  current  for  three  months, 
in  a  young  man  aged  thirty-two. 

General  treatment  consists  in  the  careful  selection  of  such  bland 
foods  as  are  found  to  be  most  easily  taken.  In  this  respect  the 
patient's  own  feelings  will  be  our  best  guide.  As  a  rule,  salt  or 
seasoned  foods  cause  discomfort  ;  solids  cannot  be  properly  made 
into  a  bolus  owing  to  the  absence  of  saliva,  and  reliance  must  be 
placed  on  thick  broths  or  soups,  milk  preparations,  jellies,  beaten  up 
eggs,  etc. 


Xerostomia.  131 

Directly  before  each  meal  the  mouth  should  be  thoroughly 
moistened  with  glycerine  of  borax.  If  artificial  teeth  are  worn, 
they  should  be  thoroughly  cleansed  after  meals,  and,  perhaps, 
only  worn  during  meals.  Glycerine  of  borax  is  useful  as  an 
occasional  lubricant  for  the  mouth. 

ARTHUR  J.  HALL. 


9—2 


132 


DISEASES    AND    AFFECTIONS    OF    THE 
TONGUE. 

Wounds  of  the  Tongue. — These  are  frequently  produced  by  the 
patient's  teeth  and  are  rarely  of  sufficient  extent  or  depth  to  require 
surgical  interference.  A  weak  carbolic  mouth  wash  may  sometimes 
be  indicated.  It  should  be  remembered  that  now  and  then  a  sharp 
piece  of  tooth  or  a  broken  clay  pipe-stem  has  been  driven  into  the 
tongue  and  become  imbedded  there ;  when  covered  over  by  the 
healed  mucous  membrane  an  indurated  lump  remains  which  may 
cause  us  to  suspect  a  tumour. 

Incised  wounds  of  the  tongue,  if  fairly  deep,  may  cause  obstinate 
haemorrhage.  If  this  is  of  the  nature  of  persistent  oozing  the  best 
treatment  will  be  to  cleanse  the  wound  and  insert  two  or  more  deep 
sutures  of  fine  silkworm-gut  by  means  of  a  curved  needle.  These 
will  hold  the  edges  together  and  control  the  bleeding.  After  two 
or  three  days  they  require  removal.  But  if  the  haemorrhage  is 
plainly  arterial  it  is  better  to  tie  the  bleeding  vessel  with  Japanese 
silk.  In  order  to  effect  this,  especially  if  the  wound  is  placed  far 
back  in  the  tongue,  it  may  be  necessary  to  give  an  anaesthetic,  to 
have  the  mouth  well  opened  by  a  gag,  and  perhaps  to  enlarge  the 
wound.  Unless  the  latter  is  very  jagged  or  already  septic,  sutures 
should  be  employed  to  bring  the  surfaces  together.  An  antiseptic 
mouth  wash  must  be  frequently  used  for  a  few  days.  Ice  is  of 
course  useful  in  checking  bleeding  from  a  small  wound  of  the 
tongue. 

It  is  a  remarkable  fact  that  a  few  cases  have  been  recorded  in 
which  "  the  whole  tongue  "  has  been  torn  out  of  the  mouth  and  yet 
the  patient  has  recovered. 

Perhaps  the  most  troublesome  form  of  arterial  haemorrhage  after 
wounds  of  the  tongue  is  secondary  haemorrhage,  coming  on  several 
days  after  an  accident  or  an  operation  when  the  mouth  has  become 
septic.  This  was  a  fairly  frequent  complication  of  removal  of  the 
tongue  by  the  ecrasenr,  especially  the  galvanic  one.  In  its  treat- 
ment no  time  should  be  lost  in  tying  one  or  both  lingual  arteries 
in  the  neck. 

Tongue  Tie. — Abnormal  shortness  of  the  fraenum  linguae  rarely 
requires  surgical  interference,  as  the  frsenum  tends  to  lengthen  with 
the  growth  of  the  child.  If,  however,  there  is  difficulty  with  suckling 


Tuberculous  Disease  of  the  Tongue.        133 

or  the  child  is  backward  in  talking  or  lisps,  the  fnenum  may  be 
divided  with  advantage.  The  framum  is  put  on  the  stretch  by  the 
forefinger  and  thumb  of  the  left  hand  and  the  free  edge  is  then 
cautiously  divided  with  a  pair  of  blunt-pointed  scissors  ;  as  soon  as 
the  mucous  membrane  is  divided  no  further  cutting  should  be  done, 
but  the  cut  mucous  membrane  is  separated  upwards  by  the  finger 
nail  or  a  blunt  dissector.  No  stitches  are  required.  It  is  not 
necessary  in  the  majority  of  cases  to  employ  general  anaesthesia ; 
the  local  application  of  a  2  per  cent,  solution  of  eucaine  will 
usually  be  found  to  be  sufficient. 

Acute  Parenchymatous  Glossitis. — This  condition  may  result 
from  a  direct  infection,  as  from  a  wound  or  during  the  course  of  an 
infectious  fever,  or  as  the  result  of  mercurial  treatment,  in  which 
case  immediate  cessation  of  such  treatment  is  necessary.  In  the 
first  instance  a  brisk  purge  should  be  given  and  an  antiseptic 
mouth  wash  (such  as  Condy's  fluid  1  part,  water  4  parts)  should  be 
ordered  to  be  used  frequently.  If  resolution  does  not  commence 
under  this  treatment  scarification  of  the  tongue  with  a  guarded 
scalpel  is  often  useful ;  this  should  be  preceded  by  the  application 
of  2  per  cent,  eucaine  as  an  anaesthetic.  As  soon  as  there  is 
evidence  of  abscess  formation  a  free  incision  should  be  made  into  the 
suspected  focus.  It  sometimes  happens  that  there  is  some  respiratory 
embarrassment  owing  to  commencing  oedema  of  the  glottis  ;  in  such 
cases  early  and  free  longitudinal  incisions  should  be  made  along 
the  dorsum  of  the  tongue  and  every  preparation  should  be  made  to 
perform  tracheotomy  if  necessary. 

Sublingual  Abscess. — Suppuration  beneath  the  tongue  should 
be  treated  by  immediate  incision  into  the  most  prominent  part  of 
the  swelling,  taking  care  not  to  injure  the  ranine  veins.  In  some 
cases  the  suppurative  process  may  also  involve  the  submental 
region  ;  if  this  is  so,  an  external  counter-opening  is  also  indicated. 
The  after-treatment  consists  in  hot  fomentations  externally  with 
the  free  use  of  antiseptic  mouth  washes. 

Naevi. — Naevi  may  be  capillary,  cavernous,  or  lymphatic.  Small 
capillary  naevi  rarely  require  treatment  unless  they  are  exposed  to 
injury  from  the  teeth,  in  which  case  they  should  be  excised,  the 
resulting  wound  being  sutured  with  catgut.  Small  cavernous  naevi 
may  be  treated  in  the  same  way ;  if,  however,  they  are  large  and 
involve  the  tongue  extensively  they  are  very  difficult  to  treat ;  the 
best  results  are  probably  to  be  obtained  by  electrolysis.  Lymphatic 
naevi,  which  if  diffuse  may  produce  a  condition  of  macroglossia, 
are  best  treated  by  electrolysis  or  electrolysis  combined  with 
excision  of  a  wedge  of  the  affected  area. 


134  Syphilis  of  the  Tongue. 

Tuberculous  Disease  of  the  Tongue  is  met  with  occasionally 
as  a  solitary  nodule  or  ulcer,  having  no  distinctive  features,  and 
therefore  readily  mistaken  for  a  syphilitic  lesion  or  an  epithelioma. 
Its  treatment  is  excision  of  the  ulcer  with  a  sufficient  margin  of 
healthy  tissue  around.  Another  form  involves  the  tongue  in 
several  places  and  is  a  complication  usually  of  advanced  phthisis, 
tuberculous  disease  of  the  larynx,  etc.  No  local  treatment  beyond 
palliative  measures  (mild  antiseptic  washes,  eucaine  solution,  etc.) 
can  be  of  use  in  these  grave  cases. 

A  dental  ulcer  requires  attention  to,  and  possibly  removal  of, 
the  sharp  tootli  which  has  caused  the  lesion,  with  the  application 
of  the  electric  cautery  or  pure  carbolic  acid  to  the  ulcer  itself. 
Great  care  should  be  exercised  not  to  mistake  an  epitheliomatous 
for  a  dental  ulcer,  and  resort  should  be  had  to  microscopic  examina- 
tion in  any  doubtful  case. 

SYPHILITIC  AFFECTIONS   OF    THE   TONGUE. 

Chancre  of  the  Tongue. — It  will  be  understood  that  infecting 
or  syphilitic  chancres  are  alone  referred  to  ;  so  far  as  is  known  the 
"  soft  chancre  "  is  never  met  with  in  this  region.  It  may  be  said 
that  the  only  difficulty  in  the  treatment  lies  in  the  correct  diagnosis 
which,  partly  owing  to  the  rarity  of  lingual  chancres,  is  often 
delayed  or  mistaken.  The  sore  may  have  been  treated  as  a  dental 
or  tuberculous  ulcer,  and  we  have  known  cases  in  which  a  portion 
has  been  excised  in  order  to  test  the  diagnosis  made  of  epithelioma. 
Stress  is  to  be  laid  on  the  bubo  nearly  always  present  in  the 
submaxillary  region  or  over  the  carotid  vessels. 

The  spirochaeta  pallida  should  be  sought  for  in  doubtful  cases, 
but  the  constant  occurrence  of  similar  spiral  micro-organisms  in 
the  secretions  of  the  mouth  must  be  borne  in  mind. 

But  little  local  treatment  is  required  for  chancres  of  the  tongue. 
Their  excision  is  rarely  if  ever  indicated,  as  by  the  time  the  correct 
diagnosis  is  made  the  poison  is  already  widespread.  Lotio  nigra 
(B.P.)  may  be  used  frequently  to  wash  the  sore  with,  and  the 
patient  must  be  brought  speedily  under  the  influence  of  mercury. 
Whether  this  is  given  by  inunction,  intramuscular  injections,  or 
by  the  mouth,  must  depend  upon  the  surgeon's  views.  For  our 
part  we  prefer  the  steady  administration  of  pulv.  hydrargyri  c 
creta  and  pulv.  ipecac,  co.  [U.S.P.  pulv.  ipecac,  et  opii]  in  pills  or 
tabloids  containing  1  gr.  of  each.  Four  of  these  should  be  taken 
at  regular  intervals  during  the  day,  to  be  diminished  to  three  if 
the  gums  become  touched.  The  patient  must  abstain  from  alcohol 
during  the  mercurial  course. 


Syphilis  of  the  Tongue  135 

Secondary  Syphilitic  Lesions  of  the  Tongue. — The  treatment 
of  these  must  vary  with  their  nature  and  duration.  Their  variety 
is  remarkable ;  the  chief  forms  are  the  following : 

(1)  Mucous  patches,  raised  white  ones  similar  to  those  often  met 
with  on  the  lips,  palate,  tonsils  or  pharynx. 

(2)  Superficial  ulcers. 

(3)  Bald  patches  or  areas  of  denudation  of  papillae  to  be  compared 
with  the  patchy  alopecia  of  the  scalp  due  to  syphilis. 

(4)  Warty  or  papillomatous  growths,  chiefly  met  with  far  back  on 
the  dorsum  of  the  tongue. 

(5)  Persistent  white  patches  or  leucomata,  which  must  be  dis- 
tinguished from  true  leukoplakia  due  to  excessive  smoking. 

Several  of  these  lesions  may  be  met  with  on  the  same  tongue. 

For  some,  especially  the  mucous  patches,  a  prolonged  course  of 
mercury  taken  internally  is  the  best  treatment,  and  this  applies  to 
the  other  forms  if  the  patient  is  really  in  the  secondary  stage.  But 
a  superficial  glossitis,  taking  the  form  of  recurrent  ulcers  or  white 
patches,  occurring  in  a  patient  whose  syphilis  dates  back  several 
years,  is  often  better  treated  by  careful  local  measures  and  the 
removal  of  all  irritants  than  by  pushing  specific  remedies.  In  such 
cases  mercury,  however  administered,  may  effect  little  or  nothing, 
whilst  iodides  may  only  depress  the  patient.  In  all  these  cases  the 
question  of  local  irritation,  especially  from  smoking  and  the  use 
of  spirits,  must  be  enquired  into.  '  The  use  of  both  cigars  and 
cigarettes  is  to  be  wholly  forbidden,  and  in  some  cases  even  the 
occasional  pipe  must  be  included  in  the  ban.  Any  sharp  teeth 
must  be  attended  to  by  the  dentist. 

The  warty  growth  seen  in  the  secondary  stage  may  be  so  persistent 
that  vigorous  treatment  with  caustics,  such  as  a  solution  of  nitrate 
of  silver  (20  to  40  gr.  to  the  ounce)  or  the  acid  nitrate  of  mercury, 
may  be  indicated.  We  have,  however,  found  that  pushing  the 
internal  administration  of  mercury,  with  or  without  iodides,  usually 
effects  a  cure.  Ulcers  in  the  early  secondary  stage  are  well  treated 
by  the  occasional  application  of  nitrate  of  silver  or  chromic  acid  in 
solution,  the  exact  strength  of  which  must  vary.  We  have  found 
the  former  the  more  useful  of  the  two.  A  solution  of  bicyanide  of 
mercury  (1  to  5  gr.  to  the  ounce  of  water)  has  a  long-standing 
reputation  as  an  application  to  syphilitic  sores  ;  it  is  very  poisonous 
and  must  be  used  with  caution  ;  we  have  not  found  that  it  possesses 
any  advantage  to  counterbalance  this  drawback.  Lotia  nigra  is  a 
safe  mercurial  wash,  though  not  a  pleasant  one  in  appearance. 
The  use  of  a  mouth  wash  of  bichloride  of  mercury  is  attended  with 
some  risk  of  salivation  and  of  damage  to  the  teeth  ;  if  it  is  used  we 


136  Syphilis  of  the  Tongue. 

advise  that  the  surgeon  alone  should  apply  it.  With  this  provision 
a  strong  solution  may  he  painted  on  any  obstinate  syphilitic  lesion, 
e.g.,  bichloride  of  mercury,  1  part ;  glycerine,  10  parts  ;  absolute 
alcohol  to  100  parts. 

Chinosol  occasionally  answers  well  when  all  mercurial  applications 
have  failed,  and  in  obstinate  cases  we  strongly  advise  that  it  should 
be  given  a  trial.  One  is  apt  to  order  chinosol,  which  has  an 
undoubted  effect  011  syphilitic  ulcers  of  all  kinds,  in  too  strong 
proportions  ;  on  such  a  sensitive  part  as  the  inflamed  lingual 
surface  it  must  be  used  exceedingly  weak.  A  mouth  wash  of 
chinosol  1  part,  water  500  to  1,000  parts,  or  an  application  of  1  in 
100  parts  is  strong  enough. 

Sir  H.  T.  Butlin  and  Sir  Henry  Morris  have  recommended  the 
use  of  the  blue  ointment  (the  ung.  hydrargyri,  B.P.)  for  syphilitic 
sores  of  the  tongue,  but  the  difficulty  of  using  it  will  be  obvious. 

To  sum  up,  the  early  syphilitic  lesions  of  the  tongue,  whatever 
their  nature,  should  be  treated  mainly  by  the  careful  administration 
of  mercury,  by  removing  all  sources  of  irritation,  and  by  the 
judicious  use  of  local  applications,  of  which  the  best  are  nitrate  of 
silver,  chinosol,  chromic  acid  and  certain  mercurial  lotions. 

Much  patience  may  be  required,  as  it  is  easy  to  obtain  healing, 
but  relapse  is  very  frequent.  Perseverance  is,  however,  well 
rewarded  if  the  condition  is  prevented  from  drifting  on  into  an 
inveterate  chronic  glossitis,  which  is  one  of  the  most  troublesome 
and  dangerous  of  all  the  remote  results  that  may  follow  in  the 
syphilitic  train.  In  this  form  ulcers,  white  patches,  sclerosis,  bald 
areas  and  papillomatous  projections  may  all  be  met  with.  In 
addition,  gummatous  lumps  or  diffuse  deep  infiltration  are  some- 
times seen.  It  is  for  the  latter  conditions  that  iodides  are  so 
valuable. 

Iodide  of  sodium,  iodide  of  potassium,  iodide  of  ammonium 
(of  each  3  to  5  gr.),  syrup  of  orange  (1  drachm),  may  be  given 
freely  diluted,  and  the  dose  increased  every  few  days.  Or,  if 
preferred,  one  of  the  many  new  preparations  of  iodine  may  be  tried 
instead  of  the  iodides,  and  this  is,  perhaps,  best  worth  doing  if  the 
latter  depress  or  produce  catarrh.  lodipin  (or  iodinol)  seems 
to  be  the  most  generally  used,  and  the  best  of  these  new  compounds  ; 
it  is  merely  iodine  and  oil  of  sesame  in  the  proportion  of  10 
per  cent,  and  25  per  cent,  of  iodine.  One  drachm  of  the  25  per 
cent,  iodipin  may  be  given  as  a  dose  either  hypodermically  or 
in  capsules,  each  dose  being  then  equivalent  to  about  5  gr. 
of  iodide  of  potassium.  As  to  their  relative  value  in  causing 
absorption  of  gummatous  material  in  the  tongue  or  elsewhere, 


Leucomata  of  the  Tongue.  137 

we  have  no  hesitation  in  saying  that  the  iodides  are  superior, 
and  should  be  employed  whenever  possible  in  preference  to  iodipin 
and  its  congeners. 

A  point  of  importance  has  now  to  be  noted.  A  considerable  pro- 
portion of  the  cases  of  cancer  of  the  tongue  develop  in  men  who 
have  had  syphilis,  and  the  transition  from  chronic  tertiary  glossitis 
to  epithelioma  is  an  easy  one  and  apt  to  be  overlooked.  Even 
a  gummatous  ulcer  of  the  tongue  may  closely  simulate  a  sloughing 
epithelioma,  and  rice  rerun.  In  any  doubtful  case  the  "therapeutic 
test,"  i.e.,  the  administration  of  increasing  doses  of  iodides,  should 
not  be  persisted  in  for  long  without  resorting  to  excision  of  part 
of  the  suspicious  edge  and  careful  microscopic  examination. 

It  may  be  noted  that  iodides  occasionally  fail  or  are  very  slow  to 
cure  true  gummatous  ulcer,  and  that,  on  the  other  hand,  their 
administration  usually  makes  a  cancerous  sore  of  the  mouth  improve 
in  appearance,  "  clean  up,"  for  some  days. 

In  the  treatment  of  obstinate  lesions  of  the  tongue  in  the 
intermediate  or  tertiary  stage  of  syphilis  (apart  from  gummatous 
infiltration,  which  has  just  been  described)  the  following  points 
should  be  noted  : 

(1)  The  measures  advocated  already  for  the  secondary  lesions  are 
likely   to   be   of   use,   and  in  addition  the  occasional   use  by  the 
surgeon  of  the  acid  nitrate  of  mercury  to  any  superficial  ulcer  is 
to  be  recommended.     This  should  be  applied  with  a  glass  brush, 
care  being  taken  to  limit  the  action  of  the  caustic  by  the  use  of 
blotting  paper. 

(2)  The  avoidance  of  local  irritants  must  be  insisted  on.     The 
syphilitic  poison  undoubtedly  leaves  the  mucous  membrane  of  the 
tongue  and  mouth  unduly  susceptible  to  such  irritants  for  many 
years  in  some  patients.     In  these  it  may  be  necessary  to  avoid  both 
alcohol   and   tobacco  as  well  as  all  condiments,  such  as  mustard, 
pepper,  etc. 

(3)  Specific  remedies  are  liable  to  be  overdone  and  may  even  cause 
harm.     For   example,  one    patient  with   relapsing  glossitis   took 
considerable  doses  of  iodides  for  ten  years  and  underwent  a  course 
of   mercurial  injections   without   any  advantage ;  another   patient 
went  through  nine  courses  of  mercurial  inunctions  at  Aix  ;  his  tongue 
being  worse  at  the  end  of  them  than  at  the  beginning. 

It  may,  however,  be  admitted  that  now  and  then  a  course  of 
injections  or  inunction  is  useful,  and  certainly  iodides  are  worthy 
of  trial  if  the  history  shows  that  specific  remedies  have  never  been 
persevered  with.  Salvarsan  may  also  be  tried. 

Leucomata   of  the  Tongue  and    Leukoplakia. — It  is  almost 


138  Epithelioma  of  the  Tongue. 

unnecessary  to  point  out  that  scars  left  by  syphilitic  ulcers  need 
no  treatment,  local  or  general.  Apart  from  these  there  is  an 
uncommon  condition  of  thin  white  patches  (leucomata)  especially 
met  with  along  the  sides  of  the  tongue,  which  simulate  syphilitic 
lesions.  Usually  their  subject  has  some  form  of  chronic  skin 
trouble,  such  as  a  dry  eczema  or  lichen  psoriasis ;  but  the  mucous 
membranes  may  be  alone  involved.  Together  with  the  local  use 
of  some  soothing  application,  such  as  the  glycerinum  boracis,  it  is 
worth  while  to  try  the  effect  of  a  course  of  arsenic  for  this  condition. 
This  remedy  is  also  useful  in  relapsing  herpetic  conditions  of  the 
•tongue  and  mouth,  especially  combined  with  small  doses  of  opium 
(in  the  form  of  liq.  arsenicalis  and  liq.  opii  sedativus).  We  have 
now  to  refer  to  the  well-known  leukoplakia  of  the  tongue,  where 
dense  white  patches  of  thickened  epithelium  are  found  on  the 
dorsum  or  lateral  aspects,  a  disease  which  is  of  remarkable  per- 
sistence and  whose  tendency  to  pass  into  epithelioma  has  been 
thoroughly  established.  That  leukoplakia  may  occur  in  those  who 
have  had  syphilis  is  true,  but  anti-syphilitic  treatment  has  no  effect 
upon  it  whatever.  True  leukoplakia  is  solely  due  to  excessive 
smoking,  aided  sometimes  by  spirit  drinking.  The  knowledge  of 
this  fact  will  point  to  the  appropriate  treatment,  but,  unfortunately, 
when  once  started,  the  removal  of  the  cause  does  not  lead  to  a  cure. 
In  fact,  there  is  no  known  remedy  that  is  really  effective  short  of 
excision  of  the  dense  white  patches,  and  this  involves  such  scarring 
of  the  tongue  that  it  cannot  be  recommended  for  most  cases.  It 
has  been  claimed  that  the  X-rays  or  radium  have  now  and  then 
led  to  cure ;  this  may  be  true,  but  the  cases  in  which  we  have 
tried  them  have  been  wholly  disappointing.  A  patient  with  leuko- 
plakia must  give  up  smoking  entirely,  must  avoid  spirits,  and 
should  be  seen  from  time  to  time  in  order  that  the  first  indication 
of  epitheliomatous  change  should  be  met  by  surgical  measures. 
The  danger  of  epithelioma,  however,  need  not  be  exaggerated  ; 
leukoplakia  may  exist  ten  or  twenty  years  without  going  on  to 
cancer.  The  occurrence  of  an  ulcer  or  of  a  papillomatous  growth 
in  the  centre  of  the  white  patch  is  almost  certain  evidence  that  this 
change  has  occurred,  and  no  time  should  then  be  lost  in  resorting 
to  excision. 

EPITHELIOMA    OF    THE    TONGUE. 

There  is  but  little  variety  in  the  forms  of  malignant  disease  of 
the  tongue.  Sarcoma  is  exceedingly  rare,  scirrhous  or  atrophic 
cancer  still  more  so;  practically  all  the  cases  are  examples  of 
squamous  epithelioma.  In  few,  if  any,  parts  of  the  body  is  the  effect 


Epithelioma  of  the  Tongue.  139 

of  chronic  irritation  and  inflammation  in  directly  producing  cancer 
more  marked.  It  may  be  said  that  in  a  large  proportion  of  cases 
there  is  a  pre-cancerous  stage  of  cancer  of  the  tongue,  one  in  which 
careful  treatment  and  absolute  avoidance  of  all  irritants  may 
succeed  for  long  in  warding  off  the  evil  day. 

Cancer  of  the  tongue,  being  a  squamous  epithelioma,  is  but  little 
amenable  to  the  influence  either  of  the  X-rays  or  of  radium ; 
rodent  ulcer  (which  is  often  cured  by  either)  is  not  a  squamous 
epithelioma,  but  has  a  very  different  histology.  Again,  the  chief 
danger  of  cancer  of  the  tongue  lies  in  early  infection  of  lymphatic 
glands,  secondary  deposits  in  the  viscera  being  of  extraordinary 
rarity ;  in  this  it  conforms  to  the  rule  as  to  squamous  epithelioma ; 
but  the  rapidity  with  which  the  cervical  glands  are  infected  by 
lymphatic  emboli  from  a  cancer  of  the  tongue  has  no  equal  in 
examples  of  squamous  epithelioma  elsewhere  in  the  body. 

These  considerations  help  to  form  the  basis  for  our  treatment  of 
lingual  cancer. 

(1)  No  trust  should  be  placed  in  X-rays  or  radium  ;  valuable  time 
will  be  lost  by  so  doing,  and  a  case  possibly  curable   by  excision 
may  be  converted  into  a  hopeless  one. 

(2)  A    thorough    operation     must    include     removal    of   those 
lymphatic  glands  which  are  likely    to   be  infected  as  well  as  a 
sufficiently  free  excision  of  the  primary  growth.     This  holds  true 
although    no    enlargement    of  the  lymphatic  glands  can  be   felt 
before  the  operation. 

The  two  points  mentioned  are  conceded  by  nearly  all  surgeons 
at  the  present  time,  but  there  is  great  variety  in  the  method  of 
carrying  out  the  "  radical  operation,"  if  indeed,  it  deserve  to  be  so 
called ;  for  even  the  most  elaborate  operations  for  cancer  of  the 
tongue  are  too  often  followed  by  recurrence  within  a  few  years. 
In  some,  fortunately,  the  term  "  cure"  is  warranted.  It  must  also 
be  pointed  out  that  a  few  of  the  most  successful  cases  have  been 
those  in  which  the  tongue  alone  was  operated  on,  but  without 
doubt  the  prognosis  is  considerably  improved  by  the  simultaneous 
removal  of  lymphatic  glands.  We  may  note  here  that  the  chance 
of  survival  for  more  than  three  or  four  years  after  a  thorough 
operation  for  cancer  of  the  tongue  appears  to  be  about  1  in  4  or  1 
in  5.  But  very  much  depends  on  the  earliest  possible  recognition 
of  the  cancerous  change. 

All  are  agreed  that  excision  of  the  tongue  is  best  performed  with 
curved  scissors  (as  introduced  by  Whitehead),  and  that  ccrascnrs  of 
every  kind  should  be  regarded  as  obsolete.  It  is  also  agreed  that 
to  perform  the  early  method  of  Kocher,  excision  of  the  tongue 


140  Epithelioma  of  the  Tongue. 

through  a  lateral  wound  in  the  neck,  is  to  run  needless  danger,  and 
that  this  operation  should  be  reserved  for  exceptional  cases  of 
involvement  of  the  floor  of  the  mouth. 

But  the  number  of  questions  still  unsettled  is  large.  They 
include  the  following :  Should  the  lower  jaw  be  divided  in  order 
to  obtain  more  free  access  to  the  tongue  ?  Should  the  operation 
be  done  in  two  stages,  separated  by  a  fortnight  or  more,  or  in 
only  one  ?  If  done  in  two  stages,  should  the  tongue  or  the 
cervical  glands  be  first  removed?  Is  laryngotomy  useful  as  a 
preliminary  measure  in  the  tongue  operation,  and  has  it  any  effect 
in  warding  off  the  risk  of  pneumonia?  Should  the  lingual 
arteries  be  secured  in  the  mouth,  or  should  they  be  tied  with  the 
facial  vessels  in  the  neck,  or  should  the  external  carotid  be 
tied? 

Exceptional  cases  require  special  measures ;  now  and  then,  for 
example,  division  of  the  lower  jaw  may  be  required,  though  quite 
unnecessary  in  most  cases.  If  the  complete  operation  on  tongue 
and  glands  can  be  carried  out  in  one  stage  there  are  obvious 
advantages  in  so  doing.  There  are  few,  if  any,  operations  which 
are  faced  by  the  patient  with  so  much  dread  and  fear  as  removal 
of  the  tongue.  In  fact,  the  most  "  heroic  "  of  these  operations, 
where  all  the  tongue  down  to  the  hyoid  bone  is  removed,  involves 
so  much  after-misery  and  discomfort  that  several  of  its  victims 
have  resorted  to  suicide.  In  any  case  where  excision  of  part  of  the 
tongue  has  been  advised  the  patient  knows  that  a  certain  amount 
of  mutilation,  and  of  impairment  of  speech  will  be  involved.  It  is 
difficult  enough  to  persuade  him  to  submit ;  it  will  be  a  much 
greater  ordeal  to  go  through  two  major  operations,  including  two 
anaesthetics,  and  doubling  the  patient's  expense  or  stay  in 
hospital.  It  is  admitted  by  Mr.  Butlin,  who  is  the  chief  advocate 
of  the  two-stage  operation,  that  in  about  40  per  cent,  of  his 
cases  the  patient  could  not  be  induced  to  submit  to  the  second 
part  (the  removal  of  the  lymphatic  glands).  This  is  an  important 
consideration. 

Another  advantage  of  the  one-stage  operation  is  that  by 
preliminary  ligature  of  both  linguals  in  the  neck  after  the 
removal  of  the  lymphatic  glands  excision  of  the  tongue  itself  is 
almost  a  bloodless  procedure. 

Epithelioma  of  the  tongue  is  most  commonly  found  on  one 
lateral  border,  and  the  danger  as  regards  lymphatic  infection 
then  lies  mainly  on  the  same  side  of  the  neck.  Secondary  deposits 
occur  in  the  glands  outside  the  submaxillary  triangle  at  the 
junction  of  the  facial  and  jugular  veins,  in  those  about  the 


Epithelioma  of  the  Tongue.  141 

carotid  bifurcation,  over  and  behind  the  internal  jugular  vein, 
along  its  course  down  the  neck.  All  these  glands  lie  beneath  the 
deep  cervical  fascia.  In  addition  to  these,  there  are  a  few 
lymphatic  glands  in  the  submaxillary  triangle,  embedded  in  the 
salivary  gland  itself,  which  are  rarely  infected  in  cancer  of  the 
tongue,  though  frequently  in  cancer  of  the  lower  lip  and  floor  of 
the  mouth. 

It  is  usually  advisable  to  remove  the  whole  submaxillary  gland 
and  to  ligature  both  facial  and  lingual  artery  on  the  affected 
side.  If  the  epithelioma  of  the  tongue  infiltrates  deeply,  or  is 
situated  near  the  middle  line,  it  is  essential  to  remove  the 
lymphatic  glands  mentioned  above  on  both  sides  of  the  neck. 

The  following  is  a  sketch  of  the  operation  advised  in  an 
ordinary  case  : 

(1)  A  curved  incision  is  made  from  the  angle  of  the  jaw  down  to 
the  hyoid  bone  and  up  to  near  the  symphysis  of  the  jaw.     From  a 
point  behind  the  centre  of  this  incision  a    second   cut   is    made 
for  several  inches  down  the  anterior  border  of  the  sterno-mastoid, 
which  is  thoroughly  exposed.     The  flaps  of  skin,  platysma  and 
fascia,  are  reflected  and  held  aside  by  suture  retractors. 

(2)  The  submaxillary  gland  is  dissected  out,  the  facial  artery  and 
vein  being  tied  in   two  places,   and  a  ligature   placed  round  the 
divided  end  of  Wharton's  duct. 

(3)  The  lymphatic  glands   over  the  carotid  bifurcation,  beneath 
the   angle  of   the  jaw  and  along  the  jugular  vein,    are   carefully 
dissected  out  so  that  the  main  vessels  are  bared.     It  often  happens 
that  a  small  portion  of  the  parotid  gland  is  removed  at  the  same 
time ;    this   is   of   no   importance.     The   jugular  vein   should   be 
cleared  of  its  glands  as  low  as  possible.     If  necessary,  the  sterno- 
mastoid  muscle  may  be  divided  to  assist  the  dissection,  but  this  is 
not  required  in  most  cases. 

(4)  The  lingual  artery  is  easily  found  through  a  small  incision 
in  the  hyoglossus  muscle,  and  is  tied. 

(5)  The  wound  is  sewn  up,  and  a  drainage  tube  is  sutured  in  its 
lower  end.     A  pad  of  gauze  is  applied,  the  neck  turned  over,  and 
the  surgeon  repeats  the  procedure  on  the  opposite  side,  or  if  the 
cancer  is  wholly  unilateral  he  limits  his  interference  to  ligature  of 
the  opposite  lingual  through  the   ordinary  incision.     After  suture 
of  this  wound  a  light  dressing  is  bandaged  round  the  neck. 

The  operation  so  far  has  been  a  tedious  one,  lasting  at  least  an 
hour,  but  the  anaesthetist  will  not  have  been  interfered  with  in  any 
way,  and  after  this  but  little  more  anaesthetic  will  be  required. 

The   mouth    is    held    open    by    a  gag,  the  cheek  retracted  (in 


142  Epithelioma  of  the  Tongue. 

exceptional  cases  it  may  be  divided  on  the  side  affected),  the 
tongue  secured  bv  volsellum  forceps  or  a  deep  suture  and  drawn 
well  out  of  the  mouth.  '  This  step  is  made  easy  by  free  division  of 
the  fraenum  and  underlying  muscle. 

The  excision  of  the  tongue  is  done  with  curved  scissors,  and  it 
must  be  made  wide  of  the  epitheliomatous  area.  As  a  rule,  a  large 
wedge-shaped  piece  should  be  taken,  sometimes  one  half  only 
suffices,  but  whenever  possible,  a  healthy  portion  of  tongue  should 
be  left  to  help  in  articulation  and  deglutition.  This  is  of  great 
importance  as  regards  the  future  comfort  of  the  patient. 

As  a  rule,  sutures  are  not  to  be  recommended  in  the  stump  of 
the  tongue,  nor  is  the  use  of  any  antiseptic  varnish  (such  as 
Whitehead's,  containing  benzoin  and  iodoform)  satisfactory. 

Sedulous  care  in  nursing  will  be  required  to  keep  the  mouth 
sweet ;  antiseptic  sprays  should  not  be  used,  but  either  of  the 
following,  employed  with  small  sponges,  are  excellent :  pure  carbolic 
acid,  ^  to  1  drachm,  rectified  spirit,  to  2  oz.,  water,  to  8  oz. ;  or 
thymoglycine  applied  in  full  strength.  Sanitas  or  peroxide  of 
hydrogen  are  also  useful. 

Similar  preparations  diluted  should  be  used  to  syringe  or  wash  out 
the  mouth  frequently.  It  is  surprising  how  soon  the  patient  can  sit 
up  and  perform  these  measures  for  cleansing  the  mouth  and  how  well 
he  manages  fluid  food  given  through  a  feeder  with  long  nozzle  or 
rubber  tube  attached.  Nasal  feeding  is  very  rarely  required. 

The  details  of  after-treatment  in  these  cases  of  extensive 
operations  on  the  tongue  deserve  special  attention.  In  over  seventy 
such  cases  treated  by  the  writer  there  have  been  only  three 
deaths  connected  with  the  operation.  In  one  of  these  death 
occurred  during  the  administration  of  the  anaesthetic,  laryngotomy 
had  been  done,  and,  owing  to  the  extent  of  the  disease,  excision 
ought  not  to  have  been  attempted.  Even  counting  this  case,  the 
direct  mortality  has  only  been  about  5  per  cent.,  without  it  only 
3  per  cent.  This  satisfactory  result  could  not  have  been  obtained 
but  for  the  great  care  in  the  after-treatment  taken  by  the  nurses, 
and  the  following  sketch  of  what  is  generally  done  will  be  found 
helpful : 

On,'  hour  Ix'fore  the  operation  an  enema  containing  strong  coffee 
(4  to  6  oz.)  and  brandy  (2  oz.)  is  given. 

Immediately  nfti-r  the  operation  and  before  the  patient  comes 
round,  an  enema  containing  a  pint  of  warm  saline  solution  and 
2  oz.  of  brandy  is  given.  Strychnine  and  caffeine  injections  of  the 
usual  strength  are  given  hypodermically  every  three  hours  if 
necessary,  but  the  amount  of  shock  is  not  great  as  a  rule. 


Epithelioma  of  the  Tongue.  143 

As  soon  us  possible  after  the  patient  has  come  round  from  the 
anaesthetic  he  sits  up  and  the  nurse  gently  syringes  or  swabs  the 
mouth  out  with  one  of  the  solutions  given  already.  This  is  con- 
tinued through  the  first  night  every  quarter  of  an  hour  unless  the 
patient  is  asleep.  Hot  water  is  allowed  in  small  quantities  through 
a  rubber  tube  or  a  feeding  cup  ;  but  if  oozing  is  troublesome  iced 
water  should  be  used.  Nutrient  enemata  are  given  every  eight 
hours  for  the  first  two  days,  after  which  the  bowel  is  cleared  out  by 
a  soap  and  water  enema,  and  sufficient  food  is  then  taken  by  mouth 
to  render  the  other  method  of  feeding  unnecessary. 

During  the  day  after  operation  the  mouth  is  carefully  cleansed 
every  half  hour ;  2  oz.  of  milk  and  1  oz.  of  water  are  given  every 
hour. 

On  th<;  second  day  cleansing  the  mouth  is  done  less  frequently, 
but  this  will  entirely  depend  on  the  state  of  the  raw  surface,  the 
absence  of  any  foetor,  etc.  The  patient  may  have  milk  and  egg,  or 
beef-tea.  Feeding  must  be  continued  through  the  night  at  regular 
intervals. 

On  or  after  the  third  day  custards  and  jellies  can  probably  be 
taken,  and  on  the  sixth  day  probably  pounded  fish  or  mince.  At 
this  time,  also,  the  patient  may  attend  to  the  mouth  if  carefully 
watched  and  instructed.  After  every  feed  the  washing-out  should 
be  done.  It  is  a  mistake  to  keep  the  patient  long  in  bed ;  he  is 
often  better  out  of  it  on  the  second  day  or  third  day. 

Care  must  of  course  be  taken  to  prevent  contamination  of  the 
neck  dressings,  but  if  the  latter  are  attended  to  daily  and  kept  • 
covered  with  mackintosh  (pink  jaconet)  trouble  in  this  direction 
ought  hardly  ever  to  arise.  There  is  no  part  of  the  body  in  which 
extensive  wounds  heal  more  kindly  than  the  neck,  and  the  scars 
from  this  operation  become  quite  inconspicuous. 

No  mention  has  been  made  of  laryngotomy,  as,  in  our  opinion,  it 
is  an  unnecessary  complication ;  in  fact,  if  the  gland  dissection 
is  done  at  the  same  time  as  the  tongue  excision  a  laryngotomy  would 
be  very  much  in  the  way.  As  already  noted,  Sir  H.  T.  Butlin  and 
some  other  surgeons  recommend  that  the  first  operation  should  be 
limited  to  removal  of  the  submaxillary  gland  and  lymphatic  glands 
in  the  anterior  triangle,  and  that  from  two  to  three  weeks  later  the 
tongue  should  be  partly  or  completely  excised  with  a  preliminary 
laryngotomy  and  ligature  of  the  lingual  arteries  in  the  mouth. 

When  an  epithelioma  of  the  tongue  invades  the  floor  of  the 
mouth  the  prognosis  of  operation  becomes  very  grave,  and  perhaps 
the  worst  cases  of  all  are  those  in  which  it  starts  far  back  and 
invades  the  pillars  of  the  fauces  and  the  tonsillar  region.  It  is  not 


144  Sarcoma  of  the  Tongue. 

possible  here  to  define  which  cases  should  be  submitted  to  operation, 
which  are  unsuitable  for  it,  and,  further,  what  exact  form  the 
operation  should  take.  Each  case  must  be  judged  on  its  merits  ; 
not  infrequently  the  patient's  general  state  of  health  will  have  some 
influence  on  the  surgeon's  mind  in  coming  to  a  decision,  as  well  as 
the  extent  of  the  local  disease.  The  most  important  factor  of  all  is 
the  condition  of  the  lymphatic  glands  of  the  neck.  If  these  are 
neither  much  enlarged,  adherent  nor  softening,  the  primary  growth 
in  the  mouth,  however  extensive,  may,  as  a  rule,  be  attacked  at  the 
same  time  that  the  glands  are  removed  and  the  external  carotid  artery 
tied.  Even  if  the  neck  wound  has  to  communicate  with  the  mouth 
for  a  time,  the  risk  of  cellulitis  is  worth  running  for  the  chance 
of  considerable  prolongation  of  life. 

But  if  large  secondary  glands  have  become  firmly  adherent  to 
the  deep  muscles,  the  jugular  vein  or  the  carotid  artery,  the 
attempt  at  excision  is  bound  to  fail  and  should  not  be  made. 

What  can  be  done  for  these  inoperable  and  for  hopeless  recurrent 
cases  of  lingual  cancer  ?  Kadium  or  the  X-rays  will  almost  surely 
be  resorted  to,  and  of  the  two  we  recommend  the  X-rays,  applied  in 
very  powerful  dosage  for  ten  to  twenty  minutes  at  a  time,  at  intervals 
of  a  few  days.  The  pain,  at  least,  will  be  diminished  by  this  means, 
though  the  rate  of  growth  may  not  be  checked. 

Opium,  best  given  in  the  form  of  nepenthe,  will  be  required 
sooner  or  later.  On  no  account  should  Coley's  streptococcic  fluid 
be  injected ;  its  absolute  failure  to  do  good  has  been  demonstrated 
again  and  again.  On  the  other  hand,  it  is  apt  to  make  the  patient 
feverish  and  ill,  and  in  nearly  all  cases  adds  to  the  discomfort  and 
pain  of  his  last  days.  (See  also  Tumours,  Vol.  I.) 

SARCOMA   OF   THE   TONGUE. 

The  only  treatment  for  this  rare  condition  that  can  be  of  the  least 
avail  is  excision.  The  growth  may  be  either  a  round-celled  or  in 
large  part  a  spindle-celled  sarcoma.  The  former  is  closely  allied 
to  lympho-sarcoma  and  has  the  terribly  malignant  character  of  the 
latter  form  of  growth.  At  the  same  time  there  is  perhaps  not 
much  to  choose  between  the  two  varieties  from  this  point  of  view. 
Excision  undoubtedly  prolongs  life,  but  those  cases  which  have 
been  well  recorded  and  followed  up  prove  that  of  every  five  patients 
with  sarcoma  of  the  tongue  that  are  operated  on  only  one  will  be 
found  alive  after  two  or  three  years  have  elapsed. 

The  tongue  in  cases  of  sarcoma  may  become  greatly  enlarged, 
and  as  it  is  not  a  question  of  dissecting  out  lymphatic  glands 


Cysts  of  the  Tongue.  145 

laryngotomy  may  be  advised  as  a  preliminary  measure.  Otherwise 
there  may  be  difficulty  and  danger  in  giving  the  anaesthetic. 

With  laryngotomy  performed  and  a  sponge  kept  in  the  pharynx 
to  prevent  blood  running  backwards,  the  operation  is  made  easier. 
The  mucous  membrane  is  freely  divided  from  the  frsenum  back- 
wards on  either  side,  keeping  the  scissors  well  down  in  the  floor  of 
the  mouth  ;  this  enables  the  tongue  to  be  drawn  well  forwards  and 
both  lingual  vessels  to  be  secured  with  ligatures  before  division. 

Sarcoma  of  the  tongue  appears  sometimes  to  be  well  limited  all 
round  as  though  encapsulated,  and  hence  its  excision  may  seem 
easy  and  very  promising ;  but  as  already  noted  the  prognosis  is 
most  grave,  death  occurring  from  secondary  deposits  in  the  lunge 
and  the  other  viscera,  occasionally  even  in  the  cervical  lymphatic 
glands. 

CYSTS  OF  THE  TONGUE  AND  FLOOR  OF   THE  MOUTH. 

The  chief  cysts  of  the  tongue  and  floor  of  the  mouth  are  mucous 
retention  cysts  (of  which  the  well-known  ranula  is  the  chief  example) 
and  dermoid  cysts.  The  former  are  by  far  the  most  frequent. 

The  only  treatment  for  dermoid  cysts  is  excision,  which  should 
be  carried  out  through  an  incision  in  the  middle  line  in  the  neck, 
between  the  chin  and  the  hyoid  bone.  The  cyst  usually  bulges 
towards  the  skin  in  this  region,  and  no  great  thickness  of  muscle 
will  have,  therefore,  to  be  cut  through.  It  will  shell  out  without 
much  difficulty.  A  fine  drain  should  be  inserted  in  the  wound  for 
a  day  or  two. 

A  Ranula  is,  on  the  other  hand,  very  difficult  or  impossible  to 
dissect 'out  whole;  moreover,  it  should,  with  rare  exceptions,  be 
attacked  through  the  mouth.  So  apt  is  it  to  recur,  that  we  advise 
that  a  general  anaesthetic  should  be  given  in  .order  that  the 
surgeon  may  have  the  best  chance  in  his  dissection.  The  mucous 
membrane  is  incised  carefully  parallel  with  Wharton's  duct,  which 
it  is  important  not  to  injure.  By  means  of  the  "  dissector,"  the 
cyst  may  be  isolated  to  a  considerable  extent  before  it  ruptures  or  is 
opened.  The  glairy  fluid  that  escapes  is  thoroughly  mopped  up. 
The  edges  of  the  cyst  wall  are  seized  with  fine  serrated  forceps ; 
the  cyst  is  then  opened  from  end  to  end,  and  as  much  as  possible 
of  its  wall  is  dissected  out.  If  the  surgeon  is  compelled  to  leave 
a  good  deal  of  the  wall  behind  he  should  apply  to  this  a  probe 
dipped  in  pure  carbolic  acid,  or  a  brush  dipped  in  strong 
nitrate  of  silver  solution.  Some  recommend  pure  chromic  acid, 
but  we  have  known  this  produce  excessive  inflammatory  reaction. 
The  operation  is  not  infrequently  performed  under  the  local 

S.T. — VOL.  n.  10 


146  Cysts  of  the  Tongue. 

application  of  cocaine  or  eucaine,  but  this  makes  a  thorough 
removal  of  the  cyst  wall  difficult,  except  in  the  most  simple  cases 
of  ranula. 

JONATHAN  HUTCHINSON. 

EEFERENCES. 

Poirier,  Professor  Paul,  "Traitement  du  Cancer  de  la  Langue,"  Bull,  et 
Mem.  Soc.  de  Chir.  de  Paris,  1905,  N.S.,  Vol.  XXXI.,  pp.  743—753.  Butlin, 
Sir  H.  T.,  "  Cancer  of  the  Tongue,"  Brit.  Med.  Journ.,  1905,  I.,  pp.  285—289  ; 
ibid.,  1909,  L,  pp.  3—10. 

Butlin,  Sir  H.  T.,  "  On  Radium  in  the  Treatment  of  Cancer,  etc.,"  Lancet, 
1909,  I.,  pp.  1411—1414. 

Treves,  Sir  F.,  and  Hutchinson,  J.,  "  Manual  of  Operative  Surgery,"  1903, 
II.,  pp.  241—258. 


147 


DISEASES  AND  AFFECTIONS  OF  THE  PALATE. 
CLEFT  PALATE. 

IN  the  great  majority  of  cases  of  cleft  palate  the  only  treatment 
that  is  advisable  is  closure  by  operation.  In  a  small  minority,  chiefly 
those  seen  for  the  first  time  in  adult  life,  mechanical  treatment  by 
some  form  of  obturator  is  preferable.  In  children  even  the  widest 
clefts  can  almost  invariably  be  closed  by  a  suitable  operation. 

Treatment  by  obturators  will  be  discussed  later.  The  operative 
treatment,  the  more  important  branch  of  the  subject,  will  be  taken 
first. 

Operative  Treatment. — In  dealing  with  the  operative  treatment 
of  cleft  palate  the  first  point  to  be  considered  is  the  age  at  ivliich 
the  operation  should  be  undertaken  in  order  that  the  best  result 
may  be  obtained. 

Theoretically,  the  sooner  the  cleft  in  the  palate  is  closed  the 
better.  If  the  palate  can  be  restored  to  the  normal  or  nearly  so, 
before  the  child  has  learnt  to  speak,  articulation  is  subsequently 
less  likely  to  be  imperfect.  In  a  certain  number  of  cases,  chiefly 
of  narrow  clefts  and  of  clefts  limited  to  the  soft  palate,  it  is  wise  to 
do  the  operation  quite  early,  within  the  first  few  months  of  life,  and 
nothing  is  gained  by  delay. 

In  most  cases,  however,  it  is  far  better,  in  the  interests  of  the 
child,  not  to  perform  a  very  early  operation  but  to  wait  a  year  or 
two,  and  to  operate  upon  the  palate  towards  the  end  of  the  second 
year,  or  even  in  some  cases  a  little  later  still.  The  harelip 
should  certainly  be  closed  quite  early,  within  a  few  weeks  or  even 
days  of  birth.  If  this  is  done  and  the  surgeon  and  parents  are  con- 
tent to  wait  a  year  or  two,  it  will  be  found  that  the  cleft  in  the  palate 
becomes  relatively  much  narrower,  and  the  operation  proportionately 
easy  and  satisfactory. 

It  is  quite  common,  for  example,  in  a  new  born  child  with  complete 
harelip  and  cleft  palate,  to  see  a  wide  space  between  maxilla  and 
premaxilla.  After  closure  of  the  cleft  in  the  lip  this  space  gradually 
diminishes  and  after  a  year  or  two  has  either  wholly  disappeared 
or  is  reduced  to  a  narrow  chink. 

It  is,  as  a  rule,  better  not  to  wait  much  longer  than  the  period 
above  named,  because  a  defective  articulation  once  thoroughly 
established  is  difficult  to  correct. 

A  cleft  which  shows  much  less  tendency  to  spontaneous  closure 

10—2 


148  Cleft  Palate. 

than  does  the  ordinary  variety  of  the  complete  cleft,  is  that  which 
involves  all  the  palate  except  the  alveolar  arch  and  which  is  not 
associated  with  harelip.  Sometimes  these  clefts  are  extremely 
wide  and  have  a  broad  rounded  anterior  end.  Such  clefts  are 
difficult  to  close  at  any  age,  but  are  best  treated,  in  my  opinion, 
towards  the  end  of  the  second  year.  A  few  of  the  very  worst  are 
best  treated  at  a  still  later  age.  I  have  not  yet  met  with  a  case  of 
this  kind  which  I  have  not  succeeded  in  closing,  but  I  have  never 
attempted  to  close  this  variety  during  the  first  year  of  life. 

It  is  sometimes  urged,  and  the  argument  at  first  sight  seems  a 
plausible  one,  that  it  is  best  to  attempt  closure  of  the  palate  before 
the  lip  is  operated  upon.  The  sole  advantage  of  this  is  that  the 
palatine  cleft  is  a  little  more  accessible  to  view.  But  this  slight 
advantage  is  far  more  than  compensated  for  by  the  greater  relative 
width  of  the  cleft.  The  real  difficulty  of  a  cleft  palate  operation  to 
'  any  one  who  is  reasonably  skilful  with  his  fingers,  lies  not  in  the 
inaccessibility  of  the  cleft,  but  in  obtaining  sufficient  tissue  for  its 
closure.  This  brings  me  to  the  kind  of  operation  which  should  be 
employed.  There  are  two  chief  methods  in  vogue  at  the  present 
day.  One  is  that  which  has  long  been  associated  with  the  names 
of  Langenbeck,  Fergusson,  Thomas  Smith  and  others,  and  in  the 
opinion  of  the  writer,  and  he  thinks,  of  most  surgeons  who  have 
had  much  practical  experience  of  cleft  palate  operations,  it  is  much 
the  best.  It  consists  briefly  in  dissecting  up  the  soft  tissues  of  the 
hard  palate  from  the  underlying  bone,  in  separating  the  soft  palate 
from  the  posterior  margin  of  the  hard  palate,  and  suturing  the  pared 
edges  of  these  soft  tissues  after  they  have  been  shifted  towards  the 
middle  line.  The  operation  is,  however,  by  no  means  an  easy  one, 
and  the  operator  should  be  thoroughly  familiar  with  all  its  details 
before  he  undertakes  to  perform  it.  The  chief  objection  that  has 
been  raised  to  this  operation  is  that  in  most  cases  it  is  necessary  to 
make  a  lateral  incision  through  the  palatine  soft  tissues  on  one  or 
both  sides,  to  enable  the  parts  to  be  approximated  without  undue 
tension.  These  incisions  are  really  in  most  cases  little  more  than 
a  tenotomy  of  the  tensor  palati  muscles. 

The  other  method,  which  certainly  has  the  merit  of  simplicity, 
consists  in  cutting  a  large  flap  of  tissue  from  one  side  of  the  palate, 
taking  up  if  necessary  the  tissues  of  the  gum,  turning  this  over  like 
the  leaf  of  a  book  and  inserting  its  edge  under  the  tissues  of  the 
opposite  side.  The  soft  palate  is  dealt  with  in  a  somewhat  similar 
way  by  splitting.  One  advantage  of  this  operation  is  that  it  avoids 
the  lateral  incisions  above  mentioned.  The  principal  objection  to 
it,  besides  its  severity,  is  the  tendency  to  sloughing  or  to  subsequent 


Cleft  Palate.  149 

atrophy  of  the  flap  thus  fashioned,  and  the  imperfect  nature  of 
the  soft  palate  that  is  thus  formed.  The  muscular  flap  formed 
by  splitting  and  turning  back  the  soft  palate  necessarily  undergoes 
atrophy.  It  is  not  an  operation  that  can  be  recommended,  as  the 
after-results  in  most  cases  seem  to  be  poor,  especially  as  regards 
the  soft  palate. 

Another  operation  which,  like  the  last,  has  become  fashionable 
of  late  years  is  that  commonly  known  as  Brophy's  operation.  The 
theory  of  it  is  good,  for  in  a  cleft  palate  there  is  no  actual  loss  of 
tissue.  The  two  halves  of  the  palate  have  simply  failed  to  coalesce. 
Brophy  forces  them  violently  together  and  unites  them  by  means 
of  a  stout  silver  wire  passed  transversely  through  the  upper 
jaws.  This  wire  is  kept  in  place  for  several  weeks,  and  the  subse- 
quent closure  of  the  cleft  is  greatly  facilitated.  The  operation,  at 
any  rate  as  performed  in  this  country,  is  undoubtedly  a  severe  one, 
and  to  my  certain  knowledge  has  been  followed  by  death  in  many 
cases.  Worse  still,  the  child  may  develop  necrosis  of  the  jaw  and 
live.  The  disastrous  effect  of  an  extensive  necrosis  upon  the 
subsequent  development  of  an  infant's  jaw  and  teeth  is  well  known. 
I  have  never  myself  performed  this  operation.  The  operation  can 
only  be  performed  in  the  first  few  months  of  life  while  the  bones 
are  still  soft  and  pliable.  It  may  be  added  that  in  the  illustration 
which  Brophy  gives  of  the  anatomy  of  the  jaw,  a  large  area  of 
cancellous  bone  is  shown  between  the  teeth  and  the  orbit,  and  it  is 
in  this  bone  that  the  wire  is  supposed  to  lie.  Eeference  to  the 
actual  skull  of  an  infant  will  show  that  no  such  area  exists,  the 
permanent  (unerupted)  teeth  being  separated  from  the  floor  of 
the  orbit  merely  by  a  very  thin  plate  of  bone  (see  the  dissections 
of  skulls  in  the  odontological  collection  at  the  Royal  College  of 
Surgeons). 

It  is  difficult  to  understand  how  a  wire  can  be  passed  through 
the  upper  jaw  of  a  young  infant  without,  on  the  one  hand,  trans- 
fixing the  orbit,  on  the  other  hand  inflicting  damage  upon  the 
germs  of  the  permanent  teeth.  The  operation  cannot  be  recom- 
mended until  more  details  are  forthcoming  as  to  the  ultimate 
results  of  the  operation.  The  few  surgeons  who  still  recommend 
the  operation  have  not  as  yet,  so  far  as  I  am  aware,  published  any 
detailed  series  of  cases  either  with  or  without  after-results. 

THE   OPERATION   FOR   CLEFT   PALATE. 

Anaesthetic. — Chloroform  is  best  for  this  operation.  It  should 
be  administered  through  a  Junker's  tube.  The  anaesthesia  should 
not  be  deep. 


Cleft  Palate. 


Haemorrhage  must  be  controlled  by  sponge  pressure  and  by 
frequent  swabbing  out  of  the  pharynx.  If  the  head  is  well  extended 
the  blood  will  tend  to  run  into  the  naso-pharynx  rather  than  towards 
the  larynx. 

Gag. — No  gag  has  yet  been  invented  for  this  operation  which  can 
compare  with  Smith's,  fulfilling  as  it  does  the  three-fold  function  of 
keeping  the  mouth  widely  open,  of  depressing  the  tongue,  and  of 
reflecting  light  towards  the  palate.  It  is,  however,  not  an  easy 
gag  to  hold  correctly,  and  the  proper  use  of  it  has  to  be  learnt.  It 

is  worth  while  for 
the  operator  to  take 
the  trouble  to  ex- 
plain to  the  nurse 
or  other  assistant 
in  charge  of  it  the 
exact  way  in  which 
it  is  to  be  held. 
Common  mistakes 
in  the  use  of  this 
gag  are  pushing  the 
tongue  backwards 
over  the  larynx,  de- 
pressing the  lower 
jaw  unduly  and  com- 


G.  'k.—r-The  operation  for  cleft  palate. — A  puncture 
has  been  made  through  the  soft  tissues  of  the  hard 
palate,  and  a  raspatory  inserted  between  the  perios- 
teum and  the  bone. 

This  and  the  next  five  figures  are  from  drawings 
of  ati  'actual  case  in  which  the  cleft  was  completely 
closed  by  the  writer.  A  cast  of  the  palate  was  taken 
before  the  operation  Was  begun. 


pressing  the  sides  of 
the  pharynx  with 
the  fingers.  All 
these  errors  can 
easily  be  avoided 
with  a  little  care. 


The  essential  steps  of  the  operation  are  : 

(1)  liaising  the  soft  tissues  of  the  hard  palate  from  the  under- 
lying bone.     This  may  be  done  by  raspatories  and  an  aneurysm 
needle,  either  from  the  inner  edge  or  through  a  small  puncture  at 
the  back  and  outer  part  of  the  hard  palate. 

(2)  Detachment  of  the  soft  palate  from  the  posterior  edge  of  the 
hard  palate.     This  is  effected  by  means  of  sharply  curved,  blunt- 
pointed  scissors,  one  blade  of  which  is  inserted  between  the  hard 
palate  and  the  newly  raised  muco-periosteal  tissues.     The    other 
blade  is  in  the  naso-pharynx.     The  cut  is  then  made  from  within 
outwards.     It  is  the  omission  or  incomplete  performance  of  this 
step  that  is  often  responsible  for  the  unsuccessful  result  of  operation. 


Cleft  Palate. 


(3)  Paring  the  margins  of  the  cleft,  and  then  careful  suture  with 
moderately  fine  fishing  gut.  The  sutures  should  be  passed  by 
means  of  slender  rectangular  needles  mounted  on  long  handles. 
They  should  be  inserted  about  J  to  J  inch  apart.  The  edges  of  the 
wound  should  be  carefully  everted  before  the  sutures  are  tied,  so  as 
to  bring  broad  surfaces  of  the  wound  into  apposition.  The  sutures 
should  not  be  tied  very  tightly,  or  strangulation  and  sloughing  of 
the  edges  may  occur. 

It  is  best  to  suture  the  soft  palate  first.  After,  or  in  bad  cases 
before,  the  sutures  have  been 
tied,  a  lateral  incision  to  re- 
lieve tension  is  made  on  one 
or  both  sides  of  the  palate 
through  the  whole  thickness  of 
the  soft  tissues.  The  exact 
position  and  length  of  these 
incisions  must  depend  on  the 
degree  of  tension.  As  a  rule 
an  incision  beginning  just 
inside  and  a  little  in  front  of 
the  posterior  palatine  foramen 
and  extending  backwards  and 
outwards  for  £  to  f  inch  will 
suffice. 

After-treatment.—  The 
child  should  be  kept  as  quiet  as 
possible.  A  small  dose  of  Tr. 
opii  given  at  the  time  of  the 
operation  is  useful.  For  the 
first  week  or  ten  days  the  child 
should  be  fed  with  milk  only, 
and  not  very  frequently.  It  is 
a  good  plan  to  give  the  child 

a  drink  of  warm  water  to  which  a  little  chlorate  of  potash  has  been 
added  (10  gr.  to  the  ounce)  immediately  after  each  feed.  Spraying 
the  mouth  or  frequent  washing  out  is  to  be  avoided,  unless  the 
wound  has  become  definitely  septic.  In  the  latter  case  foetor  of  the 
breath  will  be  noticed.  The  stitches  should  be  left  in  situ  for  at 
least  ten  days  or  a  fortnight.  Some  operators  prefer  to  leave  them 
until  they  drop  off  spontaneously.  If,  at  the  end  of  a  fortnight  or 
so,  it  is  found  that  a  considerable  part  of  the  wound  has  broken 
down,  but  the  edges  are  granulating  and  clean,  it  may  be  advisable 
to  put  the  child  again  under  chloroform,  and  to  insert  a  few  more 


FIG.  2. — Showing  the  mode  in  which  an 
aneurysm  needle  or  a  curved  raspatory 
is  used  in  the  separation  of  the  muco- 
periosteum,  working  from  the  margii. 
of  the  cleft. 


152 


Cleft  Palate. 


stitches  to  bring  the  edges  into  approximation.  But  this  should 
not  be  done  too  early  for  fear  of  breaking  down  the  parts  which 
have  already  united.  Fresh  paring  of  the  edges  is  not  advisable. 
If  the  operation  has  been  a  complete  failure,  it  is  best  to  wait 
several  weeks  and  then,  when  the  parts  are  thoroughly  clean,  to  do 
the  operation  over  again. 

After  every  operation  for  cleft  palate  great  care  should  be  taken 
to  train  the  child  to  speak  slowly  and  correctly.  The  ultimate 
result  as  regards  speech  will  depend  largely  upon  the  attention 

which  the  mother  or  nurse 
pays  to  this  point  in  the  first 
year  or  two  after  the  operation. 
In  all  cases  of  complete  cleft 
palate  associated  with  harelip 
there  will  be  more  or  less  irregu- 
larity of  the  teeth,  especially  the 
'ront  teeth.  This  irregularity 
is  partly  responsible  for  the 
defective  speech  which  may 
exist  after  the  performance  of 
an  otherwise  successful  cleft 
palate  operation.  It  is  impor- 
tant, therefore,  that  the  services 
of  a  dentist  should  be  obtained 
for  the  regulation  of  the  teeth 
during  childhood  before  the 
deformity  has  become  per- 
manent. Missing  teeth  should 
be  replaced  by  means  of  a  suit- 
able plate.  The  latter  will  have 
to  be  renewed  once  or  twice  a 
year  in  the  case  of  a  growing 

child.  It  is  a  mistake,  however,  to  think  that  treatment  by  means 
of  a  denture  should  be  postponed  until  the  child  is  grown  up. 
Much  harm  to  the  articulation  is  often  caused  by  such  delay. 

Treatment  by  Obturators.— If  any  special  reason  exists  why 
the  patient  should  not  be  treated  by  operation,  then  an  obturator 
should  be  fitted  to  the  cleft  palate.  Its  use  should  be  restricted  to 
the  following  cases : 

(1)  Most  adult  cleft  palate  patients.  In  these  patients,  although 
the  closure  of  the  cleft  by  operation  is  usually  quite  easy,  yet 
the  probable  benefit  to  articulation  is  scarcely  sufficient  to 
justify  it.  It  should  be  remembered  also  that  a  cleft  palate 


FIG.  3. — Mode  in  which  temporary  pres- 
sure can  be  applied  by  sponge  and 
thumb,  if  hasmorrhage  is  at  all 
troublesome  during  the  separation 
of  the  soft  tissues  from  the  bone. 


Cleft  Palate. 


153 


operation  on  an  adult  may  easily  render  the  speech  worse  than  it 
was  before. 

(2)  Children  who   have   undergone   an   unsuccessful   operation 
which  has  heen  followed  by  extensive  sloughing,  so  that  insufficient 
tissue  is  left  for  the  closure  of  the  cleft  by  any  subsequent  plastic 
operation. 

(3)  Cases  in  which  the  soft  palate  has  been  successfully  closed 
by   operation,  but   in   which  a    large    hole    in    the    hard    palate 
remains  which  cannot  be  closed  by  operation.     In  many  cases  of 
this    kind    in    young 

subjects,  even  the 
temporary  wearing  of 
a  plate  does  much 
good,  and  may  lead 
in  time  to  complete 
spontaneous  closure 
of  the  hole. 

It  may  be  stated  as 
a  general  rule  that 
obturators  are  very 
satisfactory  in  the 
treatment  of  aper- 
tures in  the  rigid  hard 
palate,  while  in  the 
case  of  the  soft  palate 
nothing  has  yet  been 
invented  which  gives 
really  satisfactory 
results. 

For  the  hard  palate 
all  that  is  wanted  is  a 
thin  plate  of  gold  or 
vulcanite  that  will  cover  the  opening.  Such  a  plate  is  easily  fitted 
to  the  teeth,  and  as  many  cleft  palate  patients  have  some  irregu- 
larity in  the  dental  arch,  the  plate  may  also  serve  a  useful  purpose 
in  correcting  this.  It  is  important  that  the  plate  be  laid  over 
the  cleft  and  not  inserted  into  it.  If  the  latter  mistake  is  made 
the  cleft  will  tend  to  become  wider  instead  of  narrower  as  age 
advances. 

Any  attempt  to  replace  by  mechanical  apparatus  a  muscular 
structure  such  as  the  soft  palate,  capable  of  delicate  voluntary 
movements,  must  necessarily  be  very  imperfect.  It  is  for  this 
reason  that  a  well-executed  operation  which  restores  the  soft  palate 


FIG.  4. — -The  very  important  step  of  freeiug  the  soft 
palate  froifl  the  posterior  edge  of  the  bony  palate. 
One  blade  of  the  scissors  lies  in  the  nose,  the  other 
between  the  bone  and  muco-periosteum  of  the 
palate.  Note  that  the  axis  of  the  scissors  has  been 
rotated  after  insertion  of  the  blades. 


154 


Cleft  Palate. 


FIG.  5. — The  separation  of  the  soft  tissues  having  been  effected  and 
the  edges  of  the  cleft  pared,  the  first  suture  is  about  to  be  passed 
at  the  anterior  part  of  the  soft  palate.  Note  the  direction  in 
which  the  point  of  the  rectangular  needle  is  being  inserted. 


FIG.  6.— The  soft  palate  having  been  sutured,  is  drawn  forward  by 
a  pair  of  clip  forceps  attached  to  the  uncut  sutures,  while  sutures 
are  being  passed  transversely  through  the  uvula. 


Cleft  Palate. 


while  preserving  its  movements  is  greatly  to  be  preferred  to  an 
obturator  as  far  as  the  soft  palate  is  concerned. 

Obturators  for  the  soft  palate  fall  into  two  classes,  those  in 
which  the  extension  backwards  from  the  hard  palate  is  rigid  and 
those  in  which  some  degree  of  mobility  is  aimed  at. 


B 


FIG.  7. — Showing  the  manner  in  which  sutures  often  have  to  be  passed  at  the 
anterior  end  of  the  cleft,  when  the  rectangular  needle  cannot  con- 
veniently carry  the  same  suture  through  both  sides  of  the  cleft. 

A.  The  needle  has  been  passed  through  one  edge  of  the  cleft  and  then  with- 
drawn, leaving  a  loop  of  suture  projecting  into  the  cleft. 

B.  A  second  suture  has  been  passed  through  the  other  edge  of  the  cleft  and 

then  through  the  loop  of  the  first  suture. 

C.  By  pulling  simultaneously  upon  both  ends  of  the  first  suture,  the  second 

suture  is  carried  completely  across  the  cleft  and  is  ready  for  tying. 

In  the  first  class  the  best  form  is  that  in  which  a  conical  mass 
of  vulcanite  or  some  similar  material  is  firmly  fixed  to  the  posterior 
edge  of  the  plate  that  covers  the  hard  palate.  This  mass  should 
very  nearly,  l>ut  not  quit?,  fill  up  the  space  between  nose  and 
pharynx.  Air  is  thus  enabled  to  pass  freely  through  the  naso- 
pharynx when  the  muscles  of  the  latter  are  at  rest.  But  when 
it  is  desired  to  close  this  passage  completely,  in  deglutition  or 


156  Affections  of  the  Palate. 

phouation,  a  very  slight  contraction  of  the  muscles  is  sufficient  to 
do  this. 

In  the  second  form  of  obturator  the  posterior  part  may  be  an 
elastic  flap  which  lies  against  the  under-surface  of  the  soft  palate, 
following  it  in  its  movements.  Such  an  apparatus  is  not  easily 
tolerated  and  does  not  effect  a  really  efficient  closure  of  the  cleft. 
A  much  better  form  is  that  in  which  an  oval,  more  or  less  rigid, 
mass  with  concave  sides  is  united  by  a  metallic  spring  and  swivel 
to  the  more  rigid  part  of  the  obturator.  The  posterior  part  which 
lies  in  the  cleft  of  the  soft  palate  is  grasped  by  the  latter  when  in 
action  and  follows  its  movements. 

Such  an  obturator,  if  really  well  made,  is  a  very  great  help  to 
articulation.  It  is,  however,  very  difficult  to  make.  It  should  be 
borne  in  mind  that  any  soft  palate  obturator  is  at  first  exceedingly 
irksome  and  irritating  to  the  wearer.  Much  patience  must  be 
exercised  before  the  pharynx  becomes  sufficiently  tolerant  to  bear 
it  without  great  discomfort.  In  no  case  should  an  obturator  be 
fitted  to  any  child  before  the  age  of  six  years.  Between  this  age 
and  that  of  puberty  an  obturator  may  often  be  applied  with 
advantage  if  its  object  is  to  facilitate  the  closure  of  a  hole  left  in  the 
hard  palate  after  a  partially  successful  operation;  or  it  may  be 
worn  with  advantage  to  correct  irregularities  in  the  dental  arch 
and  so  to  improve  articulation.  An  obturator  applied  to  a  growing 
jaw  will  of  course  require  frequent  renewal.  It  is  seldom,  if  ever, 
desirable  to  place  a  soft  palate  obturator  in  the  mouth  of  a  child. 

JAMES  BERRY. 

The  illustration  in  this  article  are  taken  from  Berru  and  Lfqq's  "Hare-Lip  and 
Cleft-Palate:' 


OTHER   AFFECTIONS    OF   THE    PALATE. 

Acquired  Perforations  of  the  Palate.— These  lesions  are 
almost  always  the  result  of  tertiary  syphilis.  In  the  majority  of 
cases  they  should  be  treated  by  the  use  of  obturators;  plastic 
operations  for  their  closure  are  rarely  satisfactory,  but  may  be 
attempted  when  the  perforation  is  small  and  the  other  conditions 
are  favourable. 

Tumours  of  the  Palate. — Innocent  tumours  are  easily  removed. 
Sarcoma  and  squamous-celled  carcinoma,  when  removable,  require 
partial  excision  of  the  upper  jaw. 

C.  H.  S.  FRANKAU. 


DISEASES  AND  INJURIES  OF  THE  SALIVARY 

GLANDS. 

INFLAMMATION   OF   THE    SALIVARY    GLANDS. 

Primary  Parotitis. — (1)  Mumps. — (See  Special  Article,  Vol.  I., 
p.  256.) 

(2)  Simple  Parotitis  is  occasionally  due  to  exposure  to  cold. 
It  also  results  from  the  administration  of  mercury,  the  impaction  of 
a  calculus  in  the  duct  or  to  inflammation  extending  along  the  duct 
from  the  mouth.  The  inflammation  following  an  impacted  calculus 
is  of  a  chronic  character  leading  to  an  increase  in  size  and  hardness 
of  the  gland  from  the  formation  of  fibrous  tissue,  or  it  may  be  acute 
and  cause  suppuration.  When  the  inflammation  is  due  to  infection 
spreading  along  the  duct,  suppuration  may  occur  and  pus  may  be 
seen  entering  the  mouth  from  the  duct  or  it  may  be  made  to  exude 
by  pressure  along  the  course  of  the  duct. 

When  the  inflammation  is  due  to  mercury  the  administration 
of  the  drug  should  be  at  once  discontinued.  Hot  fomentations 
should  be  applied  over  the  gland ;  chlorate  of  potash  in  doses 
of  10  gr.  should  be  given  every  four  hours,  and  astringent 
mouth  washes  containing  chlorate  of  potash  (10  gr.)  and  alum 
(5  gr.)  should  be  used  frequently.  As  this  form  of  parotitis  is 
more  likely  to  occur  in  patients  with  septic  mouths,  all  decayed 
teeth  and  stumps  should  be  removed  or  "  stopped "  before  the 
administration  of  mercury  is  begun ;  any  pyorrhoea  alveolaris 
should  also  be  treated. 

If  an  impacted  calculus  is  the  cause  of  the  affection  it  should  be 
removed.  When  the  infection  spreads  along  the  duct  from  the 
mouth,  the  state  of  the  latter  should  be  rendered  as  aseptic  as 
possible  by  the  removal  of  decayed  teeth  and  stumps,  the  regular 
use  of  antiseptic  and  astringent  gargles,  such  as  sanitas  (1  drachm 
to  a  pint  of  water)  or  chlorate  of  potash  and  alum,  or  weak 
carbolic  (1  in  80  to  100)  lotion.  The  duct  may  be  slit  up  from 
inside  the  mouth  so  as  to  provide  a  freer  exit  for  the  pus.  If 
the  pus  has  involved  a  large  portion  of  the  gland  it  must  be 
evacuated  through  an  external  incision  over  the  most  oedematous 


158      Inflammation  of  the  Salivary  Glands. 

area.  This  operation  should  not  be  delayed  too  long,  if  slitting 
up  the  duct  is  insufficient,  as  there  is  a  tendency  for  the  pus  to 
burrow  into  the  surrounding  parts.  The  incision  must  be  placed 
so  as  not  to  injure  the  facial  nerve,  and  a  medium-sized  drainage 
tube  will  be  required. 

Secondary  or  Symptomatic  Parotitis  occurs  in  the  course  of 
an  acute  infective  disease,  such  as  typhoid  fever,  pneumonia, 
pyaemia ;  during  the  puerperium  and  after  lesions  or  operations  on 
the  abdominal  and  pelvic  viscera.  Two  views  are  held  as  to  the 
origin  of  this  affection  :  (1)  That  it  is  due  to  infection  ascending  the 
duct  from  a  septic  mouth ;  (2)  that  the  infection  is  by  the  blood 
stream  and  pyaemic  in  origin.  In  the  great  majority  of  cases  the 
former  method  of  origin  is  the  correct  one,  and  hence  the  necessity 
of  keeping  the  mouth  clean  in  all  cases  of  disease  and  especially 
after  abdominal  lesions  and  operations.  The  parotitis  may  be 
simple,  but  very  often  it  is  suppurative.  Owing  to  the  density  of 
the  parotid  fascia  the  pus  is  liable  to  burrow  deeply  rather  than 
come  to  the  surface ;  thus  it  may  pass  into  the  neck  or  towards  the 
base  of  the  skull,  or  burst  into  the  mouth  or  into  the  external 
auditory  meatus  ;  hence,  as  soon  as  it  is  evident  from  the  oadema 
of  the  skin  that  suppuration  is  present,  the  abscess  should  be 
opened  by  Hilton's  method.  A  horizontal  incision  sufficiently  large 
to  provide  a  free  exit  and  drainage  for  the  pus  should  be  made, 
and  it  must  be  placed  so  as  not  to  damage  the  facial  nerve.  A  tube 
is  better  than  a  gauze  drain.  In  the  earlier  stages  of  the  affection 
hot  fomentations  must  be  applied  over  the  gland,  and  the  mouth 
kept  as  aseptic  as  possible  by  the  frequent  use  of  antiseptic  mouth 
washes,  the  use  of  a  tooth  brush,  and  the  removal  of  all  debris  and 
purulent  material  from  the  teeth  and  from  the  spaces  between 
the  gums  and  cheeks,  by  means  of  cotton-wool  swabs  held  in  forceps 
or  fastened  to  a  stick,  the  swabs  being  soaked  in  an  antiseptic, 
such  as  1  in  80  carbolic  or  sanitas  and  water.  The  tongue  should  be 
kept  as  clean  as  possible,  and  moist  thick  fur  may  be  scraped  off 
with  a  spoon  or  spatula.  Bicarbonate  of  soda  (gr.  10  ad  §j  water) 
is  very  useful  for  detaching  adherent  crusts  or  mucus ;  the  swabs 
should  be  dipped  in  the  solution  and  then  rubbed  firmly  over  the 
surface.  If  possible,  decayed  teeth  and  stumps  should  be  removed, 
especially  if  they  are  loose. 

The  Submaxillary  and  Sublingual  Glands  are  not  so  fre- 
quently affected  by  inflammation  except  as  a  result  of  an  impacted 
calculus ;  therefore  no  special  description  is  necessary.  Probably 
the  position  of  the  buccal  orifice  of  their  ducts  explain  their 
freedom. 


Salivary  Calculi.  159 

SALIVARY  CALCULI. 

Salivary  Calculi  are  not  uncommon  in  Wharton's  duct  and  are 
most  often  found  near  its  orifice.  They  may,  however,  be  present 
in  any  part  of  the  duct  and  sometimes  in  the  substance  of  the  sub- 
maxillary  gland.  The  patient's  attention  is  usually  directed  to  the 
affection  by  the  pain  on  mastication  or  by  the  chronic  enlargement 
of  the  gland.  A  fine  probe  may  sometimes  be  passed  along  the 
duct  and  made  to  grate  against  the  calculus,  or  the  calculus  may 
be  actually  protruding  from  the  orifice  of  the  duct  or  sinus.  Sup- 
puration not  infrequently  occurs  around  or  behind  the  stone.  A 
sinus  or  an  irregular  ulcer  simulating  an  epithelioma  may  be 
present  in  the  floor  of  the  mouth. 

The  treatment  is  to  remove  the  stone  as  soon  as  it  is  detected. 
If  it  is  placed  close  to  the  orifice  of  the  duct  the  mucous  membrane 
should  be  painted  with  a  10  per  cent,  solution  of  cocaine.  An 
incision  is  made  directly  down  to  the  stone,  which  is  then  removed 
with  sinus  forceps.  If  the  stone  is  placed  more  deeply  a  general 
anaesthetic  should  be  given,  and  the  mouth  being  gagged  open,  the 
stone  is  fixed  by  the  finger  pressing  it  against  the  inner  aspect  of 
the  horizontal  ramus  of  the  jaw,  the  tongue  being  forcibly  held  over 
to  the  opposite  side.  The  mucous  membrane  of  the  floor  of  the 
mouth  is  incised  directly  over  the  stone  and  the  duct  opened 
sufficiently  to  allow  the  stone  to  be  easily  removed.  No  attempt  is 
made  to  sew  up  the  incision  in  the  duct,  and  all  that  is  required  in 
the  after-treatment  is  a  mouth  wash,  such  as  weak  carbolic  acid 
solution  (1  in  80)  or  chlorate  of  potash  (gr.  10  ad  33).  The  mouth 
washes  should  be  employed  at  a  temperature  of  100°  F.  When 
the  calculus  is  deeply  situated  in  the  substance  of  gland,  the  best 
treatment  is  to  excise  the  gland  and  its  duct  by  an  external  opera- 
tion. A  curved  incision  of  sufficient  length  is  made  over  the  gland, 
and  a  flap  consisting  of  skin  and  all  the  tissues  over  the  gland  is 
turned  upwards.  The  facial  vessels  are  tied  as  they  cross  the  jaw, 
and  the  fascia  passing  from  the  jaw  to  the  gland  is  divided.  The 
finger  is  passed  between  the  margin  of  the  jaw  and  the  gland,  which 
is  then  peeled  off  the  hyoglossus  and  posterior  belly  of  the  digastric, 
from  above  downwards,  and  the  deeper  portion,  which  lies  beneath 
the  mylo-hyoid  muscle,  is  shelled  out.  In  doing  this,  the  main 
duct  will  be  exposed  and  is  tied  before  being  divided.  Finally, 
the  facial  artery  and  vein  are  ligatured  before  they  pass  beneath 
the  gland,  which  is  then  removed.  The  skin  flap  is  replaced  and 
stitched  in  position  without  a  drainage  tube,  if  all  oozing  of  blood 
has  been  arrested. 


160  Salivation. 

Calculi  in  the  parotid  gland  are  not  common.  Treatment  is 
carried  out  on  similar  lines  to  the  above. 

SALIVARY  FISTULA. 

Salivary  Fistula  occurs  almost  always  in  connection  with  the 
parotid  gland  or  Stenson's  duct  and  more  frequently  with  the  latter. 
It  is  generally  caused  by  a  penetrating  wound,  or  follows  an  opera- 
tion on  or  in  the  neighbourhood  of  the  gland  or  its  duct.  A  fistula 
once  thoroughly  established  never  closes  spontaneously.  If  the 
treatment  is  to  be  successful  a  free  passage  for  the  saliva  into  the 
mouth  must  be  made,  and  when  this  is  accomplished  the  abnormal 
opening  on  to  the  external  surface  of  the  cheek  will  heal  spon- 
taneously or  require  a  simple  plastic  operation  to  close  it.  When 
the  buccal  portion  of  the  duct  is  involved  it  may  be  possible  to 
insert  a  fine  probe  from  the  orifice  along  the  duct,  which  is  then 
slit  up  from  within  the  mouth,  and  by  keeping  the  internal  orifice 
open  the  fistula  will  rapidly  close.  If  the  masseteric  portion  of 
the  duct  is  damaged,  a  large-sized  trocar  and  cannula  is  passed 
obliquely  forwards  into  the  mouth  through  the  external  opening  of 
the  fistula.  Through  the  cannula  a  silk  thread  is  passed  and  to  it 
is  attached  a  large  drainage  tube,  which  is  then,  by  means  of  the 
thread,  drawn  into  the  tract  of  the  cannula  after  this  has  been 
removed.  One  end  of  the  tube  projects  into  the  mouth  and  the 
other  is  placed  at  the  fistulous  opening  so  that  the  saliva  flows 
along  it.  The  tube  is  maintained  in  its  position  by  means  of  a  silk 
thread  attached  to  each  end  of  it,  the  ends  of  the  thread  being 
fastened  together  behind  the  ear  or  round  the  angle  of  the  mouth. 
At  the  end  of  four  or  five  days,  the  tube  is  shortened  so  that  its 
outer  end  is  close  to  the  opening  in  the  duct.  The  margins  of  the 
fistulous  opening  may  now  be  refreshed  and  stitched  together.  As 
soon  as  the  saliva  begins  to  flow  freely  into  the  mouth  the  external 
opening  will  close  and  when  sound  union  has  occurred  the  drainage 
tube  may  be  removed. 

SALIVATION  OR  PTYALISM. 

Salivation  or  Ptyalism  (see  also  p.  129)  is  most  frequently 
due  to  large  quantities  of  mercury  being  administered,  though  in 
some  patients  the  drug  in  small  doses  will  produce  salivation  when 
given  by  the  mouth.  It  is  also  produced  by  other  drugs,  such  as 
tobacco,  potassium  iodide,  and  it  occurs  in  certain  affections  of 
gastro-intestinal  origin.  Salivation  is  frequently  a  symptom  of 
diseases  of  the  mouth,  e.g.,  stomatitis,  carcinoma  of  the  tongue. 


Tumours  of  the  Salivary  Glands.          161 

After  removal  of  half  or  the  whole  tongue  for  cancer,  inability  to 
swallow  saliva  is  a  troublesome  symptom.  The  treatment,  whenever 
possible,  is  to  remove  the  cause  or  to  substitute  some  other  method 
of  administering  a  drug,  e.g.,  inunction  or  intramuscular  injection  of 
mercury  instead  of  giving  it  by  mouth.  Not  much  can  be  done  to 
relieve  the  salivation  which  follows  removal  of  the  tongue,  but  to 
diminish  the  liability  to  it,  the  submaxillary  gland  or  glands  should 
always  be  removed  with  the  lymphatic  glands  of  the  neck.  All 
decayed  teeth  should  be  stopped  or  removed,  and  astringent  mouth 
washes,  chlorate  of  potash  (10  gr.)  and  alum  (3  to  5  gr.)  may  be  used 
frequently.  The  gums  should  be  kept  clean  by  a  tooth  brush,  or  by 
cotton-wool  swabs,  soaked  in  the  mouth  wash  and  carefully  applied 
so  as  to  get  rid  of  any  pus  about  the  tooth  sockets.  Each  individual 
tooth  may  require  to  be  dealt  with  separately,  and  stronger  anti- 
septics, such  as  carbolic  (1  in  80)  or  hydrogen  peroxide,  may  be 
necessary. 

TUMOURS  OF  THE  SALIVARY  GLANDS. 

Tumours  of  the  Parotid  Gland  may  be  simple  or  innocent, 
and  malignant ;  the  latter  may  be  grafted  on  to  the  former  or  the 
gland  may  be  involved  secondarily  to  malignant  disease  beginning 
in  adjacent  structures.  Hence  before  undertaking  an  operation,  it 
is  very  essential  to  make  a  correct  diagnosis  of  the  nature  and  site 
of  origin  of  the  tumour.  The  mobility  of  the  tumour,  the  skin  not 
being  involved,  and  the  absence  of  facial  paralysis,  are  points  in 
favour  of  an  innocent  tumour.  It  is  seldom  possible  to  remove  a 
malignant  tumour  on  account  of  the  early  wide  infiltration  of  the 
surrounding  tissues,  and  early  recurrence  is  the  rule  in  those  cases 
in  which  removal  has  been  done. 

Operation  for  Innocent  Tumour. — A  sufficiently  large  incision 
must  be  made  in  order  fully  to  expose  the  growth.  A  curved 
transverse  incision  at  the  lower  end  of  the  tumour,  enabling  a  flap 
to  be  turned  upwards,  is  sufficient  for  small  tumours.  If  the  tumour 
is  large,  an  incision  along  the  posterior  part  of  it  and  curving  for- 
wards along  its  lower  margin  should  be  made.  A  flap  of  skin  and 
subcutaneous  tissue  is  turned  upwards  and  forwards,  and  in  raising 
it  the  branches  of  the  facial  nerve  should  be  avoided.  The  capsule 
of  the  tumour  is  exposed  and  enucleation  is  carried  out  by  blunt 
dissection.  During  this  separation,  and  especially  when  the  deeper 
parts  are  being  attacked,  the  facial  nerve  may  be  damaged  unless 
great  care  is  taken  to  keep  close  to  the  capsule  and  great  gentleness 
is  exercised  in  the  separation.  The  nerve  is  usually  deep  to  the 
tumour,  but  it  may  occupy  other  situations,  and  therefore  the  wound 
S.T. — VOL.  ii.  11 


1 62  Wounds  of  the  Parotid  Gland. 

must  be  kept  as  free  from  blood  as  possible  and  by  inspection  the 
nerve  looked  for.  Any  portions  of  capsule  or  of  the  tumour  which 
may  be  broken  off  the  main  mass  must  be  carefully  removed,  other- 
wise recurrence  is  certain  to  take  place.  The  bleeding  may  be  free, 
but  is  arrested  partly  by  pressure  forceps  and  partly  by  sponge 
pressure.  Unless  a  large  cavity  remains,  a  drainage  tube  is 
unnecessary. 

Operation  for  Malignant  Tumours  involves  removal  of  the  whole 
gland.  Often  a  wide  area  of  skin  has  to  be  removed  and  the  facial 
nerve  must  always  be  sacrificed.  A  temporary  ligature  may  be 
placed  around  the  common  carotid,  or  the  external  carotid  may  be 
tied  as  high  as  possible  at  the  beginning  of  the  operation,  because 
it  may  be  necessary  to  remove  a  portion  of  this  vessel  with  the 
tumour.  The  skin  incision  begins  just  below  the  lobule  of  the  ear, 
is  carried  downwards  parallel  to  the  ramus  of  the  jaw  around  the 
angle  and  forwards  for  a  sufficient  distance  along  the  lower  margin 
of  the  horizontal  ramus.  When  it  is  necessary  to  remove  a  portion 
of  the  skin  appropriate  incisions  will  be  made.  The  removal  of  the 
tumour  should  be  begun  from  the  lower  and  posterior  portion,  and 
in  separating  the  deep  portions,  the  near  proximity  of  the  great 
veins  should  be  remembered. 

Tumours  of  the  Submaxillary  Gland  are  less  frequent  than 
parotid  new  growths.  They  are  dealt  with  in  a  similar  way. 

WOUNDS  OF  THE  PAROTID  GLAND. 

These  are  of  importance  because  haemorrhage  may  be  severe ;  the 
external  carotid  or  one  of  its  branches,  or  a  large  vein  may  be 
injured  ;  the  facial  nerve  may  be  divided ;  or  a  salivary  fistula  may 
follow  if  a  main  duct  is  wounded.  To  arrest  the  haemorrhage  the 
wound  may  be  somewhat  enlarged,  though  in  doing  so  care  must  be 
taken  not  to  injure  the  facial  nerve.  It  is  therefore  not  advisable  to 
make  a  deep  and  wide  dissection  to  expose  and  ligature  the  bleeding 
points.  If  the  haemorrhage  is  venous,  plugging  with  gauze  and  firm 
pressure  will  be  sufficient  to  arrest  it.  In  severe  arterial  bleeding, 
if  pressure  forceps  cannot  be  applied,  the  external  carotid  should  be 
exposed  at  its  origin  and  a  ligature  placed  around  it  but  not  tied. 
By  traction  on  the  ligature  the  haemorrhage  can  be  controlled 
sufficiently.  The  parotid  wound  is  then  sponged  free  of  blood,  and 
on  relaxing  the  ligature  it  may  be  possible  to  see  and  secure  the 
divided  end  of  the  injured  vessels.  If  it  is  impossible  thus  to 
secure  and  tie  the  vessel,  the  ligature  around  the  carotid  is  tied  and 
the  wound  plugged  with  gauze  for  forty-eight  hours,  in  order  to 


Wounds  of  the  Parotid  Gland.  163 

prevent  haemorrhage  taking  place  from  the  distal  end  of  the  injured 
vessel.  After  the  removal  of  the  gauze,  the  wound  is  sutured  or  is 
allowed  to  granulate. 

"When  the  branches  of  the  facial  nerve  are  damaged  it  is  almost 
impossible  to  find  and  unite  the  ends.  If,  however,  the  main  trunk 
is  divided  it  may  be  possible  by  exposing  the  nerve  to  unite  the 
two  portions  by  means  of  fine  silk  or  catgut  sutures. 


T.  P.  LEGG. 


RANULA. 
(See  p.  145.) 


11- -2 


164 


DISEASES  AND  INJURIES  OF  THE  NECK. 
CUT  THROAT. 

THE  immediate  dangers  of  a  cut-throat  wound  are :  (1)  Haemor- 
rhage ;  (2)  asphyxia.  Even  when  the  wound  involves  only  the 
superficial  structures,  the  loss  of  blood  may  be  severe,  and  there- 
fore attention  in  the  first  instance  must  be  directed  to  the  arrest  of 
the  haemorrhage  or,  if  it  has  ceased,  to  counteracting  its  effects  by 
the  infusion  of  saline  solution  into  a  vein,  by  the  rectum  or  sub- 
cutaneously.  General  warmth  must  also  be  applied.  Asphyxia 
arises  from  injury  to  the  air  passages,  and  may  be  caused  either  by 
blood  passing  into  the  trachea  or  from  the  nature  of  the  wound  in 
the  air  passages.  If  the  former,  the  haemorrhage  should  be  arrested 
as  quickly  as  possible,  the  wound  in  the  air  passages  being  kept  open 
by  forceps  or  dilators  and  an  attempt  made  to  clear  them  of  the 
blood  by  means  of  feathers  or  small  sponges  securely  held  in  forceps. 
Immediate  tracheotomy  or  laryngotomy  will  be  required  if  the 
asphyxia  is  due  to  the  nature  of  the  wound  of  the  air  passages,  e,y., 
when  the  epiglottis  is  divided  and  obstructs  the  glottis,  or  when  the 
larynx  itself  is  severely  damaged. 

When  urgent  symptoms  are  absent  the  wound  and  the  surround- 
ing parts  should  be  disinfected  and  the  extent  of  the  injuries 
investigated.  An  anaesthetic  should  be  given  when  the  wound  is 
extensive  or  deep  and  important  structures  are  likely  to  have  been 
damaged,  so  that  a  thorough  examination  may  be  made.  If  the 
wound  is  superficial  the  divided  structures  may  \>e  sutured  at  once. 
Whenever  the  wound  extends  deeper  than  the  cervical  fascia, 
drainage  by  means  of  tubes  should  always  be  provided  for  at 
least  twenty-four  hours. 

In  the  case  of  deep  wounds  above  the  hyoid  bone  the  muscles  of 
the  tongue  may  be  severed ;  they  must  be  carefully  sutured.  The 
lingual  and  facial  vessels  or  their  branches  may  have  been  divided 
and  will  require  ligaturing.  The  superficial  parts  of  the  wound 
must  be  sutured  in  layers.  Two  drainage  tubes,  one  at  each 
extremity  of  the  wound,  are  usually  necessary,  and  they  should  be 
long  enough  to  reach  to  the  bottom  of  the  wound. 

When  the  thyro-hyoid  space  is  damaged,  the  epiglottis  may  be 
partially  or  completely  severed  from  its  attachments.  It  may  be 
necessary  to  remove  a  portion  or  the  whole  of  the  epiglottis,  but 


Cut  Throat.  165 

whenever  possible  it  should  be  sutured  in  its  proper  position.  If 
the  larynx  is  injured  the  divided  structures  must  be  carefully 
united.  After  all  bleeding  has  been  arrested  the  wound  is  closed 
in  layers,  free  drainage  being  arranged  for.  It  is  in  these  cases 
that  dyspnoaa  is  an  immediate  urgent  symptom,  or  it  may  super- 
vene (and  not  infrequently)  suddenly  in  the  course  of  a  few  hours, 
from  oedema  of  the  glottis ;  therefore  a  high  tracheotomy  should  be 
done  at  once. 

When  the  trachea  is  injured  and  the  wound  is  a  clean  cut  one 
the  edges  may  be  united  completely  by  stitches.  If  the  wound  has 
lacerated  or  contused  edges,  a  tracheotomy  tube  should  be  inserted 
for  two  or  three  days,  after  partial  closure  of  the  wound  ;  but  if  the 
trachea  is  wounded  in  such  a  position  that  it  is  impossible  to  put 
the  tube  in,  the  tracheotomy  must  be  done  in  the  usual  position  and 
the  tracheal  wound  closed  as  accurately  as  possible. 

Wounds  of  the  pharynx  and  oesophagus  should  be  closed  by 
careful  suturing ;  a  drainage  tube  should  always  be  inserted  down  to 
the  site  of  the  wound  and  the  superficial  parts  left  open.  Any  nerves 
which  may  be  divided  should  be  sutured  if  possible. 

After-treatment. — The  patient  is  propped  up  with  pillows  in 
bed  with  the  head  flexed  on  the  chest.  In  suicidal  cases  a  special 
attendant  will  be  necessary  to  see  that  the  patient  does  not  tear  the 
wound  open  or  do  further  damage.  The  patient's  mental  state  must 
be  remembered  and  his  general  condition  attended  to.  Sleep  must 
be  obtained  by  the  use  of  bromides  or  morphia.  Saline  infusions 
either  intravenously  or  per  rectum  will  be  required.  Stimulants 
may  also  be  necessary.  When  deep  structures  have  been  divided  or 
food  is  refused,  the  patient  must  be  fed  through  an  cesophageal  or 
nasal  tube,  which  should  be  passed  three  or  four  times  in  the  twenty- 
four  hours.  Fifteen  to  twenty  ounces  of  milk,  thin  custard,  etc.,  may 
be  given  at  a  time,  and  this  method  of  feeding  is  continued  till  the 
deep  portions  of  the  wound  have  healed  or  the  natural  power  of 
swallowing  has  returned.  Kectal  nutrient  enemata  may  also  be 
employed  as  required. 

Complications. — These  are  mainly  inflammatory.  Septic  cellulitis 
of  the  neck  may  occur  and  must  be  treated  by  free  incisions. 
(Edema  of  the  glottis,  tracheitis  and  bronchitis,  or  broncho-pneu- 
monia and  empyema  are  frequent  complications  and  usually  septic 
in  origin.  If  the  dyspnoea  is  due  to  oedema  of  the  glottis  high 
tracheotomy  must  be  done  without  delay.  Secondary  haemorrhage 
may  occur,  and  must  be  treated  on  the  usual  lines.  Surgical 
emphysema  may  also  occur,  but  does  not  require  any  special 
treatment. 


1 66  Fistulae  of  the  Neck. 

Sequelae. — An  aerial  fistula  may  develop  and  require  a  plastic 
operation  for  its  closure.  Laryngeal  or  tracheal  stenosis  may  require 
intubation  or  the  permanent  use  of  a  tracheotomy  tube.  Aphonia 
from  damage  to  the  recurrent  laryngeal  nerve  is  usually  permanent. 
Pharyngeal  and  oesophageal  fistula  generally  close  spontaneously 
and  require  no  special  treatment. 

FISTULA  OF  THE  NECK. 

Aerial  Fistula. — Before  undertaking  treatment  for  the  cure  of 
this  affection  it  must  be  ascertained  that  laryngeal  stenosis  or 
adhesions  are  not  present.  If  these  conditions  exist,  they  must  be 
rectified  before  the  operation  for  the  closure  of  the  fistula  is  per- 
formed. This  consists  in  separating  the  skin  from  the  mucous 
membrane,  the  external  wound  being  enlarged  as  much  as  may  be 
necessary.  The  edges  of  the  mucous  membrane  are  refreshed  and 
united  by  sutures.  The  superficial  part  of  the  wound  is  then  closed 
completely  or  left  partially  open  and  packed  with  gauze  and  allowed 
to  granulate. 

Branchial  Fistulae  are  the  remains  of  the  branchial  clefts,  the 
exact  site  of  the  opening  depending  on  the  cleft  from  which  the 
fistula  originates.  The  commonest  position  is  just  above  the  sterno- 
clavicular  articulation  at  the  anterior  border  of  the  sterno-mastoid 
muscle ;  the  opening  may  be  higher  in  the  neck,  but  it  is  always 
along  the  line  of  the  anterior  margin  of  this  muscle.  Not  infrequently 
these  fistulae  are  bilateral.  The  track  may  be  quite  short  or  it  may 
be  long  and  tortuous  ;  in  the  latter  case  it  often  passes  between 
the  internal  and  external  carotid  arteries  towards  the  pharynx,  with 
which  it  may  have  a  communication.  At  the  external  orifice  there 
may  be  a  tag  of  skin  containing  a  small  piece  of  cartilage.  A  thin 
viscid  mucus  is  secreted,  and  occasionally  an  abscess  may  form  as 
the  result  of  inflammation  of  the  canal.  The  treatment  will  depend 
on  the  amount  of  inconvenience  which  the  fistula  causes.  When 
this  is  slight,  it  is  best  to  leave  it  alone.  Attempts  to  cure  it  should 
never  be  made  by  the  use  of  agents  which  destroy  the  lining  mem- 
brane. If  any  operation  is  deemed  to  be  necessary  a  fine  probe 
must  be  passed  along  the  whole  length  of  the  canal.  An  incision 
is  made  over  the  anterior  border  of  the  sterno-mastoid  and  a  careful 
dissection  to  remove  the  track  throughout  its  whole  length  is 
carried  out.  The  upper  end  is  cut  across  and  ligatured  ;  any  open- 
ing into  the  pharynx  should  be  carefully  sutured,  and  it  is  advisable 
to  put  a  small  drainage  tube  into  the  wound  before  suturing  the 
skin.  The  close  relation  between  the  track  and  the  carotid  vessels 
and  nerves,  especially  the  superior  laryngeal,  must  not  be  forgotten. 


Cysts  of  the  Neck.  167 

Median  Cervical  Fistula ;  Thyro-glossal  Fistula. — This 
is  formed  from  a  persistent  thyro-glossal  track.  The  opening  is 
single  and  situated  at  some  point  between  the  hyoid  bone  and 
upper  end  of  the  sternum.  If  the  fistulous  opening  does  not  cause 
inconvenience  it  should  be  left  alone.  Attempts  to  cure  the 
fistula  are  always  difficult,  and  an  operation  should  not  be  under- 
taken unless  it  appears  to  be  absolutely  necessary  on  account  of 
the  discomfort  or  the  amount  of  discharge.  A  median  incision  is 
made  from  the  hyoid  bone  down  to  the  orifice  of  the  fistula,  through 
which  a  probe  has  been  passed  along  the  whole  length  of  the 
track,  which  is  then  dissected  out.  Great  difficulty  is  likely  to  be 
met  with  at  the  upper  end  in  the  region  of  the  hyoid  bone,  where  it 
is  absolutely  essential  to  remove  this  portion  of  the  track  as  it 
passes  behind  this  bone.  It  may  even  be  necessary  to  continue  the 
dissection  above  the  hyoid  between  the  muscles  at  the  base  of  the 
tongue.  Exceptionally,  the  body  of  the  hyoid  may  require  to  be 
divided  to  obtain  a  satisfactory  removal. 

Thyroid  Fistulae. — These  are  usually  the  result  of  some  opera- 
tive procedure  in  which  a  septic  factor  is  present.  Free  drainage 
must  be  provided  and  the  fistula  laid  open  so  as  to  convert  it  into 
an  open  wound,  which  is  to  be  packed  so  as  to  enable  it  to  heal 
from  the  bottom.  When  there  is  much  surrounding  inflammation, 
wet  antiseptic  dressings  or  fomentations  should  be  applied  and 
frequently  changed.  The  fistula  may  be  close  to  the  large  vessels 
or  other  important  structures,  so  that  a  free  laying  open  of  the 
whole  track  may  be  impossible.  In  such  cases  the  superficial  part 
must  be  enlarged  and  the  deeper  parts  drained.  When  the  fistula 
is  caused  by  the  presence  of  infected  ligatures  it  will  not  heal  till 
these  have  been  removed  or  cast  off,  and  this  may  take  a  long 
time.  If  the  fistula  follows  tapping  and  injection  of  a  thyroid  cyst 
or  adenoma,  healing  will  not  occur  until  the  tumour  has  been 
removed. 

CYSTS  OF  THE  NECK. 

Blood  Cysts  are  quite  uncommon.  They  may  communicate 
directly  with  a  vein  or  be  derived  from  a  lymphatic  cyst  into 
which  hemorrhage  has  taken  place.  If  they  arise  in  connection 
with  a  vessel  they  should  be  left  alone  unless  they  are  increasing 
in  size  or  causing  symptoms.  If  it  is  decided  to  remove  the  cyst 
all  the  vessels  passing  into  it  must  be  ligatured  and  the  wall  of  the 
cyst  removed. 

Branchial  Cysts. — These  cysts  are  situated  along  the  line  of 
the  anterior  margin  of  the  sterno-mastoid  muscle,  and  are  derived 


1 68  Cysts  of  the  Neck. 

from  the  branchial  clefts.  They  must  be  treated  by  removal,  and 
in  the  dissection  the  close  relationship  of  the  cyst  to  the  vessels 
and  important  nerves  must  not  be  forgotten ;  therefore  it  is 
necessary  to  keep  close  to  the  wall,  every  portion  of  which  must  be 
removed.  The  operation  may  be  difficult  and  prolonged  when  the 
cyst  extends  deeply  into  the  neck. 

Bursal  or  Thyro-hyoid  Cyst. — A  bursa  is  said  to  exist  between 
the  hyoid  bone  and  thyroid  cartilage  and  to  become  enlarged, 
giving  rise  to  a  median  swelling.  The  treatment  of  such  a  cyst  is 
to  dissect  it  out  through  a  median  vertical  or  a  transverse  incision 
over  the  tumour.  The  overlying  muscles  are  separated,  and  when 
the  tumour  is  exposed  it  is  enucleated.  The  cyst  is  placed  on  the 
thyro-hyoid  membrane,  which  must  not  be  damaged  in  separating 
the  deep  connections  of  the  cyst. 

Dermoid  Cysts  in  the  neck  are  met  with  along  the  line  of  the 
anterior  margin  of  the  sterno-mastoid  or  in  the  middle  line.  In  the 
former  situation  they  are  most  frequent  in  the  submaxillary  region 
below  the  angle  of  the  jaw.  To  remove  such  a  cyst  a  transverse 
slightly  curved  incision  is  made  over  the  tumour,  and  the  deep 
fascia  and  platysma  are  divided.  The  cyst  wall  having  been 
exposed,  it  is  separated  from  the  surrounding  tissues,  partly  by 
dissection  and  partly  by  enucleation  with  the  finger  or  a  blunt 
dissector.  The  separation  must  be  carried  out  close  to  the  tumour, 
which  may  extend  deeply  and  be  in  intimate  contact  with  large 
vessels  and  the  important  nerves  of  the  neck.  These  structures 
should  not  be  damaged.  All  oozing  of  blood  should  be  arrested 
before  the  skin  incision  is  closed ;  in  most  cases  a  drainage  tube  is 
not  required. 

•In  the  middle  line  these  cysts  are  usually  placed  above  the 
hyoid  bone,  though  occasionally  they  are  much  lower  and  close 
to  the  sternal  notch.  "When  situated  above  the  hyoid  bone  they 
may  extend  between  the  genio-hyoglossus  muscles,  and  bulge  into 
the  floor  of  the  mouth  as  well  as  forming  a  tumour  between 
the  chin  and  hyoid  bone.  They  should  be  removed  through  a 
transverse  or  longitudinal  incision  in  the  submental  region.  The 
mylo-hyoid  muscle  is  divided,  the  deeper  muscles  are  separated 
and  peeled  off  the  surface  of  the  tumour,  which  is  then  enucleated. 
If  the  cyst  is  very  large  the  contents  may  be  evacuated  before 
its  wall  is  removed.  Care  should  be  taken  not  to  wound  the 
mucous  membrane  of  the  floor  of  the  mouth,  and  if  this  accident 
occurs  the  hole  should  be  closed  by  a  stitch,  and  a  drainage  tube 
placed  in  the  cavity  in  the  neck  before  the  skin  incision  is  sutured. 
When  the  cyst  is  lower  down  a  transverse  incision  is  made  over  it, 


Cysts  of  the  Neck.  169 

and  the  tumour  is  removed  in  a  manner  similar  to  that  for  a  cyst 
in  the  submaxillary  region.  The  cyst  may  extend  deeply,  and  if  a 
large  cavity  is  left  a  drainage  tube  will  be  required  for  twenty-four 
to  thirty-six  hours. 

Hydatid  Cysts  are  occasionally  met  with,  and  if  they  require 
treatment  they  should  be  removed  by  dissection. 

Hydroceles  of  the  Neck. — The  exact  origin  of  these  unilocular 
cysts  is  not  certain.  They  may  be  derived  from  the  deeper  part  of 
an  unobliterated  branchial  cleft  or  from  the  lymphatics.  They  are 
congenital  and  are  present  at  birth  or  are  noticed  soon  afterwards. 
They  may  shrivel  spontaneously  and  in  some  exceptional  cases  they 
are  liable  to  suppurate.  If  it  is  very  large,  the  cyst  may  be  tapped 
with  a  fine  trocar  and  cannula.  The  best  treatment  is  to  excise 
the  whole  of  the  swelling.  This  proceeding  will  necessitate  a  very 
careful  and  often  a  difficult  dissection.  It  should  not  be  done, 
therefore,  on  young  infants ;  the  surgeon  should  wait  till  the  child 
has  grown  older  and  is  better  able  to  stand  the  operation. 

Lymphangioma;  Cystic  Hygroma. — These  tumours  consist  of 
a  multilocular  mass,  the  locules  or  cysts  being  of  varying  size  and 
bound  together  by  fatty  and  connective  tissue.  The  tumour  is 
partly  below  the  deep  fascia  and  partly  in  the  subcutaneous  tissues. 
It  may  be  situated  in  any  part  of  the  neck  and  may  involve  a  very 
wide  area.  They  are  congenital  and  steadily  increase  in  size. 
Unless  the  tumour  is  rapidly  increasing  in  size  or  causing 
symptoms,  it  should  not  be  interfered  with  in  very  young  chil- 
dren. Tapping  and  injection  with  iodine  are  useless  and  cannot  be 
recommended.  Eemoval  by  dissection  is  the  only  method  of  treat- 
ment which  should  be  attempted,  and  in  carrying  out  the  operation 
care  should  be  taken  to  get  beyond  the  limits  of  the  tumour  in  every 
direction.  The  dissection  may  be  difficult  and  prolonged,  and  the  fact 
that  the  tumour  often  passes  into  the  neighbourhood  of  important 
structures  must  be  remembered.  It  is  advisable  to  use  a  drainage 
tube  for  twenty-four  to  thirty-six  hours,  otherwise  any  serum  or 
lymph,  which  is  frequently  poured  out  into  the  wound,  will  distend 
it  and  prevent  the  obliteration  of  the  cavity  remaining  after  the 
removal  of  the  tumour. 

It  may  be  pointed  out  that  cystic  hygromata  are  rather  prone  to 
spontaneous  attacks  of  acute  inflammation,  and  after  such  attacks 
the  swelling  may  subside  and  undergo  a  form  of  spontaneous 
cure. 

Malignant  Cysts  occasionally  arise  in  connection  with  the 
remains  of  one  of  the  branchial  clefts.  Kemoval  is  usually 
impracticable.  This  kind  of  cyst  also  arises  from  a  cystic 


170  Cysts  of  the  Neck. 

degeneration  of  malignant  glands.      It  may  then   be   possible   to 
remove  the  mass. 

Sebaceous  Cysts  are  not  infrequent  in  the  upper  part  of  the 
neck.  They  are  to  be  removed  by  dissection.  The  incision  in  the 
skin  should  be  transverse,  so  that  the  scar  may  be  almost  invisible. 
These  cysts  cannot  be  enucleated  owing  to  the  close  connection  of 
the  capsule  with  the  surrounding  subcutaneous  tissue.  Moreover, 
they  are  liable  to  become  inflamed  and  suppurate.  Under  these 
conditions  it  is  also  necessary  to  remove  the  whole  of  the  cyst  wall, 
for  if  the  cyst  is  merely  opened  and  scraped  it  is  certain  to  recur. 
If  the  inflammation  is  very  acute  and  there  is  much  cellulitis,  it 
may  be  advisable  in  the  first  instance  to  open  and  drain  the  cyst 
and  subsequently  to  remove  its  wall  (see  also  Tumours). 

Thyroid  Cysts. — The  treatment  of  these  cysts  is  described  in 
connection  with  tumours  of  the  thyroid. 

Thyro-glossal  Cysts. — These  cysts  are  derived  from  an  un- 
obliterated  portion  of  the  thyro-glossal  track,  and  may  be  placed 
in  the  neck  anywhere  between  the  hyoid  bone  and  isthmus  of  the 
thyroid,  lying  either  in  the  mid-line  or  just  to  one  side  of  this  line. 
They  must  be  treated  by  complete  removal.  Tapping  and  injection 
are  useless  and  are  liable  to  be  followed  by  a  fistula.  The  opera- 
tion for  complete  removal  is  difficult  on  account  of  the  connections 
of  the  cyst ;  any  portion  extending  up  to  the  hyoid  bone  or  down 
to  the  thyroid  isthmus  must  be  excised.  If  any  part  is  left  behind 
a  fistula  which  is  very  difficult  to  eradicate  will  form. 

T.  P.   LEGG. 


DISEASES    AND    INJURIES    OF    THE 
(ESOPHAGUS. 

STRICTURE   OF   THE   CESOPHAGUS. 

SIMPLE  STRICTURE  OF  THE  CESOPHAGUS. 

THIS  affection  is  most  frequently  secondary  to  ulceration  of  the 
mucous  membrane  produced  by  swallowing  caustic  fluids  or  by  the 
long-continued  presence  of  foreign  bodies.  The  stricture  may  be 
localised  or  involve  a  large  extent  of  the  mucous  membrane.  It  is 
important  to  make  the  diagnosis  from  malignant  stricture  if  treat- 
ment by  dilatation  is  contemplated,  for  in  carcinoma  such  treat- 
ment is  inadmissible.  Aneurysm  and  other  mediastinal  tumours 
should  be  also  excluded.  The  treatment  is  partly  medical  and 
partly  surgical. 

Medical  treatment  consists  in  giving  the  patient  highly  con- 
centrated nourishing  food  in  a  liquid  or  semi-solid  form,  if  the 
patient  is  able  to  swallow  the  latter.  The  difficulty  in  swallowing 
is  partly  due  to  spasmodic  contraction  of  the  muscular  wall,  and 
therefore  sedatives,  especially  opium,  in  the  form  of  the  tincture 
(10  to  15  min.)  [U.S. P.  6  to  9  min.],  in  glycerine  and  water, 
should  be  given  a  short  time  before  food  is  taken. 

Ee'ctal  feeding  may  be  empk>3red  to  supplement  the  natural 
method ;  if  the  patient  is  losing  ground  or  is  quite  unable  to 
swallow  and  it  is  impossible  to  pass  a  bougie,  gastrostomy 
should  be  performed  without  delay  and  before  the  wasting  is 
extreme. 

Surgical  treatment  consists  in  either  dilating  the  stricture  or 
performing  gastrostomy.  Other  surgical  operations  are  sometimes 
carried  out,  and  are  referred  to  hereafter. 

Dilatation  of  the  Stricture  is  carried  out  either  intermittently 
or  continuously  by  suitable  bougies.  There  is  a  constant  tendency 
for  the  stricture  to  recur,  and  therefore  the  use  of  the  bougies  can 
never  be  discontinued  ;  the  patient  must  either  pass  them  himself 
or  have  them  passed  at  intervals  for  the  rest  of  his  life.  The 
intervals  may  be  gradually  increased  as  time  goes  on. 

Intermittent  Dilatation. — Great  gentleness  must  be  employed 
in  using  the  bougie,  and  no  attempt  must  be  made  to  force  it 
through  the  stricture,  if  it  is  tightly  gripped.  The  calibre  of  the 


172       Simple  Stricture  of  the  (Esophagus. 

stricture  is  not  uniform,  and  there  may  be  more  than  one  stricture, 
each  having  a  different  calibre.  Therefore  a  bougie  may  pass 
easily  into  or  through  one  stricture  and  be  tightly  gripped  by 
another. 

The  bougie  should  be  left  in  position  for  a  few  minutes  and  then 


20INS 


FULL  SIZE  ENDS 
FIG.  1. — A  silk  web  oesophageal  bougie. 

withdrawn.  An  attempt  is  then  made  to  pass  a  larger-sized 
instrument,  and  as  soon  as  it  is  arrested  it  is  allowed  to  remain  in 
position  for  a  few  more  minutes  and  is  then  removed.  The  next 
day,  or  after  two  or  three  days,  the  same  procedure  is  repeated, 
beginning  with  a  bougie  a  size  smaller  than  the  largest  passed  at 


Fig.  2. —  A  black  elastic  oesophageal  bougie  with  a  bulbous  head. 

the  preceding  sitting.  The  number  of  bougies  employed  at  each 
sitting  depends  on  the  progress  of  the  dilatation ;  as  a  rule,  two  or 
three  are  sufficient,  and  attempts  must  not  be  made  rapidly  or 
forcibly  to  dilate  the  stricture.  In  the  intervals  between  the  passage 
of  the  bougies  opium  should  be  given  to  allay  the  spasm.  As  soon 


FIG.  3. — A  conical-ended  black  elastic  oesophageal  bougie. 

as  full  dilatation  has  been  reached  and  maintained  by  the  daily 
passage  of  the  bougie  it  may  be  passed  twice  a  week,  then  once  a 
week,  then  once  a  fortnight,  and  after  three  or  four  months  more 
once  a  month.  If  there  is  any  sign  of  re-contraction  the  intervals 
must  be  shortened.  Each  case  must  be  treated  on  its  merits,  and 
after  full  dilatation  has  been  obtained  the  patient  can  be  taught  to 
pass  the  bougies. 


Simple  Stricture  of  the  (Esophagus.       173 

A  silk-web  bougie  (Fig.  1)  is  the  best  form  to  use.  It  should  be 
placed  in  a  jug  of  hot  water  before  lubricating  it  with  glycerine  or 
butter.  A  large  size  (No.  20)  should  be  first  used.  Smaller  sizes 
are  then  taken  until  one  is  found  which  will  pass  the  stricture. 
The  largest  (No.  24)  bougies  are  |  inch  in  diameter.  The 
distance  the  larger  instrument  passes  before  reaching  the  stricture 
should  be  noted  ;  this  will  enable  its  situation  to  be  determined. 
Instead  of  a  silk-web,  a  soft,  black  gum-elastic  bougie  may  be  used. 
A  bougie  with  a  hard  solid  end  should  never  be  employed. 
The  end  should  be  cylindrical  or  conical  in  shape  (Fig.  3)  ;  it  is 
generally  easier  to  insinuate  the  latter  kind  of  bougie  into  the 
orifice  of  a  stricture. 

The  patient  sits  upright  on  a  chair  with  a  high  back  to  support 
the  head,  which  is  held  erect  or  slightly  flexed.  The  head  must  not 
be  extended  and  must  be  kept  firm  with  the  face  directed  forwards. 
The  mouth  is  widely  opened,  and,  unless  the  tongue  is  very  big  or 
gets  in  the  way,  a  depressor  is  not  required.  "With  a  little  experience 
it  is  not  usually  necessary  to  use  a  gag  or  to  pass  the  finger  to  the 
back  of  the  mouth  to  feel  for  the  epiglottis.  The  bougie  is  passed 
on  till  it  touches  the  posterior  pharyugeal  wall  in  the  mid-line  ; 
gentle,  yet  firm  pressure  will  then  cause  it  to  turn  downwards,  and, 
as  it  passes  over  the  larynx,  a  certain  amount  of  coughing  and 
spasm  will  occur.  The  instrument  should  not  be  removed  and  the 
patient  should  be  encouraged  to  keep  as  quiet  as  possible.  Some 
resistance  to  the  onward  passage  of  the  bougie  from  the  cartilages 
of  the  larynx  may  here  be  felt,  and  this  is  often  mistaken  for  the 
stricture.  If  the  patient  is  told  to  swallow,  the  bougie  will  be 
carried  onwards  beyond  the  aperture  of  the  larynx,  and  the  spasm 
will  diminish ;  its  further  passage  may  be  delayed  for  a  moment  or 
two  while  the  patient  inspires  a  few  deep  breaths.  The  instrument 
is  passed  on  without  any  force  being  used,  and  rotated  till  the 
point  is  felt  to  be  grasped  by  the  stricture.  When  the  bougie  is 
firmly  grasped,  no  attempt  should  be  made  to  pass  it  on  into 
the  stomach  ;  it  should  be  left  in  position  for  a  few  minutes,  then 
withdrawn  and  a  smaller-sized  one  inserted.  Sometimes  only  a 
catgut  bougie  can  be  insinuated  into  the  stricture ;  it  should  be  left 
in  position  as  long  as  the  patient  will  bear  it.  Several  strictures 
may  be  present,  and  each  one  should  be  dilated  in  succession.  It 
must  not  be  forgotten  that  the  wall  of  the  oesophagus  may  be  very 
thin,  and  therefore  readily  perforated  if  force  is  employed. 

When  the  patient  is  very  intolerant  of  the  manipulations  a  small 
dose  of  tincture  of  opium  (10  to  15  mins.)  [U.S.P.  6  to  9  mins.]  in 
some  glycerine  and  water  may  be  given  a  short  time  previously,  or 


174       Simple  Stricture  of  the  CEsophagus. 

the  throat  may  be  sprayed  or  painted  with  10  per  cent,  solution  of 
cocaine. 

Continuous  Dilatation  may  be  employed  if  the  stricture  does 
not  readily  yield  to  intermittent  dilatation  and  when  it  is  very 
narrow.  Soft,  silk-web  bougies  should  be  employed,  and  at  first  it 
may  only  be  possible  to  pass  a  catgut  bougie.  One  of  a  size  which 
is  firmly  gripped  by  the  stricture  is  passed  through  it  and  is  left  in 
situ.  The  upper  end  lies  outside  the  mouth  and  is  fastened  by  a 
silk  thread  to  the  ear.  At  the  end  of  twenty-four  to  forty-eight 
hours  the  bougie  will  lie  more  loosely  in  the  stricture.  Another  of 
a  larger  size  is  then  substituted,  and  this  one  is  left  in  for  a  further 
period  of  two  or  three  days,  when  it  is  changed  for  a  still  larger 
one,  and  so  on  till  the  stricture  is  fully  dilated  and  the  largest 
bougies  can  be  inserted.  The  length  of  time  required  to  accomplish 
this  varies  in  different  cases.  The  great  drawback  of  the  method 
is  the  annoyance  to  the  patient  by  reason  of  the  amount  of  saliva 
and  mucus  which  are  secreted  and  its  uncomfortableness.  At  first 
the  patient  must  be  kept  in  bed  with  the  head  turned  over  to  one 
side  to  allow  the  mucus  and  the  saliva  to  escape.  Liquid  nourish- 
ment, milk  and  beef-tea,  can  usually  be  slowly  swallowed,  the  fluid 
finding  its  way  into  the  stomach  alongside  the  bougie,  and  of 
course  rectal  feeding  can  always  be  employed  if  necessary. 
Instead  of  a  solid  bougie  an  cesophageal  tube  may  be  employed 
when  some  degree  of  dilatation  has  been  reached,  and  the  patient 
may  be  fed  through  the  tube  by  means  of  a  funnel  attached  to  its 
upper  end. 

The  same  treatment  to  prevent  re-contraction  will  be  required  as 
in  cases  treated  by  intermittent  dilatation. 

Operative  Treatment. — Many  methods  of  operating  directly  on 
the  stricture  have  been  devised.  These  consist  of  opening  the 
oesophagus  in  the  lower  part  of  the  neck  (external  cesophagotomy), 
and  then  dividing  or  dilating  the  stricture  ;  or,  if  the  stricture  is 
low  down,  of  opening  the  stomach  (gastrotomy),  and  dilating  it  by 
means  of  bougies  passed  upwards  through  the  opening  in  the 
stomach.  All  these  operations  are  attended  with  considerable 
risks  and  are  difficult  to  perform.  Hence  in  most  cases  where 
intermittent  or  continuous  dilatation  cannot  be  carried  out,  it  is 
better  to  perform  a  gastrostomy.  This  operation  will  at  least 
prevent  starvation,  or,  if  the  patient  has  been  brought  so  low  as  to 
be  on  the  point  of  absolute  starvation,  his  condition  may  be 
improved  to  such  an  extent  as  to  allow  other  methods  of  treatment 
to  be  carried  out  subsequently.  Moreover,  the  gastrostomy  may 
benefit  the  patient  in  another  waj',  inasmuch  as  the  rest  given  to 


Malignant  Stricture  of  the  (Esophagus.    175 

the  oesophagus  is  followed  by  so  much  improvement  in  the  local 
condition  of  the  stricture  that  the  patient  may  regain  the  power  of 
swallowing,  and  an  impassable  stricture  may  become  amenable  to 
intermittent  or  continuous  dilatation.  Whenever  gastrostomy  has 
been  done  attempts  should  be  made,  after  an  interval  of  two  or 
three  weeks,  to  dilate  the  stricture  by  bougies,  and  if  these  fail  and 
the  patient's  condition  permits,  the  possibility  of  benefit  accruing 
from  an  external  cesophagotomy  may  be  considered.  When  the 
stricture  has  been  dilated  and  is  kept  dilated,  the  gastrostomy 
opening  may  be  closed. 

Spasmodic  Stricture  chiefly  occurs  in  women  and  in  association 
with  other  neurotic  manifestations.  The  treatment  consists  in  the 
passage  of  a  full-sized  bougie,  if  necessary  under  an  anaesthetic  in 


FIG.   4. — Symonds'   short   cesophageal   tube   with  a  lateral  opening      The  silk 
threads  enable  the  tube  to  be  extracted  easily. 

the   first   instance,  and   subsequently  as   may  be   required.     The 
general  neurotic  condition  of  the  patient  must  also  be  treated. 

MALIGNANT  STRICTURE. 

This  is  almost  invariably  a  squamous-celled  carcinoma,  and  its 
most  common  seat  is  at  the  upper  end  of  the  oesophagus ;  the  next 
most  frequent  seat  is  opposite  the  bifurcation  of  the  trachea.  The 
treatment  is  palliative,  and  is  carried  out  either  by  the  use  of  tubes 
placed  through  the  stricture  or  by  gastrostomy. 

Treatment  by  Tubes. — In  this  method  the  patency  of  the 
stricture  is  maintained  by  means  of  a  tube  permanently  retained  in 
the  stricture.  The  tube  may  be  a  Symonds'  short  tube  (Fig.  4),  or 
a  long,  soft  tube.  The  former  is  suitable  when  the  disease  is  in 
the  middle  portion  of  the  oesophagus,  and  the  latter  when  the 
disease  is  in  the  upper  part.  The  long  tube  may  be  employed  if 
the  Symonds'  tube  is  not  tolerated  or  cannot  be  introduced  or  if  it 
is  frequently  blocked,  and  it  has  the  advantage  that  it  need  not  be 
changed.  The  disadvantages  of  the  long  tube  are  that  the  patient 
is  unable  to  swallow  food  naturally,  saliva  cannot  pass  into  the 
stomach,  and  it  is  unsightly,  as  the  end  projects  from  the  mouth. 
The  long  tube  is  introduced  precisely  in  the  same  way  as  an 
oesophageal  bougie. 


176    Malignant  Stricture  of  the  (Esophagus. 

Symonds'  short  tubes  are  made  of  silk-web  in  different  sizes  and 
are  4  to  6  inches  long.  The  upper  end  is  funnel  shaped,  and  has 
attached  to  it  two  silk  threads,  by  which  the  tube  may  be  with- 
drawn and  by  which  it  is  fastened  to  the  ear  or  cheek.  The  lower 
end  has  a  terminal  or  lateral  opening  which  lies  below  the  lower- 
most limit  of  the  stricture  when  the  tube  is  in  position.  The 
upper  funnel-shaped  end  prevents  the  tube  slipping  downwards. 
A  special  introducer  (Fig.  5)  is  provided,  and  the  tube  is  passed  in 
the  same  manner  as  an  cesophageal  bougie.  These  tubes  allow 


FIG.  5. — Special  form  of  introducer  for  Symonds'  short  tube. 

food  and  saliva  to  be  swallowed  naturally.  They  cannot  be 
employed  for  growths  at  the  upper  end  of  the  oesophagus  (and  it  is 
in  these  cases  that  the  distress  and  cough  produced  by  the  mucus 
and  excessive  salivation  are  most  severe),  nor  when  the  stricture  is 
at  the  lower  end  of  the  ossophagus.  They  are  not  always  easily 
introduced,  and  may  become  blocked  by  coagulated  milk,  etc. 
They  cause  a  certain  amount  of  irritation,  and  are  often  only 
tolerated  for  a  short  period.  The  constant  presence  of  the  tube  in 
the  stricture  increases  the  amount  of  sloughing  and  the  secretion  of 
mucus.  Once  the  tube  has  been  placed  in  the  stricture  it  should 


SCALE  5 


FIG.  6.— Symonds'  short  resophageal  tube  with  a  terminal  opening.     The 
silk  threads  enable  the  tube  to  be  extracted  easily. 

not  be  removed  unless  the  patient  is  quite  intolerant  of  its 
presence.  If  it  becomes  blocked,  the  whale  bone  introducer  should 
be  used  to  clear  it.  In  choosing  a  Symonds'  tube,  one  with 
a  terminal  opening  should  always  be  selected  (Fig.  6). 

Gastrostomy. — At  the  present  time  gastrostomy  is  the  most 
preferable  method  of  treating  a  patient  with  malignant  stricture  of 
the  oesophagus,  and  it  should  be  done  whenever  the  patient  becomes 
unable  to  take  sufficient  food  in  the  natural  manner  and  before 
starvation  and  excessive  emaciation  are  present.  After  a  properly 
performed  operation  the  patient  is  far  more  comfortable  than  with 
any  sort  of  tube.  There  is  practically  no  escape  of  the  contents  of 
the  stomach  at  the  opening,  and  therefore  there  are  none  of  the 


Malignant  Stricture  of  the  CEsophagus.     177 


discomforts  from  the  excoriation  of  the  skin  which  were  formerly  so 
prejudicial  to  the  operation.  Not  uncommonly  some  power  of 
swallowing  returns,  at  least,  for  a  time. 

Many  methods  of  performing  the  operation  have  been  devised. 
A  modification  of  Frank's  procedure,  Semi's  and  Witzel's  methods 
are  the  best.  One  of  the  two  latter  is  employed  when  the  stomach 
is  contracted. 

The  Modified  Frank's  Operation  (Figs.  7,  8,  9,  10,  11) 
consists  in  splitting  the  rectus  abdominis  muscle  into  an  anterior 
and  a  posterior  layer,  and  plac- 
ing a  conical  portion  of  the 
stomach  between  these  two 
planes  of  muscle  fibres.  The 
opening  at  the  apex  of  the  cone 
of  stomach  is  situated  on  the 
surface  of  the  abdomen  instead 
of  over  the  costal  margin.  The 
operation  is  done  as  follows : 
An  incision,  3  inches  long,  is 
made  to  the  left  of  the  linea 
alba,  its  upper  extremity  being 
a  short  distance  below  the  cos- 
tal margin  (Fig.  7).  The  rectus 
is  split  in  the  direction  of  its 
fibres  and  the  peritoneal  cavity 
is  opened  (Fig.  10).  The  stomach 
is  drawn  up  into  the  wound, 
and  is  examined  to  find  out  if 
it  is  contracted  or  is  sufficiently 
large  to  enable  a  conical  portion, 
with  a  length  of  3  to  4  inches, 
to  be  drawn  up  readily  into  the 
parietes  (Fig.  8).  The  next  step  is  to  make  an  incision,  1  inch  long, 
parallel  to  and  2  inches  to  the  left  of  the  first  incision  (Fig.  7).  The 
sheath  of  the  rectus  is  opened  and  the  muscle  is  split  in  a  direction 
parallel  to  the  fibres  (Fig.  10).  A  stiff  probe  or  director  is  then 
passed  through  the  substance  of  the  muscle  from  the  second  to  the 
first  incision,  so  that  half  the  muscle  thickness  is  behind  the  probe 
and  half  in  front  of  it.  The  probe  or  director  is  then  carried 
upwards  and  downwards  in  the  substance  of  the  muscle,  thus 
separating  the  superficial  from  the  deep  fibres.  This  separation 
must  be  sufficiently  wide  to  enable  the  cone  of  stomach  to  be  easily 
carried  between  the  muscle  fibres  from  the  first  to  the  second 

S.T. VOL.  II,  12 


']<;.  7.  -The  modified  Frank's  method 
of  performing  gastrostomy.  A  is  the 
incision  which  opens  the  peritoneal 
cavity  and  through  which  the  cone 
of  stomach  is  withdrawn.  B  is  the 
second  incision  placed  just  below  the 
costal  margin  and  inside  the  linea 
semilunaris  :  it  opens  the  sheath  of 
the  rectus. 


178    Malignant  Stricture  of  the  CEsophagus. 


FIG.  8. — The  modified  Frank's  method  of  performing  gastrostomy. 
The  cone  of  stomach  of  sufficient  length  to  lie  without  tension 
between  the  incisions  has  been  withdrawn  from  the  abdomen. 


Fio.  9. — The  modified  Frank's  method  of  performing  gastrostomy. 
The  cone  of  stomach  has  been  placed  between  the  fibres  of 
the  rectus  muscle.  The  stitches  fixing  the  base  of  the  cone  to 
the  parietal  peritoneum  and  rectus  muscle  are  shown.  The 
apex  of  the  cone  has  been  opened  and  the  catheter  passed  into 
the  stomach.  The  stitches  fixing  the  apex  to  the  parietes 
have  been  inserted. 

incision.  The  portion  of  stomach  selected  should  be  as  close  to 
the  cardiac  end  as  possible,  the  apex  of  the  cone  being  nearer  the 
lesser  curvature.  A  couple  of  silk  threads  are  inserted  through  the 
sero-muscular  coats  at  the  apex  of  the  cone.  A  pair  of  forceps  is 
then  passed  from  the  second  to  the  first  incision ;  the  threads  are 


Malignant  Stricture  of  the  (Esophagus.     179 

grasped  in  the  blades  of  the  forceps,  which  are  then  withdrawn. 
By  a  little  manipulation  the  cone  of  stomach  follows  the  forceps 
and  thus  comes  to  lie  between  the  layers  of  the  rectus  muscle,  the 
apex  of  the  cone  being  at  the  second  incision  and  its  base  at  the 
first  incision.  The  stomach  is  thus  completely  surrounded  by 
muscle  fibres  which  act  as  a  kind  of  sphincter  and  effectually 
prevent  any  leakage  of  the  contents.  The  base  of  the  cone  is  fixed 


FIG.  11. 

FIGS.  10  and  11. — The  modified  Frank's  method  of  performing  gastrostomy. 
Transverse  section  through  the  anterior  abdominal  wall.  Semi-diagrammatic.  In 
Fig.  10  A  is  the  parietal  incision  exposing  the  stomach.  B  is  the  second  parietal 
incision  just  inside  the  linea  semilunaris;  it  opens  the  sheath  of  the  rectus  muscle, 
the  fibres  of  which  are  separated  into  anterior  and  posterior  layers  by  means  of 
a  probe  or  director  passed  from  A  to  B  through  the  substance  of  the  muscle. 

In  Fig.  11  the  cone  of  stomach  is  shown  surrounded  by  fibres  of  the  rectus  and 
the  catheter  C  has  been  passed  into  the  stomach.  A  stitch  closing  the  superficial 
part  of  the  incision  A  is  shown.  D  is  the  linea  alba  ;  P  is  the  peritoneum  ;  M  is 
the  abdominal  muscles  ;  <S  is  the  skin  and  subcutaneous  tissue. 

to  the  abdominal  wall  by  four  or  five  interrupted  sutures  which 
penetrate  the  sere-muscular  coat  of  the  stomach  and  the  parietal 
peritoneum  and  rectus  muscle  (Fig.  9).  The  apex  of  the  cone  is 
fixed  in  the  second  incision  by  four  sutures  passing  through  the  skin 
and  anterior  layer  of  the  rectus  sheath  and  the  sere-muscular  coats 
of  the  stomach  (Fig.  9).  A  nipple- like  process  of  the  stomach  will 
project  above  the  level  of  the  skin  (Fig.  9).  An  opening  sufficiently 
large  to  take  a  No.  9  or  10  soft  rubber  catheter  is  made  into  it ; 
the  cut  edge  of  the  mucous  membrane  of  the  stomach  is  fixed  by 

12—2 


180    Malignant  Stricture  of  the  (Esophagus. 


two  or  three  stitches  to  the  opening  in  the  peritoneal  coat  (Fig.  9). 
The  catheter  is  passed  into  the  stomach,  and  it  is  a  good  plan  to 
anchor  it  by  a  stitch  to  the  skin  in  order  to  prevent  it  being 
displaced.  The  operation  is  completed  by  suturing  the  skin  of  the 
first  incision  and  putting  on  a  collodion  dressing.  The  patient 
should  be  fed  at  once  through  the  catheter  with  4  or  5  oz.  of 
peptonised  milk,  with  some  brandy  (gss  to  §j)  if  necessary. 

Senn's  Method  (Figs.  12,  13,  14, 15)  is  performed  in  the  follow- 
ing manner :  A  vertical  incision,  2^  inches  long,  commencing  just 
below  the  costal  arch,  is  made  over  the  outer  part  of  the  left  rectus 
muscle  (Fig.  12).  The  muscle  fibres  are  separated  and  the 

peritoneum  being  opened,  the 
stomach  is  sought  for  and  iden- 
tified by  its  smooth  walls  and 
the  attachments  of  the  omenta 
to  its  greater  and  lesser  curva- 
tures. When  the  organ  is  con- 
tracted it  may  be  very  deeply 
placed  on  the  posterior  abdom- 
inal wall.  A  portion  of  stomach 
midway  between  the  two  curva- 
tures and  as  far  from  the  pylo- 
rus as  possible,  is  selected  and 
brought  up  to  or  out  of  the  wound 
in  the  parietes  and  packed  around 
with  gauze.  A  small  incision 
which  will  admit  a  No.  9  or  10 
soft  rubber  catheter  is  made 
FIG.  12.— Senn's  method  of  performing  through  all  its  coats  ;  the  cathe- 

gastrostomy.     The  site  of  the  parietal  . 

incision  is  shown.  ter  is  passed  into  the  stomach 

for  3  or  4  inches,  and  is  fixed 

to  the  margin  of  the  opening  by  single  silk  or  catgut  stitch.  At 
a  distance  of  \  inen  from  the  catheter  a  purse-string  suture  is 
put  in  so  as  to  form  a  circle  round  it  (Fig.  13) ;  this  suture 
passes  through  the  sero-muscular  coat,  and  as  it  is  tightened, 
the  included  portion  of  stomach  and  the  catheter  are  pushed 
inwards.  A  second  purse-string  suture  is  now  introduced  about 
\  inch  from  the  tube,  and  as  it  is  tightened  the  stomach 
and  catheter  are  invaginated  again.  A  third  similar  suture 
may  be  required.  The  result  is  that  a  portion  of  the  stomach 
wall  becomes  invaginated  into  its  cavity,  the  catheter  being  in 
the  centre  of  this  portion  (Fig.  15).  Two  stitches,  which  include 
the  parietal  peritoneum  and  posterior  sheath  of  the  rectus  on  each 


Malignant  Stricture  of  the  (Esophagus.     181 


FIGJ13. — Senn's  method  of  perform- 
ing gastrostomy.  The  stomach 
has  been  opened  and  the  catheter 
has  hoon  passed  into  its  cavity. 
The  stitch  fixing  the  catheter  to 
the  stomach  is  shown.  The  first 
purse-string  suture  has  been 
inserted  and  is  being  tightened. 


FIG.  14. — Semi's  method  of  perform- 
ing gastrostomy.  The  purse-string 
sutures  have  been  tightened 
around  the  catheter  and  the 
stitches  fixing  the  stomach  to 
the  parietes  have  been  inserted. 


FIG.  15. — Senn's  method  of  performing  gastrostomy.  To  show  the 
invaginated  portion  of  the  stomach  around  the  catheter.  The 
position  of  the  purse-string  sutures  is  indicated. 


side  and  a  broad  piece  of  the  sero-muscular  layer  of  the  stomach, 
are   then  inserted,  one  below  and  the   other   above   the  catheter 


1 82    Malignant  Stricture  of  the  CEsophagus. 

(Fig.  14).  They  fix  the  stomach  to  the  parietal  peritoneum  and 
prevent  leakage  into  the  general  peritoneal  cavity  when  the  catheter 
comes  out.  The  superficial  portion  of  the  parietal  incision  is  closed 
in  the  usual  way.  The  patient  may  be  fed  through  the  catheter  at 
the  end  of  the  operation  with  4  or  5  oz.  of  peptonised  milk  and 
some  brandy.  The  stitch  fixing  the  catheter  generally  loosens  at 
the  end  of  ten  days.  The  catheter  may  be  withdrawn  for  cleansing 


FIG.  16. — Witzel's  method  of  performing  gastrostomy.  The  position  of  the 
catheter  lying  in  a  groove  on  the  anterior  wall  of  the  stomach  is  shown.  The 
folds  forming  the  margins  of  the  groove  are  being  united  by  a  continuous 
suture,  thus  converting  the  groove  into  a  canal  lined  throughout  by 
peritoneum. 

purposes,  but  should  always  be  replaced,  as  there  is  a  tendency  for 
the  opening  to  close. 

Witzel's  Method  (Fig.  16). — The  catheter  is  buried  for  a  dis- 
tance of  about  2  inches  in  a  gutter  on  the  stomach  wall  formed  by 
raising  up  a  fold  on  each  side  of  the  instrument  as  it  lies  on  the 
peritoneal  coat  of  the  viscus.  The  eye-end  of  the  catheter  is  placed 
in  the  stomach  through  an  opening  at  one  end  of  the  gutter  and 
the  other  end  is  brought  out  through  the  parietal  incision.  The 


Malignant  Stricture  of  the  (Esophagus.     183 

stomach  is  fixed  to  the  parietes  by  one  or  two  sutures  beyond  the 
ends  of  the  tube.  It  will  thus  be  seen  that  the  greater  part  of  the 
track  leading  to  the  stomach  is  lined  by  peritoneum  and  the  catheter 
must  be  kept  always  in  position  to  prevent  the  surfaces  of 
peritoneum  adhering  to  one  another.  The  disadvantage  of  both 
Senn's  and  Witzel's  method  is  that  the  catheter  must  always  be 
kept  in  the  opening,  whereas  in  Frank's  method  it  need  only  be 
passed  when  the  patient  is  fed. 

After-Treatment. — The  feeding  is  carried  out  by  means  of  a  glass 
funnel  to  which  is  attached  a  piece  of  rubber  tubing,  which  is  joined 
to  the  catheter  by  means  of  a  piece  of  glass  tubing  about  1  inch 
long.  The  funnel  is  filled  with  the  nutrient  fluid,  which  is  allowed 
to  slowly  run  into  the  stomach.  At  first  4  to  5  oz.  of  peptonised 
milk  with  £  oz.  of  brandy  may  be  given  every  four  hours.  It  is 
not  necessary  to  disturb  the  dressing.  Later,  the  amount  of  milk 
may  be  increased  by  degrees  to  12  oz.  or  more,  if  no  discomfort  is 
caused.  Eggs  may  be  added,  and  thin  gruel  or  Benger's  food  may 
be  given  ;  the  peptonisation  of  the  milk  may  be  gradually 
diminished.  As  soon  as  the  patient  is  able  to  swallow  he  should 
be  encouraged  to  do  so,  provided  coughing  is  not  thereby  set  up. 
Minced  meat  or  fish,  custard,  bread  and  milk,  etc.,  may  often  be 
taken  in  the  natural  manner. 

It  is  quite  impossible  to  foretell  the  length  of  time  the  patient 
will  survive  after  the  operation.  The  most  promising  case  may 
die  suddenly  from  septic  broncho-pneumonia  due  to  perforation  of 
the  growth  into  the  air  passages,  while  other  patients  in  whom  the 
outlook  appeared  to  be  bad  will  live  in  comfort  for  months.  The 
writer  has  had  one  patient  who  lived  comfortably  for  two  years, 
another  for  eighteen  months,  and  several  for  six  or  seven  months. 

Other  Methods  of  Treating  Stricture  of  the  CEsophagus. — 
Innocent  fibrous  strictures  have  been  treated  by  injections  of 
fibrolysin  ;  it  is  doubtful  if  much  benefit  follows  the  use  of  this 
preparation.  Malignant  stricture  may  be  treated  by  radium.  The 
tube  containing  the  salt  is  passed  down  to  or  into  the  stricture  by 
means  of  the  oasophagoscope,  and  it  is  left  in  position  for  some 
hours.  More  than  one  application  will  be  required.  Good  results 
have  been  reported  though  it  is  too  early  to  be  certain  that  they 

are  permanent. 

T.  P.  LEGG. 


1 84 


INJURIES   AND    MALFORMATIONS   OF   THE 
(ESOPHAGUS. 

FOREIGN    BODIES   IN   THE  OZSOPHAGUS. 

THESE  are  not  at  all  infrequent ;  masses  of  food,  pins,  needles,  fish 
bones,  coins  and  tooth  plates  are  met  with  from  time  to  time.  Large 
bodies  are  most  likely  to  be  arrested  where  the  canal  is  narrowest, 
viz.,  at  the  upper  and  lower  ends.  Bagged  irregular  bodies  may 
become  impacted  and  those  with  sharp  projections,  such  as  tooth 
plates,  are  liable  to  penetrate  the  walls.  Small  bodies,  such  as 
coins,  may  cause  no  symptoms,  and  unless  impacted  may  be  passed 
onwards  to  the  stomach.  Pins,  needles  and  fish  bones  which  pene- 


FIG.  i.- 


-(Esophageal  forceps  for  the  removal  of  foreign  bodies  high  up 
in  the  gullet. 


trate  the  walls  may  lead  to  fatal  haemorrhage  or  cause  extensive 
septic  cellulitis  in  the  neck  and  thorax. 

The  treatment  to  be  adopted  depends  upon  the  nature  of  the 
foreign  body  and  the  seat  of  its  arrest.  If  possible,  extraction 
should  be  carried  out  through  the  mouth.  Whenever  the  symptoms 
are  urgent  and  when  the  foreign  body  is  impacted  at  the  beginning 
of  the  oesophagus,  the  mouth  must  be  gagged  open  and  the  finger 
passed  rapidly  to  the  back  of  the  pharynx  and  hooked  round  the 
foreign  body,  which  is  removed.  If  this  is  unsuccessful,  various  sorts 
of  forceps  with  different  curves  must  be  employed  (Figs.  1  and  2) . 


Foreign  Bodies  in  the  CEsophagus.         185 

The  throat  may  he  painted  with  cocaine  (10  per  cent.)  and  a  large 
laryngoscope    mirror  and  a    bright   illumination  is  a  great  help. 


FIG.  2. — Another  form  of  oasophageal  forceps. 

Inversion  and  violent  shaking  may  be  tried  if  the  patient  is  a  child, 
but  these  measures  must  not  be  attempted  or  prolonged  in  the 
presence  of  severe  dyspnoea.  Laryngotomy  or  tracheotomy  must 


Kit;.  :!.  The  umbrella  or  expanding  probang.  The  upper  figure  shows  the  instru- 
ment closed  and  the  lower  the  bristles  expanded  by  means  of  the  handle  at  the 
end  of  the  instrument.  At  the  other  end  a  small  round  sponge  is  fixed. 

then  be  performed  and  the  attempts  to  remove  the  foreign  body 
postponed  till  respiration  is  re-established.  When  the  symptoms 
are  not  urgent,  the  foreign  body  should  be  localised  by  using  X-rays 


SCALE.  "5 


FIG.  4. — The  ordinary  form  of  coin  catcher.    At  one  end  is  the  cage 
and  at  the  other  a  small  round  sponge. 

for  such  things  as  coins  and  tooth  plates,  the  passage  of  the 
oesophageal  sound  or  by  direct  examination  with  a  Briining's 
cesophagoscope.  Unless  the  foreign  body  is  quite  smooth  or  very 


1 86        Foreign  Bodies  in  the  CEsophagus. 

soft,  it  should  not  be  pushed  onwards  into  the  stomach.  If  the 
foreign  body  is  small  and  pointed,  e.g.,  a  fish  bone  or  a  pin,  it  may 
be  removed  by  means  of  the  umbrella  or  expanding  probang 
(Fig.  3),  which  is  passed  closed  and  by  traction  upon  its  upper 
end,  the  horsehair  is  expanded.  The  instrument  is  then  slowly 
withdrawn  carrying  with  it,  in  the  expanded  portion,  the  foreign 
body.  Coins  which  are  usually  arrested  edgewise  may  be  removed 
by  the  coin-catcher  (Fig.  4).  The  instrument  is  well  lubricated 
and  passed  gently  down  till  its  strikes  the  coin.  The  head  of  the 
instrument  is  then  manipulated  past  the  coin  and  slowly  withdrawn 
after  the  coin  has  been  caught  in  the  cage.  When  the  coin  is  high 
up,  it  may  possibly  be  removed  by  cesophageal  forceps.  A  large 
bolus  of  food  or  a  plate  of  false  teeth  may  be  removed  from  the 
up'per  part  of  the  oesophagus  by  forceps.  When  the  foreign  body 
is  irregular  in  shape  and  has  sharp  projecting  edges,  e.g.,  a  tooth 
plate,  much  difficulty  may  be  experienced  in  removing  it.  It  must 
not  be  pushed  onwards  as  great  damage  may  be  caused  to  the 
O3sophageal  walls.  It  may  be  impossible  to  reach  it  from  the 
mouth.  An  external  operation  is  then  required,  cervical  oeso- 
phagotomy  when  the  foreign  body  is  in  the  upper  part  or  gastrotomy 
when  it  is  in  the  lower  part  of  the  oesophagus.  In  such  cases  the 
oesophagoscope  may  be  employed  instead  of  an  operation  to  extract 
the  foreign  body. 

Cervical  CEsophagotomy  is  performed  through  an  incision 
along  the  anterior  border  of  the  left  sterno-mastoid.  The  incision 
extends  from  the  sternal  notch  to  the  level  of  the  thyroid  cartilage 
and  will  be  about  3  inches  long  in  an  adult.  The  sterno-mastoid 
is  retracted  backwards  and  the  omo-hyoid  muscle  is  displaced 
upwards  or  divided.  The  sterno-hyoid  and  sterno-thyroid  muscles 
are  pulled  inwards.  The  thyroid  gland  and  trachea  are  displaced 
towards  the  mid-line  and  the  carotid  vessels  in  their  sheath  are 
retracted  outwards.  The  oesophagus  will  be  seen  lying  behind  and 
projecting  into  the  wound  on  the  left  side  of  the  trachea.  Great 
care  must  be  taken  not  to  damage  the  recurrent  laryngeal  nerve 
which  passes  in  front  of  the  oesophagus  to  gain  the  groove  between 
this  structure  and  the  trachea.  The  foreign  body  may  now  be  felt 
in  the  oesophagus  and  a  sufficiently  long  vertical  incision  should  be 
made  over  it  to  permit  of  its  easy  extraction.  Suitable  forceps  are 
introduced  and  the  greatest  care  must  be  employed  to  avoid  bruising 
the  oesophageal  walls.  If  the  foreign  body  is  lower  down,  the  incision 
in  the  oesophagus  must  be  held  widely  open  so  that  a  good  view  is 
obtained  of  its  position  and  the  way  it  is  lying  ;  a  good  bright  light 
is  essential.  Forceps  are  then  introduced  and  seize  the  body, 


Foreign  Bodies  in  the  CEsophagus.         187 

which  is  carefully  extracted.  It  may  be  necessary  to  divide  the 
foreign  body  by  means  of  cutting  forceps  and  remove  each  portion 
separately.  The  oesophageal  incision  is  closed  by  silk  or  catgut 
sutures  which  do  not  involve  the  mucous  membrane.  A  large 
drainage  tube  must  always  be  put  down  to  the  oesophagus  at 
the  lower  end  of  the  neck  incision.  Provided  free  drainage  is 
arranged  for  through  the  superficial  part  of  the  wound,  any  leakage 
through  the  oesophageal  incision  is  unlikely  to  cause  extensive 
cellulitis  and  a  permanent  fistula  is  improbable. 

After-treatment. — The  patient  may  be  fed  through  a  medium- 
sized  (No.  16)  oesophageal  tube  or  by  a  nasal  tube  passed  three  or 
four  times  daily  or  rectal  feeding  may  be  employed  for  the  first 
three  or  four  days.  When  there  is  no  tendency  for  fluids  to  escape 
through  the  wound  liquids  may  be  swallowed  in  the  ordinary  way. 
The  patient  should  be  kept  from  the  first  in  a  sitting  posture  in 
bed.  The  drainage  tube  is  removed  at  the  end  of  five  or  six  days. 

Gastrotomy. — When  the  foreign  body  is  low  down,  near  to  the 
cardiac  end  of  the  oesophagus,  the  stomach  may  be  opened  suffi- 
ciently freely  to  admit  the  hand  through  an  abdominal  incision.  The 
cardiac  orifice  is  then  stretched  by  the  fingers  or  by  dilators  passed 
upwards  and  the  foreign  body  is  removed  by  suitable  forceps. 

It  is  always  advisable  before  doing  an  operation  to  remove  a 
foreign  body,  to  be  sure  that  it  is  still  in  the  oesophagus,  and 
therefore  a  bougie  should  be  passed,  and,  if  possible,  an  X-ray 
examination  should  be  made  immediately  prior  to  operating.  A 
patient  may  have  all  the  symptoms  of  a  foreign  body  in  the 
oesophagus  even  though  it  has  passed  into  the  stomach.  When  it 
has  been  passed  into  the  stomach,  and  is  small  and  not  irregular 
in  shape,  purgatives  should  be  avoided  and  the  patient  should  be 
fed  on  porridge,  bread  and  milk,  and  such  like  foods.  The  stools 
should  be  examined  carefully  for  the  presence  of  the  foreign  body. 

Briining's  CEsophagoscope. — During  the  last  few  years,  this 
instrument,  which  is  fully  described  in  Volume  III.,  has  been 
more  and  more  used  to  remove  foreign  bodies  from  whatever  part 
of  the  oesophagus  they  may  be  situated  in.  By  its  employment 
the  operative  measures  above  described  may  be  obviated,  and  this 
is  the  most  important  practical  point ;  there  is  no  wound  to  heal, 
for  as  soon  as  the  foreign  body  is  removed  the  patient  is  well 
again.  The  disadvantages  are  that  the  instrument  is  not  always 
at  hand ;  it  is  expensive  and  requires  the  use  of  an  electric 
accumulator  or  other  apparatus  for  the  illuminating  lamp.  More- 
over, the  foreign  body  may  not  be  easily  seen  or  recognised,  it  may 
be  hidden  by  blood  or  mucus ;  or  the  instrument  may  be  passed 


1 88  Wounds  of  the  CEsophagus. 

by  it  and  therefore  it  must  be  looked  for  both  during  the  introduc- 
tion and  during  the  withdrawal,  any  blood  and  mucus  being  care- 
fully mopped  away.  There  may  be  a  good  deal  of  difficulty  in 
introducing  the  instrument,  which  should  be  passed  from  the  side 
of  the  mouth  between  the  last  molar  teeth  to  the  lateral  wall  of  the 
pharynx,  the  patient  lying  over  on  one  side,  with  the  head  extended 
and  inclined  to  that  side.  A  general  anaesthetic  will  be  necessary 
and  great  gentleness  must  be  employed  so  as  to  avoid  lacerating 
the  mucous  membrane,  which  would  cause  bleeding  and  thereby 
obscure  the  view,  and  also  so  as  not  to  perforate  the  oesophageal 
walls.  It  may  be  impossible  from  the  size  and  shape  of  the  foreign 
body  to  seize  it  or  to  remove  it  if  it  is  impacted  ;  but,  whenever 
possible,  before  resorting  to  an  external  cutting  operation,  an 
attempt  should  be  made  to  remove  the  foreign  body  by  this 
instrument. 

WOUNDS    OF    THE    CESOPHAGUS. 

Wounds  may  be  inflicted  from  without  or  within.  The  former 
are  due  to  stabs,  etc.  If  the  injuries  are  not  fatal  from  damage  to 
other  structures,  such  as  the  great  blood-vessels,  the  wound  should 
be  thoroughly  explored.  It  may  occasionally  be  possible  to  close 
the  wound  in  the  oesophagus  by  sutures,  but  whether  this  is  done 
or  not,  provision  must  be  made  for  free  drainage,  as  suppuration 
frequently  occurs. 

Injuries  from  within  are  due  usually  to  the  presence  of  a  foreign 
body,  or  from  swallowing  some  sharp  or  angular  body,  or  the  rough 
passage  of  a  bougie.  The  treatment  has  already  been  described. 

BURNS    OF    THE    CESOPHAGUS. 

Burns  are  due  to  caustic  fluids.  If  not  immediately  fatal,  a 
tight  stricture  follows  from  cicatrisation  after  the  separation  of  the 
sloughs.  The  stricture  is  often  extensive  and  irregular  in  calibre 
and  is  usually  narrowest  at  the  upper  and  lowest  portions  of  the 
oesophagus. 

Treatment. — The  caustic  must  first  be  neutralised ;  if  it  is  an 
acid,  alkalies  such  as  bicarbonate  of  soda  or  powdered  chalk,  should 
be  given ;  if  it  is  an  alkali,  dilute  acetic  acid  (vinegar  and  water) 
should  be  administered.  Lemon  juice  and  citric  acid  may  also  be 
given.  In  neither  case  should  a  stomach  tube  or  an  emetic  be 
given.  When  the  caustic  is  neutralised,  olive  oil  (^  pint),  or  milk 
and  egg  should  be  given.  The  next  indication  is  to  give  the 
oesophagus  rest,  and  therefore  at  first,  all  food  should  be  adminis- 


Malformations  of  the  (Esophagus.  189 

tered  by  nutrient  enemata.  The  pain  is  often  severe  and  should 
be  relieved  by  morphia  hypodermically  (£  gr.),  or  tr.  opii  (20  niin.) 
[U.S.P  12  min.]  in  an  ounce  of  glycerine  and  water  may  be  pre- 
scribed, a  few  drops  being  placed  on  the  tongue  and  allowed  to 
trickle  down  the  oasophagus. 

Contraction  is  prevented  by  the  passage  of  bougies.  Only  soft 
instruments  must  be  employed,  and  they  should  be  first  passed 
in  about  three  or  four  weeks.  One  of  medium  size  should  be 
chosen  and  -the  frequency  with  which  they  are  to  be  passed  will 
depend  on  the  degree  of  contraction.  The  bougie  must  be  very 
gently  insinuated,  and  if  much  pain  is  produced,  the  patient  may 
swallow  a  few  drops  of  the  glycerine  and  opium  mixture  just 
mentioned. 

MALFORMATIONS    OF    THE    OESOPHAGUS. 

These  are  usually  not  amenable  to  treatment,  with  the  exception 
of  the  following. 

Diverticula  of  the  CEsophagus. — These  are  similar  to  those 
met  with  in  the  pharynx  and  are  nearly  always  situated  at  the 
upper  end  of  the  tube  at  its  junction  with  the  pharynx.  The 
diverticulum  is  usually  placed  on  the  postero-lateral  and  left 
aspects  of  the  oesophagus.  It  may  exist  for  many  years  and  tends 
to  enlarge  owing  to  distension  from  the  food  which  passes  into  it. 
Treatment  is  by  removal  of  the  pouch,  carried  out  through  an 
incision  similar  to  that  for  oesophagotomy.  After  the  pouch  has 
been  removed,  the  oesophageal  opening  is  closed  by  two  rows  of 
sutures.  A  tube,  passed  through  the  mouth,  for  feeding  the  patient 
may  be  left  in  situ  till  healing  has  taken  place  or  nasal  feeding  may 
be  employed.  The  after-treatment  is  the  same  as  for  oasophagotomy. 

T.    P.    LEGG. 


190 


DISEASES    OF    THE    ALIMENTARY    TRACT, 
ABDOMEN    AND    PERITONEUM, 

THE  PRINCIPLES  OF  DIETETICS. 

THE  food  supplies  all  the  energy  needed  for  the  various  activities 
of  the  cells  of  the  body  ;  it  must,  therefore,  contain  material  which 
is  capable  of  oxidation  in  the  body  ;  further,  as  living  cells  are 
continually  changing  their  own  substance,  the  food  must  also 
supply  those  elements  which  are  necessary  to  replace  that  sub- 
stance. The  oxidisable  materials  of  the  food  which  can  furnish 
energy  to  the  body  are  proteins,  carbohydrates  and  fats.  Protein 
food  is  also  needed  for  the  structure  of  the  tissues.  Other 
materials,  such  as  mineral  salts  and  water,  furnish  no  energy,  but 
are  essential  for  the  maintenance  of  the  structure  and  functions 
of  the  body.  Foodstuffs  are  subjected  to  digestion  in  order  that 
they  may  be  offered  to  the  mucous  membrane  of  the  intestine  in  a 
form  capable  of  absorption  into  the  tissues. 

Although  the  evolution  of  dietetic  habits  has  led  to  the  selection 
by  civilised  man  of  foods  which  are,  on  the  whole,  easily  digested 
and  absorbed,  there  are,  nevertheless,  differences  in  the  complete- 
ness with  which  food  materials  are  absorbed.  Analyses  of  the 
faeces  in  patients  fed  upon  different  foods  show  that  animal  foods 
are  more  fully  utilised  than  vegetable.  Thus  from  meats,  milk, 
cheese  and  eggs,  100  per  cent,  of  the  protein  is  absorbed,  and 
95  per  cent,  of  the  fat,  and  from  milk  and  cheese  100  per  cent,  of 
the  carbohydrates  ;  whilst  from  vegetable  flours  and  meals  the 
proportion  is  about  85  per  cent,  for  protein  and  95  per  cent,  for 
carbohydrate.  From  coarse  flour  and  from  potatoes,  cabbages 
and  turnips  the  percentage  of  protein  absorbed  is  about  75  per 
cent.  In  estimating,  therefore,  the  value  of  a  vegetable  diet, 
allowance  must  be  made  for  the  loss  of  15  to  25  per  cent,  of  the 
protein.  The  reason  for  the  loss  is  that  the  nitrogenous  matter 
of  vegetables  is  mixed  with  masses  of  cellulose  and  starch,  so  that 
the  digestive  juices  cannot  easily  reach  the  protein  and  dissolve 
it.  With  an  ordinary  mixed  diet  over  90  per  cent,  of  the  total 
energy  of  the  food  is<used,  with  a  fruitarian  diet  about  86  per  cent. 

Different  individuals  do  not  show  much  variation  in  the  power 
of  digesting  and  absorbing  food  ;  indeed,  when  the  food  has  once 


The  Principles  of  Dietetics.  191 

passed  from  the  stomach  into  the  intestines  it  appears  to  be 
absorbed  naturally,  even  though  the  patient  observed  may  be  the 
subject  of  dyspepsia.  The  clinical  term  "  indigestion  "  refers, 
therefore,  to  the  gastric  symptoms  which  food  may  cause  ;  it  does 
not  follow  that  digestion  in  the  intestine  is  deficient.  The 
nutrition  is  poor  in  chronic  dyspepsia  because  insufficient  food  is 
taken,  not  because  assimilation  fails. 

The  proteins  of  the  food  are  broken  down  in  digestion  into 
smaller  molecules,  which  apparently  split  after  absorption  into 
a  nitrogenous  and  a  non-nitrogenous  part.  The  molecules  of  the 
nitrogenous  part,  if  needed  for  the  formation  or  the  repair  of 
tissue,  are  built  up  into  the  protoplasm  of  the  cells  ;  if  not  needed 
for  such  purposes  they  are  converted  into  urea  and  passed  out 
in  the  urine,  together  with  the  urea  formed  from  the  wear  and 
tear  of  tissue.  The  non-nitrogenous  part  is  oxidised  to  furnish 
energy  to  the  body. 

The  fat  of  the  food  is  either  oxidised  at  once  or  is  deposited  in 
the  connective  tissue  cells  in  the  fat  depots  under  the  skin,  in  the 
omentum,  about  the  kidneys  and  elsewhere  ;  before  oxidation, 
fats  are  converted,  probably  chiefly  in  the  liver,  into  more  complex 
substances. 

The  carbohydrates  are  taken  up  from  the  portal  vein  as 
dextrose  and  oxidised  without  great  delay.  A  certain  quantity 
remains  stored  as  glycogen  in  the  liver  and  to  a  less  extent  in 
other  organs.  The  glycogen  of  the  liver  is  reconverted  to  dextrose 
before  it  is  oxidised. 

For  the  formation  or  repair  of  protein  tissues  nitrogenous  food 
is  necessary.  Fat  can  be  formed  from  carbohydrate  food,  but 
it  is  not  clear  at  present  whether  it  can  be  formed  from  protein. 
Carbohydrate  can  be  formed  from  protein  and  from  fat,  though 
it  is  uncertain  to  what  extent  these  transformations  occur  in 
normal  nutrition. 

Each  of  the  foodstuffs  when  burnt  in  a  calorimeter  gives  out 
a  definite  quantity  of  heat  for  every  gramme  burnt ;  precisely 
the  same  amount  of  energy  is  supplied  to  the  tissues  when  the 
foodstuff  is  fully  oxidised  in  the  body.  The  energy  value  of  the 
food  may,  therefore,  be  expressed  in  units  of  heat,  or  calories. 
The  amount  of  heat  required  to  raise  a  gramme  of  water  through 
1°  C.  is  called  a  small  calorie.  For  dietetic  purposes  a  thousand 
of  these  small  calories  give  a  more  convenient  unit,  the  large 
calorie  or  kilocalorie,  and  this  unit  is  denoted  when  the  term 
"  calorie  "  is  employed  in  writings  on  diet.  The  heat  values  of  the 
different  carbohydrates  range  from  3'7  to  4'2  kilocalories  for  each 


The  Principles  of  Dietetics. 


gramme,  the  average  in  an  ordinary  diet  being  4'1  ;  the  fats  range 
from  9'2  to  9'5,  with  an  average  of  9*3.  As  both  fats  and  carbo- 
hydrates are  fully  oxidised  in  the  body  these  figures  represent  the 
energy  which  they  yield  when  taken  as  food.  Proteins  give  an 
average  heat  value  of  5 '7  when  burnt  in  a  calorimeter,  but  they 
do  not  give  all  of  this  to  the  body,  because  their  end  products, 
namely,  the  urea  and  other  nitrogenous  substances  in  the  urine, 
are  not  fully  oxidised  and,  therefore,  still  possess  a  heat  value. 
The  subtraction  of  the  heat  value  of  these  excreta  from  that  of  the 
original  protein  gives  a  measure  of  the  energy  which  the  protein 
food  yields  to  the  body  and  is  known  as  the  "  physiological  heat 
value  "  of  protein  ;  it  is  equal  to  4'2  kilocalories  for  every  gramme 
of  dry  protein  in  animal  food,  and  3'9  in  vegetable  food,  in  which, 
as  we  have  seen,  absorption  is  less  complete.  The  average  value 
for  protein  in  a  mixed  diet  may  be  taken  as  4'1  kilocalories  per 
gramme.  Hence,  in  an  ordinary  diet, 

1  gramme  of  dry  protein  gives  4'1  kilocalories  of  energy. 

1          „        „    fat         „  „      9-3 

1         ,,        ,,    dry  carbohydrate      ,,     4-1  ,,  „ 

COMPOSITION  OF  FOODS. 

The  composition  of  the  chief  foodstuffs  is  given  in  the  following 
table,  which  is  compiled  from  the  analyses  of  At  water  and  Bryant. 
The  last  column  of  the  table  gives  the  physiological  heat  value  of 
a  pound  of  the  food  :— 

TABLE  I. 

Chemical  Composition  of  Food  Materials. 
In  all  cases  the  edible  portion  of  the  food  is  referred  to. 


Food  Materials. 

Wat*r. 

Protein. 

.\\.-.-i-;.. 

Fat 

Total 
Carbo- 
hydrates. 

Ash. 

Fuel  value 
per  pound. 

ANIMAL  FOOD. 

Per 

Per 

Per 

Per 

Per 

Cals. 

Beef,  fresh  — 

cent. 

cent. 

cent. 

cent. 

cent. 

Ribs,  lean 

71-3 

19-5 

8-3 

— 

1-0 

715 

„      medium  fat 

62-7 

18-5 

18-0 

— 

1-0 

1,105 

„     fat 

52-0 

16-5 

31-1 

— 

0-8 

1,620 

Round,  medium  fat  . 

65-5 

20-3 

13-6 

:  

1-1 

950 

Sweetbreads,  as  pur- 

chased 

70-9 

16-8 

12-1 



1-6 

825 

Tongue   . 

70-8 

18-9 

9-2 



1-0 

740 

Beef,  cooked  — 

Roast 

48-2 

22-3 

28-6 



1-3 

1,620 

Loin  Steak 

54-8 

23-5 

20-4 



1-2 

1,300 

Beef,  corned  — 

Corned  Beef     . 

51-8 

26-3 

18-7 



4-0 

1,280 

Tongue,  whole 

51-3 

19-5 

23-2 



4-0 

1,340 

The  Principles  of  Dietetics. 


193 


Food  Materials. 

Water. 

Protein. 
NX  0-25. 

Fat. 

Total 
Carbo- 
hydrates. 

Ash. 

Fuel  value 
perjKJund. 

ANIMAL  FOOD  —  contd. 

Per 

Per 

Per 

Per 

Per 

/~i    i 

Veal,  fresh  — 

cent. 

cent. 

cent. 

cent. 

cent. 

Cals. 

Loin,  medium  fat 

68-9 

20-5 

10-4 

— 

1-0 

820 

Liver 

73-0 

19-0 

5-3 

— 

1-3 

575 

Lamb,  fresh  —  • 

Forequarter 

55-1 

18-3 

25-8 

— 

1-0 

1,430 

Lamb,  cooked  — 

Chops,  broiled. 

47-6 

21-7 

29-9 

— 

1-3 

1,665 

Mutton,  fresh  —  • 

Leg,  hind,  medium  fat 

62-8 

18-5 

18-0 

— 

1-0 

1,105 

Shoulder,  medium  fat 

61-9 

17-7 

19-9 

— 

0-9 

1,170 

Mutton,  cooked  — 

Leg,  roast 

50-9 

25-0 

22-6 

— 

1-2 

1,420 

Sheep's  Kidneys 

78-7 

16-5 

3-2 

— 

1-3 

440 

Pork,  fresh  — 

Ham 

50-1 

15-7 

33-4 

— 

0-9 

1,700 

Loin  Chops 

50-7 

16-4 

32-0 

— 

0-9 

1,655 

Liver 

71-4 

21-3 

4-5 

1-4 

1-4 

615 

Pork,     pickled,     salted 

and  smoked  — 

Ham,    smoked,    me- 

dium fat 

40-3 

16-3 

38-8 

— 

4-8 

1,940 

Bacon,  smoked,  lean 

31-8 

15-5 

42-6 

— 

11-0 

2,085 

Bacon,  smoked,  me- 

dium fat 

18-8 

9-9 

67-4 

— 

4-4 

3,030 

Bacon,  smoked 

20-2 

10-5 

64-8 

— 

5-1 

2,930 

Sausage  — 

Pork 

39-8 

13-0 

44-2 

1-1 

2-2 

2,125 

Poultry      and      Game, 

fresh  — 

Chicken  . 

74-8 

21-5 

2-5 

— 

1-1 

505 

Fowls 

63-7 

19-3 

16-3 

— 

1-0 

1,045 

Goose,  young  . 

46-7 

16-3 

36-2 

— 

0-8 

1,830 

Turkey    . 

55-5 

21-1 

22-9 

— 

1-0 

1,360 

Poultry      and      Game, 

cooked  — 

Capon 

59-9 

27-0 

11-5 

— 

1-3 

985 

Turkey,  roast  . 

52-9 

27-8 

18-4 

— 

1-2 

1,295 

Turkey,    roast,    light 

and  dark  meat  and 

stuffing 

65-0 

17-1 

10-8 

5-5 

1-6 

870 

Fish,  fresh  —  - 

Cod,  whole 

82-6 

16-5 

0-4 

— 

1-2 

325 

Eels,  salt  water  (head, 

skin,    and    entrails 

removed) 

71-6 

18-6 

9-1 

— 

1-0 

730 

Hake     (entrails     re- 

removed) 

83-1 

15-4 

0-7 

— 

1-0 

315 

Haddock        (entrails 

removed) 

81-7 

17-2 

0-3 

— 

1-2 

335 

Halibut,  steaks 

75-4 

18-6 

5-2 

— 

1-0 

565 

Herring  . 

72-5 

19-5 

7-1 

— 

1-5 

660 

Mackerel 

73-4 

18-7 

7-1 

— 

1-2 

645 

Mullet     . 

74-9 

19-5 

4-6 

— 

1-2 

555 

Salmon    . 

64-6 

22-0 

12-8 

— 

1-4 

950 

S.T. — VOL.  II. 


13 


194 


The  Principles  of  Dietetics. 


Food  Materials. 

Water. 

Protein. 
NX  6-25. 

Fat. 

Total 
Carbo- 
hydrates 

Ash. 

Fuel  value 
per  pound. 

ANIMAL  FOOD  —  contd. 

Per 

Per 

Per 

Per 

Per 

Polo 

Fish,  fresh  —  contd. 

cent. 

cent. 

cent. 

cent. 

cent. 

i^ais. 

Smelt      . 

79-2 

17-6 

1-8 

— 

1-7 

405 

Trout,  brook    . 

77-8 

19-2 

2-1 

— 

1-2 

445 

Turbot    . 

71-4 

14-8 

14-4 

— 

1-3 

885 

Fish,     preserved     and 

canned  — 

Haddock,  smoked 

72-5 

23-3 

0-2 

— 

3-6 

440 

Herring,  smoked 

34-6 

36-9 

15-8 

— 

13-2 

1,355 

Mackerel,  salt,  dres- 

sed 

43-4 

17-3 

26-4 

— 

12-9 

1,435 

Salmon,  tinned 

63-5 

21-8 

12-1 

— 

2-6 

915 

Sardines,  tinned 

52-3 

23-0 

19-7 

— 

5-6 

1,260 

Shellfish,  etc.,  fresh  — 

Crabs 

77-1 

16-6 

2-0 

1-2 

3-1 

415 

Crayfish,  abdomen    . 

81-2 

16-0 

0-5 

1-0 

1-3 

340 

Lobster  . 

79-2 

16-4 

1-8 

0-4 

2-2 

390 

Mussels  . 

84-2 

8-7 

1-1 

4-1 

1-9 

285 

Oysters   . 

86-9 

6-2 

1-2 

3-7 

2-0 

235 

Scallops  . 

80-3 

14-8 

o-i 

3-4 

1-4 

345 

Turtle,  green    . 

79-8 

19-8 

0-5 

— 

1-2 

390 

Lobster,  tinned 

77-8 

18-1 

1-1 

0-5 

2-5 

390 

Eggs  — 

Hens',  uncooked 

73-7 

13-4 

10-5 

— 

1-0 

720 

,,       boiled   . 

73-2 

13-2 

12-0 

— 

0-8 

765 

„       boiled    whites 

86-2 

12-3 

0-2 

— 

0-6 

250 

„       boiled  yolks  . 

49-5 

15-7 

33-3 

— 

1-1 

1,705 

Dairy  Products,  etc.  — 

Butter     . 

11-0 

1-0 

85-0 

— 

3-0 

3,605 

Cheese,  Cheddar 

27-4 

27-7 

36-8 

4-1 

4-0 

2,145 

„       Cheshire 

37-1 

26-9 

30-7 

0-9 

4-4 

1,810 

,,        American, 

pale 

31-6 

28-8 

35-9 

0-3 

3-4 

2,055 

„       American, 

red  . 

28-6 

29-6 

38-3 

— 

3-5 

2,165 

„       Dutch 

35-2 

37-1 

17-7 

— 

10-0 

1,435 

,,        Limburger    . 

42-1 

23-0 

29-4 

0-4 

5-1 

1,675 

„        Eoquefort     . 

39-3 

22-6 

29-5 

1-8 

6-8 

1,700 

„        Swiss  . 

31-4 

27-6 

34-9 

1-3 

4-8 

2,010 

Milk,  condensed, 

sweetened     . 

26-9 

8-8 

8-3 

54-1 

1-9 

1,520 

„     whole 

87-0 

3-3 

4-0 

5-0 

0-7 

325 

,,      skimmed 

90-5 

3-4 

0-3 

5-1 

0-7 

170 

Whey      . 

93-0 

1-0 

0-3 

5-0 

0-7 

125 

Miscellaneous  — 

Gelatine  . 

13-6 

91-4 

o-i 

— 

2-1 

1,705 

Calf's-foot  Jelly 

77-6 

4-3 

— 

17-4 

0-7 

405 

Lard,  unrefined 

4-8 

2-2 

94-0 

— 

0-1 

4,010 

The  Principles  of  Dietetics. 


195 


Food  Materials. 

Water. 

Protein. 

Fat. 

Total 
Carbo- 

liyilrati's, 
including 
Fibre. 

Ash. 

Fuel  value 
per  pound. 

VEGETABLE  FOOD. 

Per 

Per 

Per 

Per 

Per 

/~i   i 

Flours,  Meals,  etc.  — 

cent. 

cent. 

cent. 

cent. 

cent. 

Cals. 

Barley  meal  and  flour 

11-9 

10-5 

2-2 

72-8 

2-6 

1,640 

Barley,  pearled 

11-5 

8-5 

1-1 

77-8 

1-1 

1,650 

Corn  flour 

12-6 

7-1 

1-3 

78-4 

0-6 

1,645 

Corn  Preparations  — 

Hominy 

11-8 

8-3 

0-6 

79-0 

0-3 

1,650 

Oatmeal 

7-3 

16-1 

7-2 

67-5 

1-9 

1,860 

„         boiled 

84-5 

2-8 

0-5 

11-5 

0-7 

285 

gruel 

91-6 

1-2 

0-4 

6-3 

0-5 

155 

Rice    . 

12-3 

8-0 

0-3 

79-0 

0-4 

1,630 

,,     boiled  . 

72-5 

2-8 

o-i 

24-4 

0-3 

525 

,,     flaked  . 

9-5 

7-9 

0-4 

81-9 

0-3 

1,685 

Wheat  Flour,  Cali- 

fornia fine 

13-8 

7-9 

1-4 

76-4 

0-5 

1,625 

Wheat    Flour,    en- 

tire wheat 

11-4 

13-8 

1-9 

71-9 

1-0 

1,675 

Wheat  Preparations  — 

Shredded 

8-1 

10-5 

1-4 

77-9 

2-1 

1,700 

Macaroni 

10-3 

13-4 

0-9 

74-1 

1-3 

1,665 

,,         cooked  . 

78-4 

3-0 

1-5 

15-8 

1-3 

415 

Vermicelli     . 

11-0 

10-9 

2-0 

72-0 

4-1 

1,625 

Bread,  Biscuits,  Pastry, 

etc.  — 

Bread,  brown  . 

43-6 

5-4 

1-8 

47-1 

2-1 

1,050 

Rolls,  French  . 

32-0 

8-5 

2-5 

55-7 

1-3 

1,300 

„     Vienna  . 

31-7 

8-5 

2-2 

56-5 

1-1 

1,300 

Toasted  Bread 

24-0 

11-5 

1-6 

61-2 

1:7 

1,420 

White  Bread    . 

35-3 

9-2 

1-3 

53-1 

1-1 

1,215 

Gingerbread 

18-8 

5-8 

9-0 

63-5 

2-9 

1,670 

Sponge  Cake    . 

15-3 

6-3 

10-7 

65-9 

1-8 

1,795 

Lady  Fingers  . 

15-0 

8-8 

5-0 

70-6 

0-6 

1,685 

Macaroons 

12-3 

6-5 

15-2 

65-2 

0-8 

1,975 

Pie,  apple 

42-5 

3-1 

9-8 

42-8 

1-8 

1,270 

,,    mince 

41-3 

5-8 

12-3 

38-1 

2-5 

1,335 

Pudding,  tapioca 

64-5 

3-3 

3-2 

28-2 

0-8 

720 

Sugar,  Starches,  etc.  — 

Honey     . 

18-2 

0-4 

— 

81-2 

0-2 

1,520 

Starch,  arrowroot 

2-3 

— 

— 

97-5 

0-2 

1,815 

„       sago 

12-2 

9-0 

0-4 

78-1 

0-3 

1,635 

,,       tapioca 

11-4 

0-4 

o-i 

88-0 

o-i 

1,650 

Vegetables  — 

Artichokes 

79-5 

2-6 

0-2 

16-7 

1-0 

365 

Asparagus 

94-0 

1-8 

0-2 

3-3 

0-7 

105 

Beetroot,  fresh 

87-5 

1-6 

o-i 

9-7 

1-1 

215 

Cabbage 

91-5 

1-6 

0-3 

5-6 

1-0 

145 

Carrots,  fresh  . 

88-2 

1-1 

0-4 

9-3 

1-0 

210 

Cauliflower 

92-3 

1-8 

0-5 

4-7 

0-7 

140 

Celery 

94-5 

1-1 

o-i 

3-3 

1-0 

85 

Cucumber 

95-4 

0-8 

0-2 

3-1 

0-5 

80 

Leeks 

91-8 

1-2 

0-5 

5-8 

0-7 

150 

Lentils,  dried  . 

8-4 

25-7 

1-0 

59-2 

5-7 

1,620 

Lettuce  . 

94-7 

1-2 

0-3 

2-9 

0-9 

90 

Mushrooms 

88-1 

3-5 

0-4 

6-8 

1-2 

210 

13- 


196 


The  Principles  of  Dietetics. 


Food  Materials. 

Water. 

Protein. 

Fat 

Total 
Carbo- 
hydrates, 
including 
Fibre. 

Ash. 

Fuel  value 
per  pound. 

VEGETABLE  FOOD  —  contd. 

Per 

Per 

Per 

Per 

Per 

r^rtirt 

Vegetables  —  contd. 

cent. 

cent. 

cent. 

cent. 

cent. 

Lais. 

Onions,  fresh    . 

87-6 

1-6 

0-3 

9-9 

0-6 

225 

Parsnips 

83-0 

1-6 

0-5 

13-5 

1-4 

300 

Peas,  green 

74-6 

7-0 

0-5 

16-9 

1-0 

465 

„      dried 

9-5 

24-6 

1-0 

62-0 

2-9 

1,655 

Potatoes,  raw  . 

78-3 

2-2 

o-i 

18-4 

1-0 

385 

Potatoes,        cooked, 

boiled 

75-5 

2-5 

o-i 

20-9 

1-0 

440 

Potatoes,         cooked, 

chips   . 

2-2 

6-8 

39-8 

46-7 

4-5 

2,675 

Potatoes,         cooked, 

mashed  &  creamed 

75-1 

2-6 

3-0 

17-8 

1-5 

505 

Eadishes 

91-8 

1-3 

o-i 

5-8 

1-0 

135 

Rhubarb 

94-4 

0-6 

0-7 

3-6 

0-7 

105 

Spinach,  fresh 

92-3 

2-1 

0-3 

3-2 

2-1 

110 

Tomatoes,  fresh 

94-3 

0-9 

0-4 

3-9 

0-5 

105 

Turnips  . 

89-6 

1-3 

0-2 

8-1 

0-8 

185 

Vegetables,  tinned  — 

Peas,  green 

85-3 

3-6 

0-2 

9-8 

1-1 

255 

Tomatoes 

94-0 

1-2 

0-2 

4-0 

0-6 

105 

Pickles,       Condiments, 

etc.  — 

Olives,  green    . 

58-0 

1-1 

27-6 

11-6 

1-7 

1,400 

ripe      . 

64-7 

1-7 

25-9 

4-3 

3-4 

1,205 

Pickles,  mixed 

93-8 

1-1 

0-4 

4-0 

0-7 

110 

Fruits,     Berries,     etc., 

fresh  — 

Apples    . 

84-6 

0-4 

0-5 

14-2 

0-3 

290 

Apricots  . 

85-0 

1-1 

— 

13-4 

0-5 

270 

Bananas  . 

75-3 

1-3 

0-6 

22-0 

0-8 

460 

Blackberries     . 

86-3 

1-3 

1-0 

10-9 

0-5 

270 

Cherries  . 

80-9 

1-0 

0-8 

16-7 

0-6 

365 

Cranberries 

88-9 

0-4 

0-6 

9-9 

0-2 

215 

Currants  . 

85-0 

1-5 

— 

12-8 

0-7 

265 

Figs,  fresh 

79-1 

1-5 

— 

18-8 

0-6 

380 

Grapes    . 

77-4 

1-3 

1-6 

19-2 

0-5 

450 

Oranges  . 

86-9 

0-8 

0-2 

11-6 

0-5 

240 

Pears 

84-4 

0-6 

0-5 

14-1 

0-4 

295 

Pineapple 

89-3 

0-4 

0-3 

9-7 

0-3 

200 

Plums 

78-4 

1-0 

— 

20-1 

0-5 

395 

Strawberries     . 

90-4 

1-0 

0-6 

7-4 

0-6 

180 

Watermelons   . 

92-4 

0-4 

0-2 

6-7 

0-3 

140 

Fruits,  dried  — 

Apples    . 

28-1 

1-6 

2-2 

66-1 

2-0 

1,350 

Apricots. 

29-4 

4-7 

1-0 

62-5 

2-4 

1,290 

Currants 

17-2 

2-4 

17 

74-2 

4-5 

1,495 

Dates 

15-4 

2-1 

2-8 

78-4 

1-3 

1,615 

Figs 

18-8 

4-3 

0-3 

74-2 

2-4 

1,475 

Prunes    . 

22-3 

2-1 

— 

73-3 

2-3 

1,400 

Raisins    . 

14-6 

2-6 

3-3 

76-1 

3-4 

1,605 

Peaches  . 

88-1 

0-7 

0-1 

10-8 

0-3 

220 

Pears 

81-1 

0-3 

0-3 

18-0 

0-3 

355 

The  Principles  of  Dietetics. 


197 


Food  Materials. 

Water. 

Protein. 

Fat. 

Total 
Carbo- 
hydrates, 
including 
Fibre. 

Ash. 

Fuel  value 
perpuiuul. 

VEGETABLE  FOOD  —  contd. 
Nuts- 

Per 

cent. 

Per 
cent. 

Per 

cent. 

Per 

cent. 

Per 

cent. 

Cals. 

Almonds 

4-8 

21-0 

54-9 

17-3 

2-0 

3,030 

Brazil  Nuts 

5-3 

17-0 

66-8 

7-0 

3-9 

3,265 

Chestnuts,  fresh 

45-0 

6-2 

5-4 

42-1 

1-3 

1,125 

„          dried 

5-9 

10-7 

7-0 

74-2 

2-2 

1,875 

Cocoanuts 

14-1 

5-7 

50-6 

27-9 

1-7 

2,760 

Filberts  .. 

3-7 

15-6 

65-3 

13-0 

2-4 

3,290 

Walnuts  . 

2-5 

18-4 

64-4 

13-0 

1-7 

3,300 

Miscellaneous  — 

Chocolate 

5-9 

12-9 

48-7 

30-3 

2-2 

2,860 

Cocoa 

4-6 

21-6 

28-9 

37-7 

7-2 

— 

Table  II.  will  enable  the  reader  to  see  at  a  glance  which  foods 
owe  their  energy  value  mainly  to  protein,  which  to  carbohydrate, 
and  which  to  fat.  It  will  be  noted  that  milk  occupies  a  fair 
place  in  each  of  the  three  lists. 


TABLE  II. 

Common  Foods  Arranged  in  Order  according  to  their  Value 
in  Protein,  Carbohydrate  and  Fat. 


Percentage  of  Total  Heat  Value 
of  Food  Furnished  by  its 
Protein. 

Percentage  of  Total  Heat  Value 
of  Food  Furnished  by  its 
Fat. 

Percentage  of  Total  Heat  Value 
of  Food  Furnished  by  its 
Carbohydrate. 

P.c. 

P.O. 

P.c. 

Lean  beef  (boiled] 

.     90 

Butter 

99 

Tapioca  (cooked)     98 

Chicken 

.      79 

Bacon 

94 

Prunes  (dried)     .      97 

Mackerel 

.      50 

Cream 

87 

Figs  (dried)         .      95 

Skim  milk 

.      37 

Brazil  nuts 

86 

Rice  (boiled)       .     89 

Eggs     . 

.      32 

Fat  ham    . 

81 

Oysters      .          .      89 

Beef  with  fat 

.      25 

Fat  beef 

75 

Potatoes  (boiled)     88 

Cheese 

.     25 

Cheese 

73 

Bread         .          .81 

Fat  ham 

.      19 

Eggs 

68 

Peas.          .          .     72 

Milk      . 

.      19 

Boiled  mutton    . 

65 

Milk           .          .     29 

Bread   . 

.      13 

Milk 

52 

Cream        .          .       8 

Potatoes 

.      11 

Mackerel    . 

50 

Brazil  nuts          .        4 

Boiled  rice     . 

.      10 

Chicken 

21 

Cheese       .          .       2 

Brazil  nuts    . 

.      10 

Boiled  lean  beef. 

10 

Bacon  . 

6 

Bread         .       '  . 

6 

Cream  . 

5 

Bananas    . 

5 

Bananas 

5 

Potatoes    . 

1 

Butter  . 

.       -5 

In   Table   III.    representative    foods   are   arranged    in    order 
according  to  their  total  energy  value. 


198 


The  Principles  of  Dietetics. 


TABLE  III. 
Common    Foods   in    Order   of  their   Caloric   Value. 


Amount  con- 

Amount con- 

taining 100 

taining  100 

Cals.  in 

Cals.  in 

Ounces. 

Ounces. 

Butter 

0-4 

Mackerel    . 

2-0 

Brazil  nuts 

0-5 

Eggs 

2-1 

Bacon 

0-5 

Boiled  rice 

3-1 

Cheese 

0-8 

Chicken 

3-2 

Sugar 

0-9 

Baked  apples 

3-3 

Fat  ham 

1-0 

Bananas    . 

3-5 

Beef  or  mutton  with  fat 

1-2 

Boiled  potatoes  . 

3-6 

Bread 

1-3 

Milk 

4-9 

Cream 

1-7 

Apples  (raw) 

7-3 

The  following  table  (from  Hutchison)  shows  (1)  the  amount  of 
food  value  ;  and  (2)  the  amount  of  protein  which  can  be  bought 
for  a  shilling  in  ordinary  foodstuffs. 


cals.  of 
energy, 

supplies  10,764 

8,921 

3,796 

3,000 

2,884 

2,856 

2,638 

953 

839 

829 

grammes 
of  protein. 

supplies       572 

283 

272 

218 

127 

114 

79 

54 

27 

3-5 


It  is  seen  that  bread  holds  the  first  place  for  energy  value, 
and  dried  peas  for  protein. 

Cooking  destroys  bacteria  and  makes  food  nicer.  It  may  or 
may  not  render  it  easier  of  digestion.  Cooked  meat  is  slightly 
less  digestible  than  raw.  If  it  is  cooked  by  any  form  of  dry  heat 


TABLE  IV. 

(i) 

1  shillingsworth  of  Bread       at  l^d.  per  Ib. 
„                        Peas              2d.        „ 

5> 

Potatoes 

Id.      „     . 

» 

Milk 

\\d.  per  pint 

» 

Butter 

1/3  per  Ib. 

» 

Apples 

Id. 

>» 

Cheese 

6d. 

J> 

Fish 

4d. 

» 

Eggs 

I/—  per  dozen 

» 

Beef 

9d.  per  Ib. 

(2) 

J> 

,        Peas  . 

.           . 

» 

,         Bread 

. 

» 

,         Cheese 

.           . 

J> 

Fish   . 

.          . 

Beef  . 

t 

> 

Milk   . 

-T-\ 

. 

> 

Eggs  . 

.           . 

> 

,         Potatoes 

.           . 

) 

,         Apples 

.          . 

, 

,         Butter 

. 

The  Principles  of  Dietetics.  199 

its  nutritive  properties  remain  about  the  same  ;  if  boiled,  some, 
though  not  much,  of  the  food  material  passes  into  the  broth,  but  is 
not  wasted  if  the  broth  is  used  for  soup.  The  cooking  of  vegetables 
renders  them  more  digestible  by  breaking  up  the  starch  grains. 
It  is  most  economical  to  steam  and  not  to  boil  them,  for  in  boiling 
quite  a  large  fraction  of  the  nutritive  material,  a  quarter  or  more 
in  the  case  of  cabbages  and  carrots,  is  extracted.  With  potatoes, 
the  loss  is  least  when  they  are  boiled  in  their  skins,  and  greatest 
when  they  are  peeled  and  soaked  in  water  before  cooking. 

The  study  of  the  amount  of  food  needed  by  a  healthy  person 
in  different  circumstances  has  yielded  much  matter  of  scientific 
and  economic  interest.  I  need  not  go  into  the  subject  in  detail 
here,  because  in  the  dietetics  of  ordinary  practice  when  a  suffi- 
ciency of  suitable  food  is  available  the  appetite  of  each  individual 
tells  him  how  much  food  he  requires. 

The  main  considerations  affecting  the  quantity  and  quality 
of  the  diet  in  health  may  be  summarised  under  the  headings  of  : 
(1)  The  total  food  value  needed,  as  affected  by  (a)  build  ;  (6)  rest 
or  activity  ;  (c)  climate.  (2)  The  proportion  of  the  different 
foodstuffs  required,  (a)  protein  ;  (6)  carbohydrates  ;  (c)  fat. 

(1)  The  total  food  value  needed  must  be  sufficient  to  maintain 
the  temperature  of  the  body  and  supply  the  energy  needed  for 
the  work  of  the  muscles  and  other  organs.  It  will  vary  with 
(a)  the  build  of  the  individual.  Firstly,  it  must  be  proportional 
to  the  weight,  for  a  large  man  will  require  more  food,  other  things 
being  equal,  than  a  small  one  ;  secondly,  it  must  vary  with  the 
extent  of  surface,  for  the  loss  of  heat  from  the  body  is  much  greater 
in  a  thin  person  with  a  large  surface  relative  to  the  weight  than  in 
a  stouter,  more  spherical  person  with  a  small  surface  relative  to 
the  weight.  Thin  babies  and  thin  children  often  require  a  large 
amount  of  food  on  this  account. 

As  regards  the  average  food  requirement,  a  person  living  a 
quiet,  non-muscular  life  needs  about  35  kilocalories  for  every 
kilogramme  of  body  weight  (a  kilogramme  is  2  Ibs.  3  oz.).  This 
is  supplied  by  4|  pints  of  milk,  or  by  1  Ib.  2  oz.  of  bread  and  8  oz. 
of  meat.  A  man  living  a  life  of  ordinary  activity  takes  about 
40  calories  per  kilogramme,  that  is  3,000  calories  for  a  man  of 
11  stone. 

(6)  The  influence  of  rest  and  activity. — If  much  muscular  work 
is  done  the  total  amount  of  food  must  be  increased  in  proportion 
to  supply  the  necessary  energy.  Men  engaged  in  especially  hard 
and  continuous  labour  have  been  observed  to  take  5,000  to  7,000 
calories  in  the  day.  The  requirements  of  ordinary  labour  are 


2oo  The  Principles  of  Dietetics. 

met  by  adding  about  1,000  calories  to  the  diet,  thus  raising  its 
value  from  3,000  to  4,000  calories. 

A  person  resting  entirely  in  bed  needs,  on  the  other  hand,  less 
food  :  about  two- thirds  of  that  taken  by  an  individual*  leading 
a  sedentary  life  is  enough,  that  is,  about  25  calories  a  kilogramme, 
which  for  a  person  of  8  stone  is  supplied  by  3  pints  2  oz.  of  milk, 
or  by  13  oz.  of  bread  and  5^  oz.  of  meat.  Even  with  the  most 
complete  inactivity  in  bed  a  fair  supply  of  food  is  needed  to 
maintain  the  indispensable  activities  of  the  organs  of  respiration, 
circulation,  digestion,  secretion  and  excretion,  without  which  life 
cannot  be  supported.  If  the  supply  of  food  is  insufficient  the 
body  draws  upon  its  tissues  and  weight  is  lost. 

(c)  The  effect  of  climate. — In  cold  climates  the  loss  of  heat  from 
the  body  is  increased  and  more  food  is  needed,  whilst  in  tropical 
countries  the  reverse  is  the  case.  These  differences  are  neutralised 
to  a  large  extent  by  the  clothing,  which  is  varied  so  that  the  skin 
is  kept  at  approximately  the  same  temperature. 

(2)  The  proportion  of  the  different  foodstuffs  required.  - 
(a)  Protein. — Most  people  who  can  choose  their  food  select  a  diet 
which  contains  not  less  than  100  grammes  (3|  oz.)  of  dry  protein 
in  the  day.  Only  in  conditions  of  poverty  does  the  amount  taken 
by  workers  fall  below  80  to  90  grammes.  Many  people  take  much 
more  than  100  grammes  ;  for  instance,  150  grammes  in  the  day. 
The  minimum  amount  necessary  to  make  good  the  wear  and  tear 
of  the  tissues  is  probably  about  50  grammes.  Some  observers, 
following  Chittenden,  believe  that  it  is  unnecessary  and  even 
harmful  to  exceed  this  amount.  The  balance  of  opinion  is, 
however,  in  favour  of  an  allowance  midway  between  extremes, 
namely,  about  100  grammes  a  day.  Both  in  man  and  animals  the 
most  active  and  successful  races  take  a  fair  quantity  of  protein 
food. 

As  examples  of  these  figures,  the  following  diets  may  be  quoted  : 

(1)  A  diet  taken  by  Chittenden  containing  about  50  grammes 
of  protein  :    Milk,  2|  oz.  ;    cream,  5  oz.  ;    sugar,  1  oz.  ;    biscuit, 
3  oz.  ;   bread,  2|  oz.  ;   butter,  ^  oz.  ;   meat  pie,  7|  oz. 

(2)  A  diet  containing  90  grammes  of  protein  :    Bread,  19  oz.  ; 
meat,  4  oz.  ;   potatoes,  8  oz.  ;   milk,  1  pint ;   butter.  1  oz.  ;    milk 
pudding,  4  oz.  ;   tea,  1  pint.     Total,  2,300  calories. 

(3)  A  diet  containing  130  grammes  of  protein:  Bread,  16  oz.  ; 
beef,   10  oz.  ;    potatoes,   16  oz.  ;    milk,   1  pint ;    butter,   1  oz.  ; 
oatmeal,  4  oz.  ;   sugar,  3  oz.    Total  3,500  calories. 

The  energy  required  for  muscular  work  is  not,  however,  supplied 
from  protein,  but  from  the  oxidation  of  non-nitrogenous  material, 


* 

The  Principles  of  Dietetics.  201 

which  may  be  derived  from  carbohydrate  or  fat.  When, 
therefore,  a  large  amount  of  muscular  work  has  to  be  done,  the 
bulk  of  the  energy  may  be  supplied  by  the  addition  of  these 
foodstuffs  to  the  diet.  But,  as  a  matter  of  fact,  those  doing 
severe  work  alwrays  take  care  to  add  considerably  to  the  protein 
of  their  food  as  well  as  to  the  carbohydrate  and  fat.  Horses 
can  do  more  work,  and  do  it  more  quickly,  on  beans,  which  are 
rich  in  protein,  than  on  hay.  Hence  it  is  probably  wise  to 
increase  the  protein  also  to  a  moderate  extent. 

(a)  A  large  excess  of  prot ein  should  be  avoided.  An  exclusive  diet 
of  protein  cannot  be  taken  for  long  without  causing  disturbances 
of  digestion.  Unless  fat  is  added  to  the  diet,  it  would  be  difficult 
to  take  and  digest  enough  to  supply  the  caloric  needs.  When  a 
mixed  diet  is  changed  to  a  protein  or'  to  a  protein  and  fat  diet, 
diacetic  acid  and  acetone  usually  occur  in  the  urine,  from  the 
incomplete  oxidation  of  fats  (see  article  on  Diabetes  ^ellitus). 
Some  races,  however,  exist  on  a  diet  of  protein  and  fat. 

(6)  Carbohydrate. — The  bulk  of  the  food  is  most  conveniently 
and  most  cheaply  made  up  of  carbohydrate  food.  In  an  average 
diet  containing  100  grammes  of  protein  of  a  caloric  value  of  410 
calories,  the  balance  of  2,000  to  2,500  calories  would  be  supplied 
by  carbohydrate  and  by  fat,  chiefly  the  former. 

(c)  Fat  has  the  advantage  that  it  is  a  more  concentrated  food 
than  carbohydrate,  since  weight  for  weight  it  supplies  more  than 
twice  as  much  energy  as  carbohydrate.  On  the  other  hand, 
there  is  a  definite  limit  to  the  amount  which  most  people  can 
stomach,  and  it  is  more  expensive  than  starchy  foods  ;  for  the 
latter  reason,  fat  is  commonly  deficient  in  the  dietary  of  the  very 
poor.  The  ideal  diet  should  contain  about  as  much  fat  as  protein, 
say  100  grammes  of  each,  the  remainder  of  the  energy  needs  being 
supplied  by  carbohydrate. 

An  average  diet  for  a  man  of  11  stone  would  contain  : 

Protein  .          .100  grammes       410  kilocalories 

Fat  .          .     100        „  930 

Carbohydrate          .     360        „  1,480 

2,«20 

This  gives  for  every  kilogramme  of  bodyweight  40  kilocalories 
of  energy  and  T4  gramme  of  protein.  It  is  contained  in  : 
Bread,  1  Ib.  ;  meat,  4  oz. ;  eggs,  4  oz.  (two  small  ones) ;  cheese, 
2  oz.  ;  potatoes,  1  Ib.  ;  butter  (or  other  fat),  2  oz.  ;  milk,  £  pint ; 
sugar,  \  oz.  ;  tea,  coffee. 


2O2  The  Principles  of  Dietetics. 

The  ordinary  diet  at  St.  George's  Hospital  for  an  average 
weight  of  9|  stone  is  :  Bread,  12  oz.  ;  meat,  6  oz.  ;  potatoes, 
|  Ib.  ;  butter,  1  oz.  ;  milk,  1£  pint  ;  sugar,  1  oz.  ;  milk  pudding, 
8  oz.  ;  soup,  1  pint. 

DIET  IN  CHILDHOOD. 

In  childhood  a  larger  amount  of  food  is  needed,  relatively  to 
the  bodyweight,  than  in  adult  life.  I  found,  for  instance,  that 
a  boy  of  four  weighing  2  stone  4  Ibs.  in  hospital  was  eating  food 
of  the  value  of  121  calories  per  kilogramme.  In  a  school  of  540 
boys,  of  an  average  weight  and  age  of  12|  years  and  5  stone  5  Ibs. 
respectively,  food  giving  94  calories  per  kilogramme  was  con- 
sumed. At  sixteen  years  of  age  a  child  will  often  eat  as  much  as 
a  man. 

The  diet  of  childhood  should  be  simple  but  varied,  consisting 
mainly ^}f  milk,  porridge,  bread,  puddings,  an  egg,  fresh  vegetables 
and  fruit,  jam,  butter,  dripping,  with  a  little  meat  or  fish  once  a 
day.  Fat  is  the  element  which  is  most  likely  to  be  deficient,  and 
should  be  supplied  in  the  form  of  butter,  dripping,  in  suet  puddings 
and  in  milk.  The  meals  should  be  three  in  number,  with  the 
addition  of  a  slice  of  bread-and-butter  and  some  milk  at  bedtime, 
and  must  be  eaten  slowly.  As  age  advances,  the  helping  of  meat 
or  fish  is  increased,  but  is  not  needed  more  than  once  a  day,  until 
the  child  is  eight  or  nine  years  old,  when  the  more  strenuous 
school  life  may  justify  the  addition  of  bacon  or  fish  to  the  break- 
fast fare.  Children  should  be  allowed  to  drink  freely  at  the  end 
of  the  meal,  and,  if  they  are  thirsty,  between  meals.  Milk  and 
water  may  be  just  flavoured  with  tea  or  coffee  if  desired  after  the 
age  of  five  years. 

DIET  IN  DISEASE. 

Acute  Fevers. — It  is  seldom  possible  to  supply  sufficient  food 
in  acute  fevers  to  maintain  the  full  nutrition  of  the  body.  It  is 
important,  however,  to  furnish  as  much  energy  as  possible  in  the 
food,  especially  in  protracted  fevers,  for  experimental  observations 
have  shown  that  when  plenty  of  suitable  food  is  supplied  collapse 
is  less  likely  to  occur,  convalescence  is  shorter,  and  the  loss  of 
nitrogen  saved  to  a  considerable  extent.  Water  should  be  given 
freely  in  all  fevers  to  replace  that  evaporated  from  the  skin,  and 
to  promote  diuresis  ;  even  very  large  quantities  improve  rather 
than  diminish  the  absorption  of  food. 

Typhoid  Fever. — In  this  disease  the  diet  is  of  special  import- 
ance. Milk  must  form  the  chief  food,  but  should  only  be  given  at 


The  Principles  of  Dietetics.  203 

regular  intervals.  The  taste  should  be  continually  varied  by  the 
addition  to  it  of  barley-water,  weak  tea  and  coffee.  To  make  up 
the  loss  of  nitrogen  from  the  toxic  breakdown  of  protein,  plasmon 
may  be  added  to  one  or  two  feeds  a  day.  As  soon  as  the  patient 
has  an  appetite  there  is  probably  nothing  but  advantage  in  supply- 
ing more  satisfying  food,  provided  that  it  is  of  a  nature  which  will 
be  of  a  fluid  or  semi- solid  consistence  when  it  reaches  the  diseased 
intestine.  Soups,  prepared  meals,  strained  gruels,  soft  eggs, 
minced  meat,  jelly,  blancmange,  biscuit  soaked  in  milk,  thin 
bread-and-butter,  and  sponge  cake  all  satisfy  this  requirement. 
Such  foods  should  be  allowed  in  small  quantities  at  first,  the 
digestion  and  the  temperature  being  carefully  watched.  Sugar 
may  also  be  given  freely,  dissolved  in  water  and  flavoured  with 
a  little  lemon-juice.  It  has  been  shown  that  sugar  can  save  the 
tissues  from  being  used  up  in  febrile  conditions  as  it  does  in 
health. 

Tuberculosis. — The  wasting  of  pulmonary  tuberculosis  is  due  to 
an  insufficient  appetite  and,  in  the  active  disease,  to  a  breakdown 
of  nitrogenous  tissues  by  the  bacterial  toxins,  as  in  other  infective 
diseases.  It  may  be  generally  stated  that  the  absorption  of  the 
plentiful  diet  prescribed  is  good.  According  to  the  work  of 
Mircoli  and  Soleri,  a  phthisical  patient  needs  a  diet  having  30  per 
cent,  more  heat  value  than  that  of  a  healthy  person  in  order  to 
put  on  weight.  The  protein  should  be  increased  in  at  least  the 
same  proportion.  Bardswell  and  Chapman  recommend  that 
this  should  be  maintained  until  the  weight  becomes  stationary  at  a 
few  pounds  above  the  usual  weight  of  the  individual ;  it  should 
then  be  somewhat  reduced  to  a  value  about  15  per  cent,  above 
that  of  the  physiological  diet,  and  kept  at  that  value  until  the 
disease  is  obsolete.  The  meals  should  not  be  bulky,  concentrated 
foods  being  used  ;  they  should  be  given  at  considerable  intervals, 
and  be  as  well  cooked  and  varied  as  possible.  The  following 
foods  formed  a  sample  diet :  Milk,  2|  pints  ;  bread,  6  oz.  ;  por- 
ridge, 4  oz.  ;  butter,  1|  oz.  ;  bacon  or  fish,  1  oz.  ;  meat,  6  oz.  ; 
pudding,  10  oz.  ;  vegetables. 

The  diet  must  not  be  increased  to  a  degree  which  will  set  up 
dyspepsia  and  loss  of  appetite. 

It  was  formerly  stated  that  an  excess  of  meat  had  a  beneficial 
effect,  but  it  appears  that  the  value  of  meat  lies  in  its  being  a 
concentrated  and  digestible  form  of  protein  food  rather  than  in 
the  possession  of  any  specific  property.  Bardswell  and  Chapman 
found  that  vegetable  protein  is  satisfactory  if  a  sufficient  amount 
is  taken,  but  a  meat-free  or  meat-poor  diet  must  only  be 


204  The  Principles  of  Dietetics. 

prescribed  for  patients  with  normal  appetites  and  digestions, 
owing  to  its  bulky  nature. 

The  following  (Bardswell,  "  Sutherland's  System  of  Diet  ")  is 
an  outline  of  a  dietary  for  a  well-to-do  consumptive  : 

Breakfast. — Two  breakfast-cups  of  milk  flavoured  with  coffee  ; 
four  pieces  of  toast  or  bread  with  butter  ;  one  egg  ;  a  helping  of 
bacon,  ham,  tongue  or  fish.  Porridge  with  milk  or  cream  may 
be  taken  in  place  of  half  the  toast  or  bread. 

11  a.m. — A  tumbler  of  milk. 

Lunch. — A  tumbler  of  milk  ;  a  helping  of  fish  or  entree  ;  a 
large  helping  of  meat ;  two  potatoes,  the  size  of  an  hen's  egg  ; 
green  vegetables,  as  desired  ;  half  a  thick  round  of  bread  with 
butter  ;  a  large  helping  of  milk  or  other  pudding,  stewed  fruit 
and  custard  or  creams,  etc. 

Tea. — Tea,  thin  bread-and-butter  and  cake,  etc. 

Dinner. — A  tumbler  of  milk  ;  soup  if  desired  ;  fish  or  entree  ; 
meat,  vegetables,  pudding,  bread  or  toast  and  butter,  as  at 
lunch  ;  savoury  or  cheese  and  dessert,  as  desired. 

Bedtime. — A  tumbler  of  milk. 

If  dinner  be  taken  in  the  middle  of  the  day,  cold  meats  will  be 
substituted  at  supper  time. 

The  following  is  an  example  of  an  economical  diet  for  poorer 
people,  which  Bardswell  and  Chapman  state  can  be  bought  for 
just  under  a  shilling  a  day  :  Milk,  24  oz.  ;  meat  (as  purchased), 
8|  oz.  ;  liver,  fish,  2  oz.  ;  butter,  1  oz.  ;  dripping,  |  oz.  ;  egg 
(one  per  week)  ;  cheese,  |  oz.  ;  bacon,  2  oz.  ;  bread,  9  oz.  ; 
potatoes,  8  oz.  ;  pulse,  3  oz.  ;  oatmeal,  2  oz.  ;  sugar,  5|  oz.  ; 
jam,  1  oz.  ;  rice,  |  oz.  ;  flour,  2  oz.  They  recommend  such  a 
diet  as  suitable  for  convalescent  consumptives  who  are  doing 
some  muscular  work. 

Nephritis. — (a)  In  acute  nephritis  there  may  be  an  almost  com- 
plete suppression  of  urine.  In  such  a  condition  it  is  eminently 
reasonable  to  give  no  protein  at  all.  The  body  will  then  break  down 
a  certain  small  proportion  of  its  own  protein  and  the  kidneys  will 
have  quite  enough  to  do  to  pass  out  the  disintegration  products 
of  this.  Adding  protein  increases  the  quantity  of  urea,  whereas, 
on  the  other  hand,  the  excretion  of  nitrogenous  bodies  can  be 
pushed  to  its  lowest  limits  by  a  liberal  allowance  of  fat  and 
carbohydrate  foods,  the  metabolism  of  which  do  not  throw  work 
on  the  kidney.  Hence,  while  the  urine  is  scanty,  the  following 
foods,  served  in  various  ways,  should  form  the  basis  of  the  diet : 
Arrowroot,  rice  with  added  dextrine  (v.  Noorden),  jam,  sugar, 
cream,  and  butter  ;  a  certain  amount  of  milk  may  also  be  given, 


The  Principles  of  Dietetics.  205 

but  the  less  the  better,  and  certainly  not  more  than  1  pint  in  the 
day,  as  milk  contains  a  good  proportion  of  protein.  Such  a  diet 
can,  of  course,  only  be  prescribed  for  a  few  days,  after  which  the 
diet  of  chronic  nephritis  should  be  given.  The  drinking  of  water 
in  acute  nephritis  does  not  usually  lead  to  diuresis  ;  enough 
should  be  allowed  to  satisfy  thirst,  but  not  more. 

(6)  In  sub-acute  and  chronic  nephritis  the  power  of  the  kidney 
to  excrete  nitrogen  is  impaired.  In  a  healthy  person,  if  extra 
protein  be  added  to  the  food,  the  corresponding  nitrogen  is  passed 
out  in  a  few  hours  ;  in  nephritis  it  may  not  all  appear  in  the  urine 
for  a  few  days  ;  there  is,  in  fact,  an  oscillation  of  excretion, 
normal  periods  alternating  with  periods  of  retention. 

It  is  clear  from  these  considerations  that  only  a  limited  amount 
of  protein  should  be  allowed  ;  experimental  observations  show 
that  this  should  be  about  60  to  70  grammes,  which  is  contained 
in  2 1  pints  of  milk.  Such  a  quantity  of  protein  does  not  usually 
impose  a  greater  strain  upon  the  kidney  than  it  is  able  to  bear, 
and  it  is  sufficient  for  an  individual  living  an  inactive  life.  On 
the  other  hand,  the  amount  of  protein  should  not  be  allowed  to 
fall  below  this  figure,  for  patients  with  nephritis  must,  like  other 
people,  be  supplied  with  a  sufficient  proportion.  The  following 
diet  (v.  Noorden)  contains  60  grammes  of  protein  and  2,900 
calories  :  Milk,  1|  pint ;  cream,  12  oz. ;  rice,  If  oz. ;  biscuit,  1|  oz. ; 
butter,  If  oz. ;  sugar,  1  oz.  It  may  be  ordered  after  the  diet  for 
acute  nephritis  given  above.  Many  patients  cannot  manage  so 
much  cream,  but  as  the  total  caloric  value  is  greater  than  that 
necessary  for  a  patient  in  bed,  the  full  amount  need  not  be 
insisted  upon. 

As  to  the  kind  of  protein  which  may  be  ordered  as  the  patient 
improves,  or  in  cases  of  granular  kidney,  careful  experiments 
have  shown  that  ordinary  simple  foods,  such  as  fish,  fowl,  veal, 
lamb,  mutton  and  beef,  do  not  injuriously  affect  the  albuminuria 
or  the  kidneys.  Beef  and  mutton  only  do  harm  when  given  in 
too  great  quantity  or  in  an  unsuitable  form.  The  following  diet 
contains  a  little  over  60  grammes  of  protein  and  furnishes  2,100 
calories  :  Milk,  If  pint ;  cream,  4  oz.  ;  potatoes,  8  oz.  ;  bread, 
12  oz.  ;  meat  or  fish,  4  oz.  ;  milk  pudding,  4  oz.  ;  butter,  3  oz. 

Boiled  meats  are  better  than  roast,  because  they  contain  less 
extractives.  No  highly  seasoned  and  indigestible  foods,  green  or 
pungent  vegetables,  salt  or  preserved  meats  or  fish,  or  strong 
cheeses  should  be  included  in  the  diet. 

The  following  scheme  of  diet  may  be  useful  : 

Breakfast. — Gruel  with  cream  ;  fat  bacon  or  fat  ham  in  plenty  ; 


206  The  Principles  of  Dietetics. 

bread  with  abundant  butter  ;  weak  tea,  coffee  with  cream  and 
milk. 

Midday. — Two  oz.  of  fish  with  melted  butter,  plenty  of  potato  ; 
bread,  biscuit  and  butter  ;  water  or  aerated  water. 

Tea. — Weak  tea  flavouring  milk  and  water.  Bread  or  toast 
and  butter,  jam,  cake. 

Dinner. — Strained  vegetable  soup  ;  2  oz.  of  meat  or  chicken, 
with  potato  ;  pudding  ;  stewed  fruit ;  water  or  aerated  water. 

Starchy  and  fatty  foods  may  be  allowed  freely. 

Eggs  do  not  increase  the  albumin  in  the  urine  when  eaten  with 
other  foods  in  a  mixed  diet.  An  egg  may,  therefore,  be  substi- 
tuted when  desired  for  an  equivalent  amount  of  protein  in  milk 
(7  oz.  of  milk)  or  meat  (1  oz.). 

Salt  should  be  limited,  for  in  many  cases  of  nephritis  the  urine 
does  not  excrete  it  so  freely  as  in  health.  This  is  another  reason 
for  restricting  the  amount  of  milk,  which  contains  1  gramme  to 
1  pint.  Ordinary  bread  contains  5  to  7  grammes  to  the  pound,  and 
should  be  baked  specially  without  salt.  If  this  is  done,  and  sea 
fish,  lentils,  and,  of  course,  salt  itself  are  excluded  both  at  table 
and  in  cooking,  the  diet  will  be  nearly  free  from  salt,  for  most  other 
articles  of  food,  for  instance,  flour  and  meals,  meat,  poultry,  one 
or  two  eggs,  tea  and  coffee,  contain  very  little. 

The  salt-free  dietary  is  most  useful  in  cases  with  oedema  :  it 
should  be  tried  for  a  week  or  two,  but  need  not  be  persisted  in 
strictly  if  no  improvement  follows.  In  all  cases  of  nephritis, 
however,  it  is  wise  to  prohibit  the  use  of  salt  at  meals. 

The  allowance  of  water  in  nephritis  should  vary  with  the  type 
of  disease.  When  oedema  is  present,  the  tissues  are  overloaded 
with  a  saline  solution  :  it  is  uncertain  in  any  given  case  whether 
the  cause  of  this  is  poisoning  of  the  capillary  walls,  inability  of 
the  kidney  to  excrete  water,  or  inability  to  excrete  salt.  In  some 
cases,  at  all  events,  inability  to  excrete  salt  appears  to  be  primary ; 
in  such,  a  salt-free  diet  with  a  free  supply  of  water  is  likely  to  help 
the  reduction  of  the  oedema,  because  such  salt  as  the  kidneys  can 
still  excrete  will  be  more  easily  passed  out  if  there  is  a  free  supply 
of  water.  In  parenchymatous  nephritis  it  is  a  good  plan  to  allow 
a  measured  amount  of  water,  adding  an  extra  |  pint  or  pint  on 
one  or  two  days.  If  the  quantity  of  urine  is  correspondingly 
increased  there  is  no  need  for  restriction  of  fluid  ;  if,  on  the  other 
hand,  oedema  is  increased,  the  urine  remaining  the  same,  a  smaller 
quantity  of  fluid  should  be  given. 

In  chronic  granular  kidney,  water  should  usually  be  allowed 
freely,  for  the  diuresis  of  this  disease  may  be  regarded  as 


The  Principles  of  Dietetics.  207 

advantageous  to  the  kidney,  less  work  being  involved  in  passing 
out  the  solids  of  the  urine  in  a  weak  solution  than  in  a  strong  one. 
There  is  no  evidence  that  the  cardio-vascular  changes  of  granular 
kidney  are  due  to  overwork  thrown  on  the  circulation  by  the 
passage  through  the  body  of  so  much  water,  as  v.  Noorden 
suggested,  for  in  diabetes,  where  much  greater  quantities  of  fluid 
are  dealt  with,  no  such  cardiac  hypertrophy  is  found. 

In  other  diseases  of  the  kidney  in  which  the  active  tissue  is 
reduced  in  quantity  the  diet  should  be  of  a  similar  nature  to  that 
recommended  in  chronic  nephritis. 

Calculous  Disease.— Renal  calculi  are  commonly  composed 
of  uric  acid,  calcium  oxalate  or  calcium  phosphate.  When  a  stone 
has  once  formed,  dietetic  treatment  is  not  likely  to  lead  to  its 
removal ;  but  when  a  stone  has  been  passed  or  removed,  and  when 
symptoms  of  renal  irritation  with  the  passage  of  gravel  are  present, 
the  food  should  be  adjusted  to  the  particular  condition  present. 

The  deposition  of  uric  acid  usually  takes  place  from  a  highly 
acid  urine.  The  diet  should  contain  but  little  purin  bases  (see 
diet  in  Gout)  and  plenty  of  vegetables.  It  is  doubtful  wisdom, 
however,  to  take  so  much  vegetables  that  the  urine  is  alkaline  in 
reaction,  as  phosphates  are  then  likely  to  be  deposited  upon  any 
particles  in  the  pelvis  of  the  kidney. 

If  the  calculus  is  formed  of  calcium  oxalate,  foods  rich  in  calcium 
and  those  which  give  rise  to  an  excess  of  oxalates  in  the  urine 
should  be  avoided.  The  bulk  of  the  diet  should  consist  of  bread, 
butter,  dripping,  potatoes,  with  meat  or  fish  at  two  meals  in  the 
day.  Of  fruits,  apples  may  be  taken  freely,  raw  or  cooked.  Eggs, 
milk,  alcohol  and  vegetables  should  be  taken  sparingly.  The 
following  articles  of  diet  should  be  avoided  altogether  :  Rice, 
rhubarb,  tomatoes,  radishes,  asparagus,  spinach  and  hard  water. 

Soft  water,  or,  if  that  is  not  available,  distilled  water,  which 
may  be  aerated  if  desired,  should  be  drunk  freely,  at  least  a 
tumblerful  being  taken  after  each  meal  in  addition  to  what  is 
drunk  during  the  meal.  Tea  and  coffee  are  allowed. 

The  urine  of  twenty-four  hours  should  be  measured  once  a  week, 
and  if  its  quantity  does  not  exceed  2  pints,  more  fluid  should  be 
taken. 

Gout. — The  food  should  be  free  from  purin  bases,  so  far  as  is 
compatible  with  the  proper  nourishment  of  the  patient.  If  meat 
is  entirely  excluded,  some  people,  though  not  all,  suffer  in  their 
general  health  from  the  change  to  an  unaccustomed  diet.  A 
purin-free  diet  may  be  constructed  from  bread,  butter,  milk,  eggs, 
cheese,  meals,  sugar,  jams,  sweets,  and  fruits,  and  is  to  be  advised 


2o8  The  Principles  of  Dietetics. 

during  attacks  of  acute  or  subacute  gout.  All  alcohol  should  be 
forbidden,  and  in  stout  persons  sweets  also  should  be  limited,  and 
in  others  with  whom  much  starchy  or  sweet  food  disagrees. 

Between  the  attacks  meat  need  not  be  excluded.  The  meals 
should  be  simple  and  the  food  thoroughly  and  slowly  masticated. 
Care  should  be  taken  not  to  eat  larger  meals  than  are  necessary 
to  satisfy  the  appetite,  and  to  avoid  any  food  which  experience 
has  shown  to  disagree.  One  meat  meal  a  day  is  sufficient, 
but  this  rule  does  not  exclude  the  use  of  bacon  at  breakfast.  The 
following  foods  may  be  allowed  :  Bread,  butter,  fish,  chicken, 
game,  meat,  fried  fat  bacon,  milk,  cheese,  nuts,  fruit,  spinach, 
cabbage,  French  beans,  salads,  simple  puddings,  and  sweets  ;  rice, 
tapioca,  sago,  and  floury  potatoes  in  moderation  only,  no  new 
potatoes.  It  is  better  to  avoid  the  following  :  Rich  meats,  soups, 
salted  fish,  lobster,  crab,  eels,  duck,  goose,  high  game,  cured  or 
pickled  meats,  and  meats  cooked  more  than  once,  the  roe  of  fish, 
rich  pastry  and  sweets,  rhubarb,  mushrooms,  and  beetroot. 

Two  or  three  pints  of  water  should  be  drunk  in  the  day,  either 
as  water  or  as  Imperial  drink,  or  still  lemonade  made  by  pouring 
boiling  water  on  lemons.  If  the  water  is  hard,  distilled  aerated 
water,  Malvern  or  Evian  water,  should  be  used.  If  alcoholic 
drinks  are  desired,  one  or  two  glasses  of  well-diluted  spirits  may 
be  taken  in  the  day,  or  a  glass  of  light  sherry.  It  is  essential  to 
take  regular  exercise,  short  of  fatigue. 

Diseases  of  the  Stomach  and  Intestines. — A  most  striking 
fact,  which  analyses  of  the  excreta  have  established,  is  that 
the  more  common  gastro-intestinal  disorders  have  but  little 
effect  upon  the  absorption  of  food.  When  nutrition  fails  it  is 
usually  because  appetite  is  wanting  ;  but  if  in  spite  of  this  food  is 
introduced  into  the  alimentary  canal  and  is  not  rejected  by 
vomiting  it  is  made  use  of.  Even  after  the  stomach  has  been 
excised  or  gastro-enterostomy  performed  no  marked  effect  upon 
assimilation  has  been  observed  in  animals  or  in  man,  except  that 
when  digestion  in  the  stomach  is  in  abeyance  undigested  connec- 
tive tissue  occurs  in  the  faeces  ;  in  such  conditions,  therefore,  the 
meat  should  be  well  cooked,  and  it  is  better  to  mince  it. 

In  the  treatment  of  dyspepsia  it  is  a  great  advantage  if  the 
diagnosis  of  the  kind  of  dyspepsia  has  been  confirmed  or  corrected 
by  a  microscopical  and  chemical  examination  of  the  gastric 
contents  after  a  test  meal.  As  a  general  rule,  dyspeptics  should 
avoid  potatoes,  pastry,  greens,  new  bread,  alcohol  and  tea  ;  they 
should  take  their  fluid  at  the  end  of  the  meal,  or  in  severe  cases 
an  hour  before  meals. 


The  Principles  of  Dietetics.  209 

In  hyper-secretion  meals  should  consist  of  solid  food  only, 
and  be  given  every  three  or  four  hours,  with  at  least  \  Ib. 
of  meat  at  chief  meals,  and  plenty  of  butter  and  other  forms  of 
fat,  with  a  moderate  allowance  of  starchy  foods.  Fluids  are 
drunk  an  hour  before  meals. 

In  chronic  gastric  catarrh  the  bulk  of  the  dietary  should  consist 
of  milk  with  cream,  butter  and  eggs.  Very  hot  and  very  cold  food 
or  drinks  should  be  avoided.  If  the  hydrochloric  acid  is  in  normal 
proportion  or  in  excess,  protein  may  be  taken  more  freely  in  such 
forms  as  eggs,  tender  chicken  or  mutton,  and  fish.  Meats  must 
be  minced  or  very  tender.  If  the  acid  is  diminished  or  absent, 
flavoured  soups  and  foods  may  be  given  to  arouse  a  secretion,  but 
no  peppers  or  irritating  spices. 

If,  in  the  absence  of  catarrh,  there  is  deficiency  of  secre- 
tion, spicy  foods  should  be  ordered  in  minced  or  semi-solid 
form. 

In  milder  cases  of  dyspepsia  with  some  deficiency  a  diet  such 
as  the  following  may  be  prescribed  : 

7  a.m. — -Glass  of  milk,  biscuit. 

Breakfast. — Toast,  butter,  ham  or  devilled  kidney,  lightly 
boiled  egg. 

Lunch. — One  tablespoon  of  meat  soup,  fish  or  chicken  cutlet, 
pigeon  or  game  or  mutton  or  undercut  of  beef,  omelette  or  milk 
pudding,  dry  toast,  spinach. 

Tea. — Milk  with  a  little  tea,  dry  cake  or  biscuit. 

Dinner. — As  lunch.  Stewed  apple,  fruit  'compote,  a  little 
sound  raw  fruit. 

Spicy  foods  and  condiments  are  ordered  to  be  taken,  especially  at 
the  beginning  of  the  meal.  The  following  foods  must  be  avoided  : 
Preserved  fish  or  meats,  sausages,  buttered  and  fried  eggs,  new 
bread,  hot  rolls,  buttered  toast,  entrees,  pies,  pork,  duck,  goose, 
any  stringy  greens,  potatoes  (except  a  little  as  puree),  suet 
puddings,  cheese  (except  in  very  small  quantity),  ices,  black 
coffee,  alcohol. 

Half  a  pint  of  water  or  aerated  water  should  be  drunk  an  hour 
before  each  meal.  No  fluid  to  be  taken  at  meal  times,  except  a 
cup  of  weak  tea  at  tea  time,  and  one  small  cup  of  coffee  made  with 
milk  at  breakfast  time.  The  patient  should  rest  half  an  hour 
before  and  after  each  meal. 

Motor  insufficiency  is  often  due  to  obstruction  at  the  pylorus, 
which  should,  if  possible,  be  treated  surgically.  The  meals  should 
be  small,  fluid  being  taken  between  and  not  at  them  and  restricted 
to  2  pints  a  day.  The  stomach  should  be  washed  out  regularly 

S.T. — VOL.  ii.  14 


2io  The  Principles  of  Dietetics. 

to  ensure  that  decomposing  material  does  not  remain.  Such  foods 
as  milk,  cream,  eggs,  minced  underdone  meat,  fish,  toast  or  dry 
bread,  and  butter  are  ordered. 

In  gastric  ulcer  the  patient  may  either  be  fed  by  means  of 
nutrient  enemas  followed  by  a  graduated  milk  diet  or  may  be 
given  a  protein  and  fat  diet  of  milk  and  egg  by  the  mouth  from 
the  beginning,  or  the  two  methods  may  be  combined. 

If  no  food  be  allowed  by  the  mouth  at  first,  the  following  enema 
may  be  ordered  three  times  in  the  twenty-four  hours  at  six- 
hourly  intervals,  to  be  given  slowly  from  a  funnel  (F.  D. 
Boyd)  : 

The  yolk  of  two  eggs,  1  oz.  of  pure  dextrose.  8  gr.  of  salt, 
peptonised  milk  to  10  oz. 

At  the  fourth  six-hourly  period  the  bowel  should  be  washed 
out  with  saline  solution.  In  well-nourished  women  the  nutrient 
enema  may  be  dispensed  with,  an  enema  of  normal  saline  solution 
being  given  three  times  a  day.  The  enemas  are  continued  for 
from  three  days  to  ten  days.  Milk  is  then  ordered  by  the  mouth 
in  2  oz.  doses  every  two  hours,  diluted  with  water,  barley-water 
or  lime-water  in  the  proportion  of  2  of  milk  to  1  of  the  diluent, 
the  enemas  being  discontinued. 

The  milk  is  then  increased  until  4  to  6  oz.  at  a  time  and  3  to 
4  pints  in  the  day  are  being  taken  ;  after  some  days  on  milk, 
additions  are  gradually  made  to  it,  beginning  with  arrowroot, 
bread  and  milk,  rusks  and  milk,  cornflour  or  Benger's  food,  and 
then  thin  bread  and  butter.  Later  eggs  are  allowed,  with  milk, 
soup  and  beef  tea  followed  by  fish  and  chicken.  The  time  taken 
in  passing  through  the  regime  will  vary  with  the  severity  of  the 
case  :  many  cases  reach  fish  and  chicken  in  three  weeks ;  in  others 
it  is  wise  to  make  the  period  six  weeks. 

On  the  Continent  this  plan  is  modified  as  follows  (v.  Leube)  : 
The  period  of  rectal  feeding  is  two  or  three  days  only,  then  for 
ten  days  boiled  milk,  soup  and  unsweetened  biscuits  are  allowed  ; 
for  the  next  seven  days  soups,  rice  and  sago  cooked  with  milk,  raw 
and  lightly  boiled  eggs,  boiled  calves'  brains  and  boiled  chicken  ; 
for  the  next  five  days,  minced  underdone  beefsteak,  potato  or 
rice  soup,  a  little  tea  or  coffee  ;  from  the  twenty-second  day  to 
the  twenty -eighth,  beef,  chicken,  pigeon,  macaroni  and  white  bread 
are  added. 

If  the  patient  is  fed  on  protein  and  fat  food  from  the  beginning 
(Lenhartz),  8  oz.  of  milk  and  one  egg  are  mixed  and  given  in 
teaspoon  sips  spread  over  the  first  day  ;  the  second  day  12  oz. 
of  milk  and  two  eggs  are  ordered,  and  4  oz.  of  milk  and  one 


The  Principles  of  Dietetics.  211 

egg  added  each  day  until  If  pints  of  milk  and  six  or  eight 
eggs  are  consumed  in  the  day.  From  the  third  to  the  eighth 
day  1  oz.  of  raw,  or  almost  raw,  minced  meat  is  added  in 
divided  doses,  either  with  the  egg  and  milk  or  alone,  and,  if 
well  borne,  increased  to  2  oz.  On  the  seventh  day  boiled  rice  is 
given,  followed  later  by  softened  bread  and  then  by  bread  and 
butter.  By  the  eighth  day  one  or  two  of  the  eggs  may  be  lightly 
boiled.  Meat  and  pounded  fish  are  now  gradually  substituted  for 
the  eggs  and  the  patient  led  to  an  ordinary  mixed  diet.  The  objects 
of  the  method  are  to  ensure  that  protein  shall  be  constantly  in  the 
stomach  in  the  first  few  days  to  neutralise  the  acid  of  the  gastric 
juice  and  prevent  it  from  digesting  the  surface  of  the  ulcer,  and 
to  lessen  the  flow  of  juice  by  the  inhibitory  effect  of  the  fat  in  the 
milk  and  in  the  yolk  of  egg. 

Each  of  these  dietetic  methods  has  given  good  results  when 
carefully  carried  out,  with  reasonable  modifications  to  suit  the 
individual  case.  Whichever  plan  be  adopted,  the  patient  should 
be  entirely  in  bed  and  should  remain  there  if  possible  for 
three  weeks  or  a  month.  The  diet  must  also  be  controlled 
for  at  least  three  months  afterwards,  as  relapses  are  liable  to 
occur. 

In  duodenal  ulcer  the  Lenhartzdiet  given  above  may  be  employed 
with  success,  but  in  patients  who  can  take  it  the  treatment  by 
olive  oil  (Cohnheim,  Walko)  is  to  be  recommended.  Half  an  ounce 
of  olive  oil  is  taken  every  three  hours,  and  increased  on  the  second 
day,  if  possible,  to  an  ounce.  Extreme  thirst  develops  in  two  or 
three  days  and  may  be  met  by  frequent  tablespoon  doses  of  water 
made  just  alkaline  with  bicarbonate  of  soda.  After  three  days  a 
graduated  diet  of  egg  and  milk  is  begun  as  in  gastric  ulcer,  the  oil 
being  continued  but  the  quantity  reduced  as  may  be  necessary. 
Even  when  the  patient  has  reached  a  full  diet  \  oz.  of  oil  should 
still  be  taken  half  an  hour  before  meals.  Oil  diminishes  the 
secretion  of  gastric  juice,  is  non-irritating  and  of  a  high  caloric 
value. 

In  ulcerative  colitis  an  entirely  fluid  bland  diet  consisting  chiefly 
of  milk  and  custard  is  given.  In  non-ulcerative  muco-membranous 
colitis  one  of  two  kinds  of  diet  is  commonly  ordered,  either 
nourishing,  non-irritating  food,  or  food  containing  much  cellu- 
lose. In  severe  cases  with  a  little  blood  with  the  membrane, 
in  which  ulceration  may  supervene,  a  milk  diet  like  the  early 
diet  of  gastric  ulcer  should  be  employed.  In  milder  cases  follow- 
ing obstinate  constipation  the  opposite  plan  is  often  successful. 
Bulky  and  irritating  foods  are  given  with  the  object  of  relieving 

14—2 


212  The  Principles  of  Dietetics. 

the  colitis  by  preventing  constipation.  The  following  is  a  suitable 
regime  for  such  a  case  : 

Before  Breakfast. — Half  a  pint  of  water. 

Breakfast. — Milk  half  a  pint,  bread,  butter,  honey,  one  egg  or 
fat  bacon,  one  baked  apple  or  fruit,  such  as  strawberries,  rasp- 
berries, pears,  according  to  season. 

Lunch. — Scrambled  eggs,  or  an  omelette  or  some  light  food, 
bread  or  toast,  butter  ;  a  moderate  helping  of  beetroot,  parsnips, 
cabbage,  turnips  or  French  beans  ;  half  a  pint  of  water. 

Tea. — Half  a  pint  of  freshly  made  tea  ;  bread  or  toast,  butter. 

Dinner. — Milk  soup  ;  fish  or  meat,  vegetables  as  at  lunch  ; 
apple  fritters  or  stewed  apples,  prunes  or  figs  ;  bread  or  toast, 
butter  ;  half  a  pint  of  water  or  still  fresh  lemonade. 

Brown  or  wholemeal  bread  is  to  be  preferred  and  must  not  be 
new.  Exercise  should  be  taken  daily. 

In  constipation  due  to  a  slow  passage  of  the  food  residues  along 
the  large  intestine,  owing  to  deficiency  of  bulk,  of  fluid  or  of 
irritative  constituents,  dietetic  treatment  is  of  great  value.  The 
following  foods  should  form  a  large  part  of  the  dietary  :  Brown 
bread,  gingerbread,  apples  (stewed  or  raw),  and  other  fruits, 
especially  stewed  prunes,  and  figs,  cooked  or  raw  ;  cabbage, 
sprouts,  spinach,  salads  ;  suet  pudding  with  golden  syrup  ;  butter, 
dripping  and  fatty  foods.  A  large  glass  of  water  should  be 
sipped  on  rising  and  plenty  of  water  or  still  lemonade  taken  with 
meals.  Tea  should  be  weak,  freshly  made,  and  not  taken  more 
than  once  a  day.  Jams  and  sweets  may  be  eaten  in  modera- 
tion. 

The  following  should  be  avoided  or  eaten  very  sparingly  :  New 
bread,  pastry,  eggs,  nuts,  milk  and  milk  puddings.  Cream  may 
be  taken  in  tea  or  coffee. 

In  Obesity  many  dietetic  cures  are  practised  and  are  suitable 
to  various  cases.  I  shall  confine  myself  here  to  simple  directions 
which,  if  carried  out  with  reasonable  care,  will  often  be  found 
effectual.  It  is  important  to  begin  by  small  restrictions  ;  if  too 
much  is  asked  of  the  patient  at  first  there  is  risk  that  all  effort 
will  be  abandoned. 

The  clothes  should  be  light  and  the  rooms  cool.  A  good 
amount  of  exercise  should  be  taken  every  day. 

The  following  foods  should  be  avoided :  Sugar,  potatoes, 
parsnips,  carrots,  turnips,  beetroot,  salmon,  turbot,  eels,  preserved 
herring  or  mackerel,  sardines,  cream  ;  pork,  beer,  wines  (except,  if 
desired,  a  little  claret  or  sherry). 

The  following  foods  may  be  eaten  freely  :   Eggs,  meat  and  fish 


The  Principles  of  Dietetics.  213 

(except   as   above    stated),    unsweetened    stewed    fruits,   green 
vegetables. 

Wholemeal  bread,  toast  and  rusks,  and  all  puddings  and  cakes 
made  with  flour  should  be  taken  in  great  moderation.  It  is  well 
to  ascertain  the  amount  of  bread  taken  each  day  by  weighing. 
No  fluid  should  be  drunk  at  meals  until  all  solid  food  has  been 
taken. 

E.  I.  SPRIGGS. 


214 


INFANT   FEEDING. 

THE  proper  food  of  the  infant  is  its  mother's  milk.  Should  the 
mother,  from  physical  or  moral  incapacity,  fail  to  feed  her  child, 
the  milk  of  the  cow,  modified  in  imitation  of  human  milk,  is  used. 

The  quantity  of  milk  which  the  child  needs  can  only  be  given 
in  average  figures,  for  it  varies  with  the  weight,  the  conformation, 
the  activity  and  the  age. 

A  heavy  child  will  naturally  require  more  food  than  a  light 
one.  The  effect  of  conformation  is  less  obvious,  but  not  less 
important ;  other  things  being  equal,  a  thin  child  needs  more  food 
than  a  fat  child,  because  its  surface  in  relation  to  its  weight  is 
so  much  greater.  The  greater  the  surface  relatively  to  the  weight, 
the  greater  the  loss  of  heat  and  the  more  food  required,  for  a 
large  part  of  the  energy  of  the  food  is  used  in  keeping  up  the  body 
heat.  The  plumper  a  child  is,  and  the  nearer  its  contours  approach 
the  spherical,  the  less  surface  it  has  as  compared  with  the  thin 
child,  with  hills  and  hollows  over  and  between  its  bones.  The 
non-conducting  layer  of  fat  beneath  the  skin  also  protects  the  plump 
infant  from  an  undue  loss  of  energy  in  the  form  of  heat. 

An  active  or  a  restless  infant  needs  more  food  than  a  placid  one, 
to  provide  energy  for  the  muscular  work  done.  Carbohydrate  is 
the  food  chiefly  used  by  the  muscles,  but  does  not  need  to  be 
increased  in  infancy  so  much  as  when  the  child  begins  to  run 
about. 

The  effect  of  age  on  the  food  requirements  of  the  baby  is  such 
that  whilst  the  older  the  child  is  the  more  it  needs,  yet  the  amount 
of  food  required  for  each  pound  of  body  weight  becomes  smaller. 
This  is  partly  because  the  baby's  surface,  as  compared  with  its 
weight,  gets  less  as  the  baby  grows  larger,  and  partly  because  the 
rate  of  growth  also  diminishes. 

The  energy  required  for  proper  growth  has  been  estimated  by 
weighing  a  child  before  and  after  it  has  been  put  to  the  breast 
during  the  early  months  of  life,  or,  in  hand-fed  children,  by 
measuring  the  cow's  milk  taken.  A  plump  child  should  receive  a 
minimum  of  about  100  calories  per  kilogramme  soon  after  birth ; 
this  is  furnished  by  2|  oz.  of  cow's  milk  for  each  pound  weight, 
or  a  pint  of  milk  a  day  for  a  child  of  9  Ib.  A  very  thin 
or  premature  child  may  require  125  to  150  calories,  or  3J  oz. 


Infant  Feeding.  215 

of  cow's  milk  to  the  pound.  At  six  months  of  age  the  average 
figure  sinks  to  80  or  even  70  calories  per  kilogramme  :  expressed 
in  quantities  of  milk,  80  calories  per  kilogramme  is  If  oz.  to 
each  pound.  A  healthy  hand-fed  infant  should,  therefore,  receive 
daily  from  1£  to  3-oz.  of  cow's  milk  for  every  pound  of  its  weight. 

Premature  infants  cannot  always  assimilate  the  amount  of  food 
necessary  to  maintain  their  body  heat,  especially  as  their  nervous 
mechanism  for  the  regulation  of  temperature  is  not  properly 
developed.  Loss  of  energy  in  the  form  of  heat  may  then  be 
prevented  by  keeping  the  baby  in  an  incubator  at  about  body 
temperature:  the  amount  of  food  required  will  now  be  less,  and 
may  fall  within  the  limit  of  what  can  be  digested. 

BREAST    FEEDING. 

Every  healthy  woman  ought  to  feed  her  own  child.  No  personal 
or  social  inconvenience,  nothing,  indeed,  but  the  necessity  of 
earning  wages,  should  prevent  the  fulfilment  of  this  duty  to  the 
child  and  to  the  nation.  The  modern  tendency  among  mothers 
of  all  classes  to  bring  up  babies  artificially  is  unfortunately 
pandered  to  by  some  medical  men,  who  have  perhaps  been 
misled  by  their  own  skill  in  prescribing  imitations  of  human 
milk.  But  any  doctor  who  is  accustomed  to  deal  with  the 
digestive  troubles  of  babies  of  all  classes  knows  that  the  great 
majority  of  infants  brought  for  consultation  are  being  hand-fed. 
In  other  words,  breast-fed  babies  seldom  need  the  doctor. 
Recent  observations  also  show  that  the  good  effects  of  breast  feeding 
are  continued  long  after  infancy  in  the  ultimate  development  of  the 
man  or  woman.  Monthly  nurses,  except  the  very  best,  are  often  to 
blame  in  this  matter.  They  do  not  follow  the  babies  after  the  first 
month  of  life,  and  they  take  a  great  pleasure  in  giving  them  food 
out  of  a  bottle.  The  mother,  with  very  likely  the  best  will  in  the 
world  to  feed  her  baby,  is  obliged  to  listen  to  the  nurse's  statements 
that  the  baby  is  hungry  every  time  it  cries,  and,  impressed  by  the 
relation  of  former  "  cases,"  she  becomes  convinced  before  long  that 
she  cannot  feed  it.  Bottle  feeding  is  then  begun,  with  the  result 
that  the  nurse  gets  a  quiet  month,  whilst  'the  unconscious  victim, 
the  baby,  has  to  run  the  risk  of  digestive  troubles  later  on. 

The  infant  needs  but  little  food  in  the  first  day  or  two,  until  the 
breasts  have  begun  to  secrete.  It  should  be  put  to  the  breast  four 
times  on  the  first  day  and  six  times  on  the  second.  A  little  boiled 
water,  sweetened  with  sugar,  should  be  given  out  of  a  spoon  in 
between.  During  the  first  month  the  baby  should  be  fed  every  two 
hours  during  the  daytime.  Between  nine  at  night  and  seven  in 


216  Infant  Feeding. 

the  morning  it  should  be  allowed  to  sleep  as  long  as  it  will,  being 
fed  twice  in  the  night  wrhen  it  wakes.  The  breasts  should  be  used 
alternately.  The  nipples  should  be  cleansed  after  nursing  with 
warm  boric  acid  lotion  and  dried.  The  baby  should  not  be  allowed 
to  take  the  milk  too  quickly  or  to  remain  longer  than  a  quarter  of 
an  hour  or  twenty  minutes  at  the  breast.  The  baby  must  not  be 
fed  when  it  cries,  but  only  at  the  proper  hours.  It  may  cry  from 
cold,  from  heat,  from  the  discomfort  of  a  wet  napkin,  of  tight  clothes, 
or  the  scratch  of  a  pin,  or  from  an  uncomfortable  position,  from 
the  boredom  of  its  cot,  and  want  of  a  little  nursing,  from  wind  or 
colic,  from  hunger  or  thirst.  If,  after  investigation,  the  baby  is 
thought  to  be  hungry  or  thirsty,  and  the  time  for  food  has  not 
arrived,  then  £  oz.  of  boiled  sugar  water,  or  plain  boiled 
water,  may  be  given  from  a  teaspoon,  and  will  often  make  it 
content. 

In  the  second  and  third  months  the  infant  should  be  put  to  the 
breast  every  two  and  a  half  hours  in  the  daytime,  and  after  the 
third  month  every  three  hours.  By  this  time  the  baby  will 
probably  only  want  feeding  once  in  the  night ;  after  the  age  of 
five  or  six  months  it  should  sleep  without  a  feed  from  ten  at  night 
to  seven  in  the  morning.  It  is  important  to  keep  the  intervals 
between  the  feeds  both  in  the  day  and  night,  not  only  because  the 
digestion  of  the  child  must  not  be  overworked,  but  also  because  the 
breasts  of  the  mother  must  be  allowed  time  to  produce  a  proper 
supply  of  milk  between  the  feeds.  Especially  are  the  long  night 
intervals  valuable ;  if  the  mother  gets  good  sleep  she  will  usually 
have  a  sufficient  supply  of  milk. 

In  judging  of  the  adequacy  of  the  mother's  milk  the  chief  points 
to  be  attended  to  are  the  weight  and  condition  of  the  baby.  A  baby 
may  seem  dissatisfied  at  the  end  of  its  feeds  and  in  want  of  more 
milk,  and  yet  be  in  good  health  and  put  on  weight  regularly.  It  is 
a  good  and  not  a  bad  sign  for  such  a  child  to  be  hungry ;  it  may 
object  to  leaving  the  breast,  but  will  be  comfortable  in  a  few 
minutes  when  it  has  brought  .the  wind  up.  The  actual  amount  of 
milk  taken  at  each  feed,  as  ascertained  by  weighing  the  baby  on 
delicate  scales  before  and  after  it  is  put  to  the  breast,  should  be 
about  2  oz.  at  the  end  of  the  first  month,  3  oz.  in  the  third  month, 
and  4  oz.  in  the  fourth.  Amounts  above  and  below  these  figures 
are,  however,  compatible  with  health. 

If  there  is  no  doubt  that  the  milk  is  scanty  and  the  baby's  weight 
diminishes  for  more  than  a  week  (excluding  the  first  week  in 
which  a  loss  of  weight  is  natural),  or  is  stationary,  then  steps 
must  be  taken  to  improve  the  supply.  The  food  of  the  mother 


Infant  Feeding.  217 

must  be  abundant  and  contain  a  good  proportion  of  meat  and  fat. 
Nitrogenous  food  is  more  efficient  than  fat  in  increasing  the  fat  of 
the  milk.  In  all  but  the  poorest  homes  we  may  assume  that 
enough  food  of  good  quality  is  available.  We  then  have  to  see  that 
the  mother  has  appetite  and  leisure  for  her  meals,  sufficient  rest, 
fresh  air  and  suitable  exercise.  Of  these  I  put  rest  first.  If  the 
mother  lies  down  on  a  couch  for  half  an  hour  before  and  after  her 
meals  and  takes  a  sleep  in  the  afternoon  the  quantity  of  milk 
becomes  greater  at  once.  A  moderate  walk  out-of-doors  in  the 
middle  of  the  morning  is  also  of  great  value,  and  a  short  walk  or  drive 
in  the  late  afternoon.  Such  measures  are  sometimes  as  much 
needed  by  stout  healthy  women  as  by  delicate  ones.  Strong 
emotions,  such  as  anger  and  sorrow,  are  prejudicial  to  a  proper 
supply  of  milk.  >If  the  child  does  not  suck  strongly,  light 
massage  of  the  breasts  for  ten  minutes  three  times  a  day  may 
stimulate  the  flow.  In  anaemic  mothers  an  iron  pill  should  be 
ordered  two  or  three  times  a  day. 

The  opinion  that  benefit  follows  the  addition  of  some  alcoholic 
drink  to  the  diet  of  the  nursing  mother  does  not  appear  to  be 
confirmed  by  the  careful  observations  of  late  years.  The  alcohol 
itself  is  of  doubtful  value,  especially  in  those  unused  to  it.  But 
some  beverages  containing  alcohol  may  be  useful,  if  by  improving 
the  appetite  they  help  the  mother  to  make  a  good  meal.  For 
this  purpose  a  light  bitter  ale  or  stout  is  allowed,  or  a  glass  of  wine 
if  the  mother  is  accustomed  to  take  it.  Strong  tea  or  coffee  is 
best  avoided. 

Sometimes  the  milk  is  too  rich  :  the  baby  suffers  from  pains 
and  undue  sickness  ;  curds  and  many  small  yellow  particles  of  fat  are 
observed  in  the  stools.  An  analysis  of  the  milk  drawn  off  shows 
that  it  contains  more  than  about  1£  or  2  per  cent,  of  protein  and 
4  per  cent,  of  fat.  The  mother  should  then  be  allowed  rather  less 
meat,  no  alcoholic  beverages,  and  should  take  more  exercise.  A 
tablespoonful  of  lime-water  may  be  given  to  the  baby  before  each 
feed  to  dilute  the  milk.  A  little  regurgitation  of  milk  after  a  feed 
is  natural  to  many  infants  and  need  not  be  treated. 

The  progress  of  the  baby  must  be  estimated  from  its  general 
condition,  increase  in  weight,  capacity  for  sleep  and  the  state  of 
the  motions.  An  infant  growing  well  will  put  on  3  or  4  oz.  a 
week.  Common  troubles  are  flatulence  with  colic,  and  consti- 
pation. Flatulence  is  often  due  to  the  child  taking  the  milk  too 
quickly,  or  being  allowed  to  drop  to  sleep  before  the  wind  is  brought 
up  after  feeding.  If  it  persists  when  these  points  have  been 
attended  to,  it  will  usually  be  relieved  by  a  mild  carminative, 


218  Infant  Feeding. 

such  as  a  teaspoonful  of  dill  water.  The  most  important  measure 
for  constipation  is  to  have  the  baby  held  out  at  the  same  hour 
every  day  in  order  that  a  proper  habit  may  be  formed.  If  no 
motion  is  passed,  a  stimulus  may  be  applied  by  inserting  a  piece 
of  soap,  but  this  should  only  be  done  after  the  infant  has  made 
unsuccessful  muscular  efforts.  If  the  motions  are  hard,  water 
should  be  given  two  or  three  times  a  day  between  the  feeds,  or, 
if  this  fails,  a  teaspoonful  of  olive  oil  once  or  twice  a  day  mixed 
with  milk  and  sugar. 

If,  in  spite  of  all  care  and  precautions,  the  baby  does  not  steadily 
increase  in  weight,  then  the  mother's  milk  must  be  supplemented 
by  one  or  two  feeds  a  day  of  modified  cow's  milk.  This  change 
should  not  be  made  hurriedly,  or  until  careful  trial  has  proved  that 
the  mother  is  unable  to  give  the  child  enough  food,  as  shown  by  the 
scales,  for  the  baby  fed  on  the  breast  alone  is  usually  immune  from 
the  severer  forms  of  indigestion  and  from  many  of  the  infectious 
diseases  which  are  so  dangerous  in  infancy.  Slight  illness  of  the 
mother,  even  if  accompanied  by  fever,  does  not  make  it  necessary 
to  give  up  breast  feeding  ;  neither  does  the  appearance  of 
menstruation.  The  condition  of  the  child  must  be  the  guide.  In 
any  prolonged  illness,  such  as  enteric  fever,  the  child  must,  of 
course,  be  weaned.  Neither  should  mothers  who  are  more  than 
three  months  pregnant  or  are  the  subjects  of  constitutional  disease, 
such  as  tuberculosis,  nurse  their  babies. 

If  it  is  decided  to  supplement  the  breast  milk,  the  bottle  may  be 
given  in  the  afternoon,  about  four  o'clock  :  this  allows  the  mother 
a  longer  interval  to  provide  a  natural  feed  for  the  baby  when  it 
goes  to  bed.  If  a  second  bottle  is  needed,  it  should  be  given  for  the 
last  feed  at  night  at  about  ten  o'clock.  A  full  meal  at  that  hour 
ensures  the  mother's  rest  during  the  first  hours  of  the  night :  she 
will  then  have  a  good  supply  for  the  baby  when  it  wakes  up.  When 
a  third  bottle  is  needed,  it  is  given  in  the  middle  of  the  morning. 
The  milk  in  the  bottle  should  be  prepared  by  the  directions  given 
below  (p.  222),  according  to  the  age  of  the  baby.  It  should  always 
be  sterilised. 

WEANING. 

The  child  should  be  weaned  gradually  at  about  the  age  of  nine 
months.  In  a  hungry,  dissatisfied  baby  the  bottle  may  be  begun 
at  six  or  seven  months  in  addition  to  breast  milk.  The  feed  will 
be  prepared  according  to  the  table  on  p.  223,  the  bottles  being 
increased  in  number  as  the  mother's  milk  diminishes.  At  nine 
months  a  little  starchy  food  may  be  added,  with  gravy  or  meat 


Infant  Feeding.  219 

juice.  If  for  any  reason  it  is  necessary  to  wean  suddenly, 
or,  indeed,  when  any  change  from  one  food  to  another  is 
made,  the  bottle  feeds  should  he  fairly  dilute  at  first ;  the 
strength  is  then  gradually  raised  to  that  suitable  to  the  age  and 
development  of  the  baby.  It  is  unwise  to  wean  a  child  during  very 
hot  weather,  because  cow's  milk  is  then  especially  liable  to  be 
contaminated. 

Wet-Nursing. — If  a  mother  can  give  her  child  no  milk  at  all,  the 
best  substitute  is  the  milk  of  a  wet-nurse,  who  should  be  a  young 
adult  free  from  suspicion  of  tuberculosis  or  syphilis,  shown  to  be 
healthy  by  a  thorough  medical  examination,  not  nervous  or 
anaemic.  She  should  have  a  good  supply  of  milk,  her  own  child 
being  well  nourished  ;  according  to  Holt,  it  is  not  essential  that  her 
child  should  be  of  the  same  age  as  the  infant  to  be  nursed,  except 
that  if  the  latter  is  only  two  or  three  weeks  old,  her  child  should 
not  be  more  than  about  six  weeks  old.  If  the  infant  is  six  weeks 
old,  a  wet-nurse  "  whose  milk  is  anywhere  between  one  and  five 
months  old  will  usually  answer  perfectly  well."  Wet-nursing  is 
not  justifiable  if  the  infant  to  be  nursed  is  suspected  of  syphilis. 

FEEDING    WITH   COW'S   MILK. 

The  only  practicable  substitute  for  mother's  milk  in  most  cases 
is  the  milk  of  the  cow.  The  composition  of  cow's  milk  is  similar 
to,  though  far  from  identical  with,  human  milk.  It  is  often, 
moreover,  exposed  in  transmission  to  contamination,  which  may 
render  it  a  dangerous  food  for  children.  It  is  to  be  hoped  that  in 
the  near  future  the  State  will  take  over  the  duty  of  ensuring  a  pure 
milk  supply,  for  experience  has  shown  that  private  enterprise 
cannot  be  relied  upon.  Until,  however,  medical  officers  of  health  have 
greater  control  than  at  present,  it  must  remain  the  duty  of  the  family 
practitioner,  acting  with  the  parents,  to  ascertain  so  far  as  possible 
that  the  milk  is  derived  from  sound  cattle  and  is  protected  from 
infection.  The  dairy  must  be  clean,  and  all  working  in  it  healthy. 
The  cows  should  be  groomed  as  horses  are  groomed,  and  milked  in 
a  stall  devoid  of  litter  ;  the  udder  of  the  cow  and  the  hands  of  the 
milker  must  be  cleaned  before  milking,  and  the  milk  received  in 
vessels  sterilised  with  steam.  As  soon  as  drawn  it  should  be 
covered  over  and  artificially  cooled. 

Cow's  milk,  as  delivered,  is  usually  an  acid  fluid,  unless  alkali 
has  been  added  to  it,  whereas  mother's  milk  is  amphoteric  or 
alkaline.  Cow's  milk  contains  millions  of  bacteria,  mother's  milk 
being  sterile,  or  nearly  so.  Many  of  the  bacteria  are  not  known  to 
be  pathogenic,  but  they  are  associated  with  putrefactive  processes 


22O  Infant  Feeding. 

which  may  be  very  harmful  in  the  child's  intestine.  Not  infrequently, 
however,  the  germs  of  disease,  especially  of  tuberculosis,  enteric 
fever,  scarlet  fever  and  diphtheria,  are  conveyed  by  milk. 

Sterilisation  of  Milk. — The  greatest  care  must  be  taken  to 
prevent  the  bacteria  with  which  cowr's  milk  swarms  from  harming 
the  infant.  Their  growth  can  be  prevented  to  a  great  extent  by 
keeping  the  milk  cold.  The  living  bacteria  in  milk  may  be  killed 
by  boiling  or  by  pasteurisation. 

It  follows  that  milk  should  be  as  fresh  as  possible,  should  be 
artificially  cooled  directly  it  is  drawn,  and  kept  cold  both  in 
transmission  and  in  the  home  until  it  is  used,  and  should  be 
sterilised.  This  counsel  of  perfection,  however,  cannot  always  be 
followed,  for  various  reasons.  Eeally  fresh  milk  is  unobtainable  in 
towns,  where  delivery  is  not  made  until  the  milk  is  twelve  hours 
old.  The  second  precaution,  that  of  keeping  the  milk  cold,  can  and 
ought  to  be  taken.  In  the  home,  vessels  containing  milk  should  be 
stood  in  cold  water,  or  in  summer  upon  ice.  This  applies  to  milk 
which  has  been  boiled  or  pasteurised  just  as  much  as  to  fresh  milk. 
If  milk  is  boiled  directly  it  reaches  the  house,  strained  and  cooled, 
the  fear  of  infection  through  the  milk  is  reduced  to  a  minimum. 
Boiled  milk  has  not,  however,  quite  the  pleasant  taste  of  fresh  milk, 
and  children  fed  upon  it  entirely  may  develop  scurvy.  Pasteurisa- 
tion consists  in  heating  the  milk  in  a  double  saucepan,  or  in  a  special 
apparatus,  to  150°  to  160°  F.,  and  keeping  it  at  that  temperature 
for  twenty  minutes.  It  should  then  be  covered  and  cooled.  Nearly 
all  living  bacteria  are  destroyed  and  the  taste  is  not  altered  so 
much  as  by  boiling.  It  is  claimed  that  pasteurised  milk  does  not 
produce  scurvy,  and,  if  this  is  so,  it  is  certainly  always  to  be  recom- 
mended. There  is,  however,  still  some  doubt  on  the  matter.  If  the 
child  is  obtaining  any  milk  from  the  breast,  all  cow's  milk  should  be 
boiled,  as  the  mother's  milk  will  protect  it  from  the  danger  of 
scurvy.  For  this  additional  reason  it  is  advisable  to  keep  on  breast 
feeding  as  long  as  possible.  In  children  fed  entirely  upon  cow's 
milk  the  advice  differs  according  to  the  circumstances.  In  cleanly 
homes,  when  the  source  of  the  milk  is  known  to  be  safe,  as  in  many 
country  houses,  I  recommend  that  a  feed  should  be  given  from  the 
fresh  milk  immediately  it  is  brought  in,  the  remainder  being  boiled. 
In  poorer  homes  and  where  the  source  of  the  milk  is  uncertain  it  is 
safer  to  boil  all  milk  directly  it  reaches  the  house.  A  watch  will  be 
kept  upon  the  health  of  the  children,  and  a  little  orange  juice  or 
raw  meat  juice  given  two  or  three  times  a  week  to  prevent  scurvy. 

In  all  cases  the  milk  is  warmed  to  body  temperature  before  it  is 
taken  by  the  infant. 


Infant  Feeding.  221 

Attention  must  be  paid  to  the  bottle,  which  should  be  of  a  form 
in  which  the  teat  is  directly  attached  to  the  neck.  The  bottle  and 
teat  should  be  washed  after  each  feed,  and  the  bottle  boiled  in  a 
saucepan  once  a  day.  Between  the  feeds  both  the  bottle  and  teat 
must  be  kept  in  clean  cold  water. 

COMPOSITION. 

The  milk  of  individual  cows  varies  greatly,  but  the  mixed  milk 
from  a  herd  should  give  the  following  composition  (the  figures  for 
woman's  milk  are  placed  below  for  comparison)  : 


Protein. 

Fat. 

Milk  Sugar. 

Cow's  milk 

3-5 

4-0 

4-5 

Woman's  milk 

1-5 

4-0       • 

7-0 

These  figures  show  that  cow's  milk  contains  more  than  twice  the 
protein  and  about  two-thirds  of  the  sugar  of  mother's  milk.  The 
average  amount  of  fat  is  the  same.  Further,  cow's  milk  contains 
three  times  the  salts  and  six  times  the  calcium,  but  only  one-half 
the  iron  of  human  milk. 

The  protein  of  cow's  milk  is  nearly  all  caseinogen,  whilst  in 
mother's  milk  more  than  half  of  it  is  lactalbumin,  which  does  not  clot 
in  the  stomach.  Many  infants  find  it  difficult  to  digest  the  casein- 
ogen of  cow's  milk,  not  only  because  of  its  greater  quantity,  but 
also  because  the  clots  of  casein,  which  are  formed  from  it  in  the 
stomach,  are  harder  and  larger  than  those  of  the  casein  of  mother's 
milk.  The  formation  of  hard  clots  may  be  modified  by  dilution, 
especially  with  lime-water  or  soda-water,  or  by  thickening  with 
arrowroot  or  cornflour.  Barley-water  renders  the  clot  a  little  softer, 
in  virtue  of  the  starch  which  it  contains.  Lime-water,  with  or 
without  ordinary  water,  is  the  most  useful  diluent  to  use  for 
infants. 

Cow's  milk  may  be  given  in  various  forms,  which  will  be 
considered  under  the  following  headings :  (1)  Whole  milk ; 
(2)  Diluted  milk ;  (3)  Milk  diluted  and  modified  by  adding  sugar 
and  fat ;  (4)  "  Top  milk,"  diluted  and  modified  by  adding  lactose  and 
lime-water;  (5)  Citrated  milk ;  (6)  Eredigested  milk ;  (7)  Whey  and 
cream. 

(1)  Whole  Milk. — No  argument  is  needed  to  show  that  the 
infant's  stomach  may  acquire  the  power  of  digesting  milk  which 
differs  considerably  from  that  natural  to  it,  for  innumerable 
children  have  been  brought  up  on  unmodified  cow's  milk  in  the 


222 


Infant  Feeding. 


past.  Professor  Budin  has  been  a  modern  advocate  of  the  use 
of  sterilised  whole  milk  for  hand-fed  babies.  The  method  has 
the  advantage  over  methods  of  dilution  that  a  smaller  bulk  of  milk 
suffices  to  furnish  the  food  value  which  the  child  needs.  Unfortu- 
nately, a  great  many  infants  at  the  present  day  are  unable  to  digest 
cow's  milk  properly  unless  it  is  modified. 

(2)  Diluted  Milk. — The  dilution  of  cow's  milk  approximates  the 
strength  of  protein  to  that  in  human  milk,  and  renders  the  clot 
more  friable.  The  milk  is  consequently  more  digestible.  Since  the 
protein  of  cow's  milk,  consisting  chiefly  of  caseinogen,  is  less  easily 
dissolved  than  that  of  human  milk,  of  which,  as  we  have  seen 
above,  lactalbumin  forms  the  major  part,  it  is  sometimes  necessary 
in  young  infants  to  carry  the  dilution  to  such  a  degree  that  the 
percentage  of  protein  is  even  less  than  in  human  milk.  When  we 
turn  from  the  protein  to  the  other  constituents  of  milk  the  effects 
of  dilution  are  seen  to  be  far  from  beneficial.  The  fat  and  sugar 
are  brought  to  a  strength  far  below  that  in  human  milk,  and  the 
heat  value  of  the  milk  is  lessened  in  proportion  to  the  dilution.  In 
short,  we  must  beware  lest  in  making  the  food  digestible  we  starve 
the  baby.  The  dilutions  which  experience  has  shown  that  most 
infants  can  digest  are  one  of  milk  to  three  of  water  in  the  first 
month,  one  to  two  in  the  second  and  third  months,  half  and  half  in 
the  fourth,  two  of  milk  to  one  of  water  in  the  fifth  and  sixth,  and 
three  to  one  after  the  sixth  month.  If  we  take  the  average 
weight  of  a  child  in  the  first  months  of  infancy  we  can,  knowing 
the  average  number  of  calories  per  unit  of  weight  required  at  those 
ages,  calculate  how  much  whole  milk  the  baby  should  receive  at 
each  month.  These  figures  are  placed  in  a  column  below,  and  are 
compared  with  the  amount  of  diluted  milk  required  to  supply  the 
the  needs  of  the  child : 


(1) 

(2) 

(3) 

(4)                     (5) 

(6) 

(7) 

Month. 

Oz.  of 
Whole  Milk 
Required. 

Dilution 
Commonly 
Recommended. 

Oz.  of  Diluted 
Milk  Necessary. 

Amount  of 
Feed  Suitable 
to  Age. 

1 

18 

1—3 

72  =  10  feeds  of 

7  oz. 

2        oz. 

2 

21 

1—2 

62=    9 

7 

3—4 

3 

24 

1—2 

72  =    8 

9 

4—5 

4 

27 

1—1 

52=    7 

7* 

6 

5  and  6 

29 

2—1 

43=    7 

6 

6 

7,  8,  and  9 

m 

3—  I 

43  =    6 

7 

8 

Column  2  gives  the  average  amount  of  whole  milk  required  at  the 
various  ages,  and  columns  7  and  5  the  quantities  at  a  feed  and  the 
number  of  feeds  suitable  to  the  age,  as  established  by  experience. 


Infant  Feeding. 


223 


Columns  4  and  6  show  in  a  striking  manner  that  if  enough  milk  is 
to  be  supplied  with  such  dilutions,  the  amount  taken  at  each  feed 
must  be  far  in  excess  of  what  an  average  baby  can  manage  in  the 
first  four  months.  At  the  fifth  month  the  dilution  is  less  and  the 
capacity  of  the  baby  greater. 

We  may  conclude  that  the  simple  dilution  of  milk  is  not  likely 
to  provide  enough  food  for  the  baby  until  the  age  is  reached  at 
which  a  strength  of  two  parts  of  milk  to  one  of  water  can  be  given 
in  feeds  of  6  oz.  at  a  time. 

(3)  Milk  Diluted  and  Modified  by  Adding  Sugar  and  Fat. — 
The  diluted  milk  may  be  made  stronger  in  sugar  and  fat  by  the 
addition  of  these  foodstuffs.  The  sugar  and  the  fat  of  milk,  namely, 
lactose  and  cream,  are  easily  obtainable.  Cream  as  sold,  however, 
cannot  be  looked  upon  .as  a  desirable  food  for  a  baby,  because  it  has 
been  kept  longer  than  milk,  and  generally  contains  either  enormous 
numbers  of  bacteria  or  an  excess  of  some  preservative.  "  Centri- 
fugal "  cream  is  less  objectionable,  though  the  best  way  to  provide 
a  larger  amount  of  fat  is  by  the  use  of  "  top  milk,"  as  described  in 
the  next  section.  But  it  is  useless  to  recommend  any  method  of 
preparing  milk  which  needs  time  and  care  for  poor  homes  with  busy 
and  perhaps  ignorant  mothers.  For  these  it  is  better  to  adopt  the 
less  perfect  but  simpler  plan.  To  this  end  the  dilution  mentioned 
above  should  be  advised,  with  the  addition  of  a  dessertspoonful  of 
milk  sugar  and  a  dessertspoonful  of  cream  to  each  bottle.  In  the 
poorest  homes,  instead  of  cream,  half  a  teaspoonful  of  cod-liver  oil 
should  be  used.  The  prescriptions  will  then  be  written  according 
to  the  following  table  : 


Amount  of 

Alilk 

Water 

Oz. 

1st  month    . 

1 

3 

9—10 

l*-2 

'2nd  and  3rd  months 

1 

2 

8 

4 

4th  month   . 

1 

1 

7 

6 

5th  and  6th  months 

2 

1 

6 

8 

7th  to  9th  mouths 

3 

1 

5 

8 

9th  to  12th  months 

7 

1 

5 

8 

To  each  feed  will  be  added  one  dessertspoonful  of  milk  sugar  and 
a  small  teaspoonful,  or  half  a  larger  teaspoonful,  of  cod-liver  oil. 
Further,  in  each  feed  one  tablespoonful  of  lime-water  should  replace 
an  equivalent  quantity  of  the  water  used  for  dilution.  For  instance, 
if  4  oz.  of  water  are  to  be  added  to  2  oz.  of  milk,  the  4  oz.  will  be 
made  of  3J  oz.  of  water  and  ^  oz.  of  lime-water. 


224 


Infant  Feeding. 


(4)  "  Top  Milk  "  Diluted  and  Modified  by  Adding  Lactose.— 
In  all  homes  where  care  and  cleanliness  may  be  expected,  the  milk 
should  be  prepared  so  that  it  may  resemble  as  closely  as  possible 
the  mother's  milk,  in  composition,  in  total  heat  value,  and  in 
digestibility.  The  chief  difficulty  in  preparing  imitations  of  human 
milk  is  to  obtain  a  product  rich  enough  in  fat  to  bear  the  dilution 
which  the  amount  and  character  of  the  protein  in  cow's  milk 
renders  necessary.  Objection  has  already  been  made  to  the  use  of 
commercial  cream.  But  if  the  new  milk  be  allowed  to  stand  in  a 
cool  place,  the  upper  layers  become  rich  in  cream  and  may  be  used 
to  prepare  the  feeds.  If  milk  has  been  standing  for  four  hours,  the 
upper  third  of  it  will  contain  on  the  average  10  per  cent,  of  fat,  the 
upper  half  7  per  cent.  From  this  "  top  milk  "  milk  of  any  com- 
position within  the  limits  required  may  be  obtained  by  the  addition 
of  suitable  quantities  of  lactose  and  water.  The  method  is  some- 
times known  as  the  "  percentage  "  method,  because  of -the  ease  with 
which  the  percentage  of  the  fat,  protein  and  sugar  can  be  varied  : 
we  are  indebted  to  Eotch,  of  the  United  States,  for  its  elaboration. 
A  milk  suitable  to  the  age  of  the  infant  may  be  made  as  follows : 

Top  milk  is  prepared  by  allowing  new  milk  to  stand  in  a  cool 
place,  as  above  mentioned.  The  top  milk  must  not  be  poured  off  the 
lower  milk,  but  taken  off  by  a  cup  or  dipper.  To  prepare  food  for 
infants  up  to  the  age  of  three  months  the  top  third  is  used ;  from 
the  fourth  to  the  ninth  month  the  top  half.  Of  this  milk  a  quantity 
depending  upon  the  age  and  development  of  the  baby  is  taken, 
according  to  the  table  below.  To  that  quantity  1  oz.  of  lime-water 
and  1  oz.  of  milk  sugar  is  added,  and  the  whole  then  made  up  to 
1  pint  with  water.  The  number  of  feeds  and  the  amount  to  be  given 
at  each  feed  are  shown  in  the  table,  as  are  the  percentages  of 
protein,  carbohydrate  and  fat  which  the  product  contains : 


(1)                                      (2) 
Month.                               Oz. 

1  (3) 
No.  of 
Feeds. 

(4) 
Amount  of 
Peed. 

(5)                    (6)                   (7) 
Percentages  of 
Protein.            Pat.          Carbohyd. 

1       \  Top  Milk  (  2 

10 

\\  —  3  oz. 

•3 

1-0 

5'5 

2        -     (upper     <  6 

9 

3—4 

1-0 

3-0 

6-0 

3       )     third)     (7 

8 

3—5 

1-2 

3-5 

6-5 

4  ,  „  }  Top  Milk  (  I 
o  and  6  f     ,  F            ]  8  —  9 

7 
7 

4—5 
5—6 

1-2 
1-5 

2-5 
3-0 

6-5 
6-8 

7  and  8  j    ^Pff?r    j  10—11 

7 

6—7 

1-8 

3-7 

7-0 

9       /                    \  12 

6 

7—8 

2-0 

4-0 

7-0 

Mother's  inirk  contains     . 

1-5 

4-0 

7-0 

Full  cow's  milk  contains  . 

3-5 

4-0 

4-5 

Infant  Feeding.  225 

Take  the  quantity  of  milk  given  in  column  2,  add  1  oz.  of  milk 
sugar  dissolved  in  water,  1  oz.  of  lime-water,  and  water  to  1  pint. 
Order  feeds  according  to  columns  3  and  4. 

The  night  feeds  in  the  early  months  will  be  given  as  described 
above  under  Breast  Feeding. 

A  consideration  of  columns  5,  6  and  7  shows  that  in  this  scheme, 
which  is  adapted  from  Holt's  "  Diseases  of  Infancy  and  Childhood," 
the  percentage  of  fat  is  very  low  at  first,  as  the  newly-born  infant 
may  not  digest  the  fat  of  cow's  milk  well,  but  is  rapidly  raised,  and 
kept  at  3  per  cent,  and  above  for  the  second  and  third  months.  The 
protein  is  increased  much  more  gradually,  and  its  percentage  does 
not  reach  that  of  mother's  milk  until  the  fifth  month.  The  pro- 
portion of  sugar  is  kept  high  throughout.  The  above  outline  will 
be  found  to  work  well  in  practice.  If  the  infant  seems  hungry  and 
is  doing  well,  the  strength  should  be  gradually  increased  throughout 
by  using  more  of  the  top  milk ;  for  instance,  the  2  oz.  mentioned  in 
the  first  month  should  be  gradually  changed  to  the  6  oz.  of  the 
second.  Increases  in  the  quantity  given  at  a  feed  should  be 
made  alternately  with  changes  in  the  strength  until  a  total 
amount  in  the  day  of  If  pints  to  2  pints  is  reached,  after  which 
the  strength  should  be  increased  and  not  the  quantity.  An  altera- 
tion should  not  be  made  on  account  of  slight  and  passing 
disturbances  of  digestion  ;  but  when  made  it  should  be  persisted  in 
for  a  few  days,  even  if  the  weight  is  stationary,  in  order  that  the 
infant  may  become  accustomed  to  it.  The  physician  will  not 
follow  the  table  blindly,  but  will  be  guided  in  prescribing  the  food 
by  the  condition  of  the  child  as  well  as  its  age.  He  will  pay  special 
attention  to  whether  it  is  comfortable  or  restless  when  awake,  to  its 
sleep,  and  to  the  stools. 

If  the  baby  must  be  fed  artificially  in  the  first  week  of  life, 
peptonised  milk  or  whey  should  be  used. 

(5)  Citrated  Milk. — It  has  long  been  known  that  the  clotting  of 
milk  is  prevented  by  the  precipitation  of  its  calcium.  Sir  Almroth 
Wright  suggested  the  use  of  sodium  citrate  for  this  purpose.  The 
milk  may  be  diluted  as  well  (Poynton),  or  whole  milk  may  be  used 
(Langmead).  The  curd  of  milk  to  which  citrate  of  sodium  has 
been  added  (in  the  proportion  of  2  gr.  to  1  oz.)  is  soft  and  flocculent. 
The  advantage  of  this  modification  is  obvious,  for  it  is  the  tough 
curd  of  cow's  milk  which  otters  the  chief  difficulty  to  the  digestive 
powers  of  the  infant.  Another  advantage  is  that  infants  can  often 
take  citrated  milk  whole,  and  thus  are  more  likely  to  get  enough 
food  than  when  diluted  milk  is  used.  A  third  advantage,  and  by 
no  means  the  least,  is  the  simplicity  of  the  preparation.  Hence  the 

S.T. — VOL.  ii.  16 


226  Infant  Feeding. 

method  is  of  especial  value  for  infants  of  weak  digestion  living  in 
poor  homes. 

A  solution  of  the  sodium  citrate  is  prepared  of  the  strength  of  20  gr. 
to  1  drachm  of  water.  The  milk  is  brought  to  the  boil  and  1  drachm  of 
the  solution  added  to  each  ^  pint  of  milk.  The  amount  of  the  feed 
must  be  judged  by  the  weight  and  condition  of  the  child  ;  if  the 
milk  is  undiluted  it  will  not  need  to  be  great,  and,  especially  in 
ill-nourished  children,  may  be  less  than  the  quantities  in  column  7 
of  the  table  on  p.  222.  The  baby  may  be  thirsty,  and  should  be 
given  warm  water  from  a  teaspoon  between  the  feeds.  I  have  used 
this  method  with  success.  If  the  whole  milk  gives  rise  to 
indigestion  it  should  be  diluted  ;  but  it  is  not  necessary  to  add  so 
much  water  as  when  citrate  of  sodium  is  not  used.  Dr.  Lang- 
mead  saw  no  untoward  results  in  150  cases  with  the  proportion  of 
sodium  citrate  mentioned  above.  Distress  after  food  may  be 
relieved  by  the  addition  of  1  grain  of  bicarbonate  of  soda  to  1  oz. 
of  milk.  Citrated  milk  should  not  be  employed  in  the  first  three 
weeks  of  life ;  in  the  fifth  month  the  citrate  should  be  gradually 
lessened,  and  at  the  sixth  month  omitted. 

(6)   Predigested  Milk. — The  difficulty  which  the  infant  finds  in 
dissolving  the  coagulated  protein  of  cow's  milk  may  be  got  over  by 
partially  digesting  the  milk  beforehand  with  pancreatic  ferment. 
For  this  purpose  one-third  of  its  bulk  of  water  is  added  to  the  milk, 
so   that    1    pint  then   consists    of   f   pint  of    milk    and    £    pint 
of  water.     Peptogenic  powder  is  put  into  the  milk  in  the  quantity 
mentioned  in  the  manufacturer's  directions,  the  vessel  placed  in 
hot  water,  and  the  temperature  raised  to  104°  F.  and  kept  there 
for  twenty  minutes.     The  milk  is  then  brought  to  the  boil  to  arrest 
the  action  of  the  ferment.     It  is   probably  better,  .though    more 
laborious,  to  prepare  each  feed  separately,  in  which  case  the  milk 
need  not  be  boiled,  but  may  be  given  at  once,  the  ferment  action 
going  on  for  some  time  in  the  stomach.     The  terms  peptonised 
milk  or  predigested  milk  are  not  strictly  accurate  when  applied  to 
milk  which  has  been  digested  for  twenty  minutes,  for  only  a  par- 
tial conversion  to  albumose  or  peptone  takes  place  in  that  time. 
Albumoses  have  a  bitter  taste,  and,  if  they  are  formed  in  quantity, 
the  child  may  refuse  the   milk  at  first,  though  it  soon  becomes 
accustomed  to  it.     Peptonised  milk  need  not  be  used  for  healthy 
children,  except,  perhaps,  in  the  first  week  or  two  of  life  ;  in  such  a 
case  the  period  of  peptonisation  should  be  made  shorter  and  shorter 
until  the  process  is  omitted.      The  prolonged  use  of  predigested 
food  may  be  expected  to  lead  to  a  weak  digestion.     In  digestive 
disorders  and  in  malnutrition  peptonised  milk  is  a  valuable  food. 


Infant  Feeding. 


227 


(7)  Whey  and  Cream. — In  the  first  few  days  whey  is  sometimes 
given  alone,  though  its  food  value  is,  of  course,  low,  less  than  a  third 
of  that  of  milk.  In  the  later  life  of  a  healthy  infant  whey  will  not 
be  needed.  But  if  cow's  milk,  even  when  modified,  is  associated 
with  vomiting,  and  poor  nutrition,  and  there  are  abundant  curds  in 
the  stools,  it  is  often  a  good  plan  to  avoid  giving  any  caseinogen 
at  all  for  a  few  days,  and  to  give  only  whey  and  cream.  A  mixture 
of  these  may  be  made  of  considerable  nutritive  value,  as  the  sub- 
joined table  (from  Holt)  shows.  The  cream  used  is  gravity  cream 
of  medium  thickness,  containing  20  per  cent,  of  fat : 


Fat. 

Whey  19  parts  : 

Cream  1  part  gives 

1-0 

1-8 

4-9 

„      15       „ 

,,       1     ,,         ,, 

1-0 

2-2 

4-9 

9 

1      ,, 

1-1 

2-8 

4-9 

7 

1     ,, 

1-2 

3-3 

4-8 

o       „ 

„       1     ,, 

1-2 

4-0 

4-8 

The  protein  in  these  mixtures,  consisting  of  lactalbumin,  is  low, 
but  not  lower  than  in  the  humanised  milk  for  the  first  month  or 
two  mentioned  on  p.  224.  The  fat  increases  rapidly  as  the  cream 
is  added.  The  amount  of  each  feed  should  be  rather  larger  than 
the  amount  of  milk  recommended  on  p.  228,  column  4. 

PREPARED    FOODS. 

Many  prepared  foods  for  infants  are  placed  upon  the  market. 
They  are  more  expensive  than  milk  when  the  food  value  of  the  two 
is  compared ;  that  is  to  say,  no  artificial  fluid  roughly  corresponding 
in  heat  value  and  composition  to  human  milk  can  be  prepared  so 
cheaply  as  by  the  use  of  fresh  cow's  milk  and  milk  sugar.  The  high 
relative  cost  of  infant  foods  is  largely  due  to  the  huge  sums  which 
the  manufacturers  spend  on  advertising,  all  of  which  the  consumer 
pays.  We  may  consider  such  foods  under  the  headings  of  (1)  Con- 
densed milk ;  (2)  Dried  milk ;  (3)  Foods,  added  to  fresh  milk, 
which,  when  prepared,  contain  no  starch  ;  (4)  Floury  foods. 

It  is  beyond  the  scope  of  this  article  to  describe  all  the  better- 
known  foods  ;  I  shall,  therefore,  confine  myself  to  a  few  remarks  on 
each  group.  The  statements  made  about  the  various  brands  are 
founded  mainly  upon  the  analyses  quoted  in  Cautley's  article  on 
Patent  and  Proprietary  Foods  in  Sutherland's  "  System  of  Diet 
and  Dietetics,"  and  in  Hutchison's  "  Food  and  the  Principles  of 
Dietetics." 

(1)  Condensed   Milk. — Genuine  condensed  milk  should  be  made 

15—2 


228  Infant  Feeding. 

from  good  fresh  milk  and  have  nothing  added  to  it.  Unsweetened 
condensed  milks  are  sold  under  the  names  Ideal,  First  Swiss,  Viking, 
and  Hollandia.  The  last-named  is  relatively  poor  in  fat.  When 
preparing  these  milks  for  infants  they  should  first  he  diluted  to  the 
strength  of  cow's  milk,  then  further  diluted  according  to  the  age  of 
the  child  with  the  addition  of  cream  and  sugar,  in  the  same  way  as 
cow's  milk  is  treated  to  make  it  comparable  to  human  milk. 

Many  condensed  milks  have  cane  sugar  added,  which  acts  as  a 
preservative.  They  have  the  disadvantage,  when  used  for  infants, 
that  they  are  too  sweet  to  take  unless  diluted  to  such  a  degree  that 
the  protein  and  fat  are  much  reduced.  Well-known  brands,  such  as 
Nestle's,  Milkmaid,  Rose,  Full  Weight  and  Anglo-Swiss,  contain  five 
times  as  much  sugar  as  they  do  fat,  the  protein  being  a  little  less  than 
the  fat.  The  Peacock  brand  contains  less  cane  sugar,  and  is,  there- 
fore, intermediate  between  the  unsweetened  and  sweetened  brands. 

(2)  Dried  Milk. — Various  brands  of  desiccated  milk  can  be 
obtained.  The  milk  is  passed  over  hot  rollers,  wrhich  drive  off  the 
water,  leaving  a  sterile  powder.  "  Full  cream  "  and  "  half  cream  " 
brands  are  supplied.  When  mixed  with  water  a  fluid  is  obtained 
with  a  biscuit-like,  boiled-milk  taste,  by  no  means  unpleasant.  The 
fat  tends  to  separate  out  in  globules  and  float  to  the  top  of  the  fluid. 
Glaxo  and  Lac  Vituni  are  the  names  of  two  brands.  The  Tru-milk 
brand  is  made  by  concentrating  the  milk  at  a  reduced  pressure,  and 
then  spraying  it  into  a  vacuum  chamber ;  by  this  means  the 
remaining  moisture  is  evaporated  and  the  solids  fall  like  snow  on 
the  floor.  I  have  used  dried  whole  milk  with  success  for  severe  cases 
of  malnutrition  in  hospital  practice,  especially  in  hot  weather.  It 
has  the  nutritive  properties  of  condensed  unsweetened  milk,  with 
the  advantage  that  it  does  not  go  bad  so  quickly  after  a  tin  is 
opened ;  it  is  also  lighter  for  travelling.  As  a  regular  food  for  healthy 
infants,  it  is  inferior  to  food  prepared  from  fresh  milk,  but  may  be 
recommended  when  good  milk  cannot  be  obtained.  The  various 
forms  of  dried  caseinogen  separated  from  the  sugar  and  fat  of  milk, 
such  as  Plasmon,  are  not  suitable  for  infant  feeding.  Allenbury  No.  1 
is  made  from  dried  milk,  modified  to  contain  less  protein  and  more 
fat  and  sugar ;  it  is  nearer  the  composition  of  human  milk  than 
plain  dried  milk,  but  is  still  deficient  in  fat  and  protein.  This  may 
be  an  advantage  in  digestive  disorders.  The  food  is  useful  as  a 
temporary  expedient  in  disease  occurring  in  the  early  months. 

Certain  infant  foods  consist  of  dried  or  condensed  milk  to  which 
inverted  starch,  that  is,  dextrin  and  maltose,  has  been  added.  Such 
are  Allenbury  No.  2  and  Horlick's  Malted  Milk. 

In  hot  weather,  when  good  milk  is  not  obtainable,  and  in  the 


Infant  Feeding.  229 

digestive  disorders  of  infancy  condensed  or  dried  milks  are  of  great 
value.  They  have  the  advantage  of  not  forming  a  hard  clot  of 
casein  in  the  stomach  as  cow's  milk  does.  Children  take  them  well, 
hut  to  form  a  suitable  food  for  young  infants  they  require  to  be 
modified  as  above  mentioned  by  the  dilution  and  addition  of  sugar 
and  fat.  The  risk  of  scurvy  must  be  met  by  the  use  of  fruit  or 
meat  juice.  Of  the  condensed  milks  the  unsweetened  brands  are 
to  be  preferred.  The  sweetened  brands  of  condensed  milk,  when 
used  as  the  regular  diet,  are  harmful  to  the  proper  development  of 
the  child  on  account  of  the  great  deficiency  of  protein  and  fat  and 
the  excess  of  sugar.  The  child  may  become  fat,  but  will  be  flabby, 
anaemic,  inactive,  and  prone  to  bronchitis,  intestinal  disorders  and 
rickets.  Many  condensed  milks  are  made  from  skim  milk ;  these 
are  still  more  unsuitable  for  infants. 

(3)  Foods  which  when  Prepared  Contain  no  Starch. — These 
contain   flour,  which    is   either   inverted  by  the  manufacturer  or 
becomes  so   during  the  preparation  by  the  action  of   a  ferment, 
usually  maltose.     Such  are  Mellin's  Food,  Paget's  Malted  Farina, 
Diastased    Farina,    Cheltine    Maltose   Food,   Hovis   No.    1    Food. 
Benger's  Food  is  wheat-flour  and  pancreatic  extract ;  when  mixed 
with  warm  milk  the  starch  is  inverted.    These  are  wholesome  foods, 
but  are  not  suitable  for  the  regular  diet  of  infants  on  account  of 
their  excess  of  carbohydrate  and  deficiency  in  fat. 

(4)  Floury  Foods. — These  are  foods  made  with  starch  which  is 
either  incompletely  inverted  to  maltose  or  is  not  changed  at  all. 

In  the  following  the  starch  is  partly  inverted :  Carnrick's  Soluble 
Food,  Nestle's  Milk  Food,  Manhu  Infant  Food,  Milo  Food,  Savory 
and  Moore's  Food  (starch  nearly  all  inverted),  Allenbury  No.  3, 
Coombs'  Malted  Flour,  Theinhardt's  Infantina  and  Hygiama,  Chel- 
tine Infant's  Food,  Hovis  No.  2  Food,  Albany  Food,  Worth's  Perfect 
Food,  John  Bull  No.  2  Food,  and  Nutroa  Food.  The  last-named 
contains  much  more  fat  than  the  others,  though  far  less  than  in 
cow's  or  human  milk. 

In  the  following  there  is  little  or  no  pre-digestion  of  starch :  Eidge's, 
Neave's,  Frame  Food,  Anglo-Swiss,  Franco- Swiss  and  American- 
Swiss  Foods,  Opmus,  Falona,  Albany,  Imperial  Granum,  Robinson's 
Groats,  Robinson's  Patent  Barley,  Chapman's  Whole  Flour,  Scott's 
Oat  Flour,  Nichol's  Food  of  Health,  Triticumina  Food,  "  I.  and  I." 
Food,  Muffler's  Food. 

Floury  foods  are  in  no  case  suitable  for  infants  under  seven 
months  ;  further,  even  for  older  children  most  of  them  merely 
supply  that  element  of  the  food  which  is  cheapest  and  which  the 
child  has  least  difficulty  in  obtaining,  namely,  carbohydrate.  For 


230  Infant  Feeding. 

children  able  to  take  starch  in  any  quantity,  rusks,  rice-flour,  bread 
pap  or  bread-and-butter  are  more  convenient  and  equally  nutritious 
additions  to  the  milk.  When  advertising  and  manufacturing 
expenses  are  taken  into  account  it  is  probably  not  worth  any  manu- 
facturer's while  to  sell  a  food  containing  protein  and  fat  in  the 
proportions  required,  except  perhaps  dried  milk,  for  the  price  would 
be  so  high  that  even  ignorant  parents  would  see  that  they  could 
feed  their  children  more  cheaply  on  milk,  cream  or  cod-liver  oil, 
rice  or  wheat  flours,  bread,  butter  and  meat,  according  to  their 
age. 

MODIFICATIONS    OF    DIET   IN    SIMPLE    DIGESTIVE   DISORDERS. 

The  treatment  of  gastro-enteritis,  marasmus  and  other  diseases 
of  infancy  will  be  found  described  under  the  appropriate  headings. 
I  shall  here  only  refer  briefly  to  modifications  of  the  diet  which  are 
called  for  in  the  treatment  of  slight  disorders  of  digestion  in 
infancy. 

In  all  digestive  disorders  the  first  care  must  be  to  see  that  the 
meals  are  given  at  the  proper  hours,  in  the  proper  quantities,  and 
at  the  right  temperature ;  feeding  at  irregular  times,  because,  for 
instance,  the  baby  cries,  is  a  frequent  cause  of  disorder.  Alterations 
of  the  diet  should  not  be  made  without  due  thought.  A  child  may 
be  fretful  and  uncomfortable  from  many  other  causes  besides 
unsuitable  food,  especially  from  want  of  fresh  air,  of  proper 
exercise  and  rest,  or  of  entertainment,  from  incipient  disease  of 
any  kind,  and  from  want  of  cleanliness.  If  it  is  decided  to  change 
the  food  it  is  well  to  make  a  definite  change,  not  a  slight  one. 

Vomiting. — Many  babies  regurgitate  a  little  food  after  a  meal 
and  are  none  the  worse.  Others  are  sick  soon  after  a  meal  because 
the  ritual  designed  to  "  bring  up  the  wind  "  is  not  properly  performed, 
or  because  they  are  not  kept  quiet  after  feeding,  or  their  clothes  are 
too  tight.  Or  the  food  may  be  taken  too  quickly  because  the  per- 
foration in  the  teat  is  too  wide.  If  vomiting  persists  after  these 
points  have  been  attended  to,  the  amount  of  the  feed  should  be 
lessened  until  a  quantity  is  reached  that  is  retained ;  the  baby 
should  then  be  given  this  quantity  for  a  time,  after  which  a  gradual 
increase  may  be  made.  The  interval  between  the  feeds  may  also  be 
lengthened.  Constipation,  if  present,  must  be  corrected.  If  large 
curds  are  vomited  the  amount  of  protein  should  be  reduced  by  the 
use  of  the  table  on  p.  224.  This  will  usually  be  successful ;  if  it  is 
not,  a  good  plan  is  to  peptonise  the  milk  for  a  few  days ;  if  this 
fails,  a  milk  should  be  prepared  from  an  unsweetened  condensed  or 
dried  milk,  and  used  with  the  addition  of  lactose  and  cream  or 


Infant  Feeding.  231 

cod-liver  oil.  If  reducing  the  curd  does  not  arrest  the  vomiting,  a  food 
poor  in  fat,  such  as  diluted  peptonised  cow's  milk  without  any  addi- 
tion of  cream,  should  be  ordered.  As  a  rule  a  weaker  milk  than  that 
which  has  been  taken  should  be  prescribed  in  digestive  disorders. 
In  severe  vomiting  it  is  well  to  take  the  child  off  milk  entirely  for  a 
day  or  two,  supplying  whey  and  cream,  or  whey  alone,  or  albumen- 
water,  and,  if  necessary,  washing  out  the  stomach  with  a  1  per  cent, 
solution  of  sodium  bicarbonate. 

The  treatment  of  vomiting  with  diarrhoea  is  described  in  a  special 
article. 

If  there  are  flatulence  and  colic  with  stools  containing  curds 
the  feeds  must  be  given  with  the  strictest  regularity,  the  quantity 
being  not  too  great ;  the  protein  in  the  milk  may  be  reduced, 
or  the  clot  softened  by  adding  barley-water  or  gelatine,  or  by 
peptonising.  The  addition  of  a  little  alkali,  such  as  bicarbonate 
of  soda  (1  or  2  gr.  to  1  oz.),  is  often  beneficial,  or  a  teaspoonful  of 
dill  water  may  be  given  after,  or  a  tablespoonful  of  lime-water 
before  the  feed.  If  these  measures  are  not  successful  the  use  of 
modified  dried  milk  or  condensed  milk  or  Allenbury  No.  1  food  may 
give  relief,  but  should  not  be  resorted  to  unless  the  child  is  losing 
weight,  and  if  used  should  be  gradually  replaced  by  fresh  modified 
milk  in  the  course  of  two  or  three  weeks.  Whenever  the  infant's 
food  is  changed  there  may  be  a  slight  loss  of  weight  for  the  first  few 
days  of  the  new  diet,  to  which  too  much  attention  need  not  be  paid. 
The  giving  of  starchy  foods  to  infants  is  a  frequent  cause  of 
flatulence  and  pain. 

Loose  green  stools  without  large  curds  may  be  due  to  an  excess  of 
fat  or  sugar,  and  should  be  treated  by  modifying  the  milk  in  these 
respects.  Very  large  and  light-coloured  stools  of  a  bad  odour  are 
associated  with  an  excess  of  fat.  If  mucus  is  present  in  the  stools, 
a  dose  of  castor  oil  should  be  given  before  any  alteration  is  made  in 
the  diet. 

Constipation  is  commoner  in  hand-fed  than  in  breast-fed  infants. 
It  is  treated  by  allowing  water  between  the  feeds  and  massaging  the 
colon  along  its  course  just  before  the  hour  at  which  a  motion  should 
l>e  passed.  The  fat  of  the  milk  may  be  increased,  or  1  drachm  of 
olive  oil  mixed  with  milk  and  sugar  given  once  or  twice  a  day.  In 
older  infants  the  addition  of  a  teaspoonf ul  of  ground  oatmeal  or  of 
some  farinaceous  food  to  each  bottle  is  often  effectual. 

DIET    IN    LATER    INFANCY. 

At  the  seventh  or  eighth  month  the  milk  should  be  thickened 
with  well-boiled  oatmeal  or  barley  gruel  (one  tablespoonful  of  the 


232  Infant  Feeding. 

meal  to  1  pint  of  water),  or  one  of  the  prepared  farinaceous  foods, 
the  milk  and  sugar  being  correspondingly  reduced ;  the  addition 
should  not  be  made  to  every  feed,  but  only  two  or  three  times  in  the 
day.  As  soon  as  a  tooth  appears  the  baby  may  be  allowed  to  bite 
at  a  crust  occasionally,  so  that  when  the  time  comes  it  will  not 
refuse  solid  food.  After  the  ninth  month  whole  milk  will  be  taken 
with  the  addition  of  a  tablespoonful  of  lime-water  to  each  bottle. 
At  twelve  months  the  lime-water  may  be  omitted.  At  about  the 
tenth  month  a  dessertspoonful  of  raw  meat  juice  is  added  to  the 
bottle  and  a  little  orange  juice  given  every  morning.  The  next 
step  will  be  to  allow  bread  and  milk  at  one  meal ;  after  that  a  little 
gravy  and  bread-crumb  at  the  midday  meal,  followed  later  by 
some  milk  pudding ;  then  come  bread-and-butter  and  a  lightly 
boiled  egg,  the  infant  being  gradually  introduced  to  the  diet  of 
childhood  (p.  202).  The  child  will  now  drink  water  at  dinner,  but 
milk  at  other  meals. 

E.  I.  SPRIGGS. 


233 


FOOD    FEVER. 

FOOD  fever  is  a  name  given  to  a  derangement  which  is  far  from 
uncommon  in  growing  boys  and  girls.  It  begins  with  an  attack 
of  acute  indigestion,  accompanied  by  fever  ;  but  at  the  end  of  the 
attack,  when  the  temperature  .falls  and  convalescence  may  be 
expected  to  begin,  the  temperature  instead  of  remaining  at  the 
level  of  health  is  curiously  unsettled  and  subject  to  sudden  rises. 
In  the  morning  it  is  normal  or  even  below  the  normal  standard, 
but  later  in  the  day,  usually  after  the  midday  meal  or  in  the 
evening,  it  becomes  febrile  and  may  rise  to  102°,  103°  F.,  or 
even  higher.  It  remains  at  this  point  for  an  hour  or  two  and 
then  sinks  again  to  its  former  level.  This  state  of  things  goes 
on  day  after  day,  and  all  the  time  the  patient's  condition  is  unsatis- 
factory. He  shows  by  his  pasty  complexion,  his  listlessness,  his 
loss  of  appetite  and  the  unhealthy  state  of  his  evacuations  that 
his  normal  digestive  activity  has  not  yet  been  restored.  Even 
when  the  temperature  has  finally  become  normal  the  appetite, 
although  it  may  improve  to  some  extent,  often  remains  poor,  and 
the  child  shows  no  sign  of  beginning  to  regain  flesh.  Moreover,  at 
any  time  he  is  liable  to  a  renewal  of  the  febrile  state  and  a  return 
of  the  more  acute  symptoms  with  which  his  illness  had  begun. 

This  state  of  things  may  continue  for  months,  being  marked 
by  febrile  attacks  of  varying  duration,  followed  by  intervals  in 
which,  although  the  temperature  is  not  abnormal,  the  feet  are 
habitually  cold,  the  appetite  is  poor,  and  the  patient  remains  pale 
and  thin ;  but  at  the  same  time  between  the  attacks  his  spirits  are 
good  as  a  rule,  and  he  joins  eagerly  enough  in  all  the  sports  of 
his  age.  When  the  attacks  of  fever  recur  frequently,  as  they  often 
do,  the  anxiety  they  occasion  is  usually  in  proportion  not  to  the 
severity  but  to  the  mildness  of  the  general  symptoms  with  which 
they  are  conjoined  ;  and  the  family  practitioner  remarking  the 
daily  rise  of  temperature,  and  finding  no  striking  indications  of 
local  distress  by  which  to  explain  the  failure  of  health,  begins  to 
suspect  that  there  must  be  a  tuberculous  cause  for  the  child's 
continued  indisposition.  The  subjects  of  the  complaint  are  usually 
spoken  of  as  "  delicate" ;  but  if  the  expression  is  used  to  imply  a 
constitutional  weakness  or  special  morbid  tendency,  it  is  here  mis- 
applied. The  children,  as  a  rule,  are  healthy  enough  and  naturally 


234  Food  Fever. 

strong.  Their  nutritive  failure  is  the  direct  consequence  of  per- 
sistent gastric  derangement,  for  owing  to  their  languid  circulation 
and  chilly  extremities  the  resisting  power  of  the  body  to  cold  is 
reduced  to  a  minimum.  The  patient  remains  curiously  responsive 
to  atmospheric  changes  and  becomes  a  chronic  sufferer  from 
mild  catarrh  of  the  gastric  mucous  membrane,  which  is  maintained 
or  continually  renewed  by  a  succession  of  little  chills.  As  a  con- 
sequence the  appetite  remains  poor,  the  nutritive  needs  of  the 
system  are  insufficiently  supplied,  and  the  bodily  heat  is  subject 
to  frequent  fluctuations,  owing,  probably,  to  re-absorption  from  the 
bowel  of  injurious  products  of  decomposition. 

In  many  cases  of  food  fever  the  symptoms  remain  indefinite 
and  mild,  and  anxiety  is  occasioned  only  by  the  fluctuating  tempera- 
ture, the  poor  appetite,  and  the  persistent  thinness  and  pallor  of 
the  patient.  It  may  happen,  however,  that  special  symptoms 
arise.  A  highly  neurotic  child  may  have  his  nervous  system  so 
disturbed  by  the  acute  attack  that  he  is  thrown  into  a  fit  of  convul- 
sions, and  the  seizures  may  be  repeated  again  and  again.  I  have 
seen  this  happen  in  impressionable  children  up  to  the  age  of 
eleven  or  twelve  years.  In  other  cases  the  gastro-intestinal  derange- 
ment may  be  marked  by  violent  and  repeated  vomiting,  and  for 
two  or  three  days  the  patient  rejects  almost  immediately  every 
form  of  liquid  nourishment  which  he  can  be  induced  to  swallow  ; 
or  there  may  be  marked  signs  of  intestinal  irritation,  and  the  child 
passes  loose  stools  containing  mucus  and  blood.  Another  com- 
plication may  be  sharp  abdominal  colic,  with  or  without  vomiting 
or  looseness  of  the  bowels,  and  the  patient  may  remain  for  several 
days  crying  out  with  the  pains  and  showing  a  temperature  of 
103°  or  104°  F.  But  whether  a  complication  is  present  or  not, 
and  whether  the  symptoms  are  mild  or  severe,  the  stools  are 
never  satisfactory.  They  may  not  be  increased  in  number  or 
even  especially  loose,  but  they  are  unhealthy  and  offensive  and 
often  contain  mucus.  Such  unhealthy  evacuations  are  proof  of 
gastro-intestinal  derangement,  and  point  at  once  to  a  definite  cause 
for  the  febrile  movement.  When  we  notice  also  that  the  course  of 
the  complaint  is  curiously  uneven,  that  the  patient  is  better  or 
worse  as  the  catarrh  varies  in  intensity,  and  that  sometimes  for  a 
week  or  so  the  improvement  is  such  that  he  seems  to  have  thrown 
off  his  indisposition  completely,  we  may  exclude  tuberculosis 
without  the  least  hesitation. 

The  above  sketch  of  the  symptoms  which  mark  the  course  of 
food  fever  has  been  necessary  in  order  to  make  clear  the  means 
by  which  the  complaint  may  be  brought  to  an  end.  But  to  be 


Food  Fever.  235 

successful  it  is  necessary  fully  to  realise  the  conditions  with  which 
we  have  to  deal.  It  is  not  enough  to  put  an  end  to  the  prevailing 
disturbance  and  set  up  a  merely  temporary  improvement,  for  that 
can  do  little  to  bring  the  illness  to  a  definite  close.  We  must 
remember  that  what  we  have  to  do  is  to  cut  short  not  one  single 
attack  but  a  series,  and  that  the  persistence  of  the  gastric  difficulty 
and  consequent  check  to  nutrition  is  the  result  of  repeated  renewals 
of  the  original  derangement.  In  order,  then,  to  make  improve- 
ment permanent  we  must  not  merely  put  an  end  to  the  actual 
attack,  but  must  take  the  necessary  steps  to  prevent  its  return. 
This  we  can  only  do  by  recognising  the  remarkable  susceptibility 
to  atmospheric  conditions  and  vicissitudes  shown  by  the  subjects 
of  this  complaint,  especially  if  the  indisposition  is  of  some  standing. 
The  patient's  resistance  diminishes  with  each  fresh  attack,  so 
that  as  time  goes  on  he  becomes  less  and  less  able  to  withstand 
sudden  changes  of  temperature,  and  is  upset  by  an  impression  of 
cold  which  would  be  powerless  to  harm  a  child  who  retains  his 
normal  resisting  power. 

In  the  management  of  these  cases,  then,  we  must  take  immediate 
steps  to  protect  the  child's  sensitive  body  from  chills.  We  must 
dress  him  warmly  in  substantial  woollen  underclothing,  and  cover 
up  his  legs  and  knees  with  long  stockings.  Even  in  the  heat  of 
the  summer  light  woollen  combinations  should  be  insisted  upon, 
for  it  is  at  this  season  that  changes  of  temperature  occur  with  such 
startling  suddenness,  and  a  quick  fall  in  the  thermometer  is  often 
found  to  be  followed  at  once  by  a  fresh  outbreak  of  catarrh.  In 
addition,  special  care  must  be  taken  to  keep  the  feet  warm  if  the 
weather  is  cold.  The  nurse  should  be  instructed  to  feel  them  with 
her  hand  several  times  a  day,  and  warm  them  if  necessary.  In 
the  winter  particular  attention  should  be  directed  to  this  point 
before  the  child  leaves  the  house  for  his  daily  exercise,  for  he  must 
never  be  allowed  to  go  out-of-doors  with  cold  feet. 

Care  must  also  be  taken  that  the  patient  does  not  get  chilled  in 
his  daily  bath.  Owing  to  his  heightened  sensitiveness  to  cold  the 
whole  process  must  be  carried  out  with  the  utmost  expedition,  so  as 
to  avoid  evaporation  from  the  surface  of  the  body.  In  bathing 
these  subjects  it  is  the  soaping  which  involves  the  greatest  risk, 
for  the  unavoidable  exposure  thereby  entailed  is  often  attended  by 
ill  consequences.  The  safest  method  is  to  bath  the  patient  in  hot 
soap-suds  (100°  F.)  as  directed  elsewhere.1  I  make  no  apology  for 
insisting  upon  these  domestic  details,  for  attention  to  such  matters 
constitutes  the  main  treatment  of  this  stubborn  derangement ; 
indeed,  without  extreme  care  in  this  respect  all  other  measures, 


236  Food  Fever. 

however  well-intentioned,  are  bound  to  fail.  We  cannot  put  an  end 
to  a  catarrh  as  long  as  we  allow  it  to  be  continually  renewed.  We 
may  diet  and  dose  such  a  child  for  weeks  and  months  together 
without  permanent  good  if  we  take  no  steps  to  counteract  the 
continually  recurring  cause  of  the  complaint.  The  cause  is  chill, 
and  we  must  see  that  the  child  is  properly  protected  against  it. 
The  prevailing  objection  to  covering  up  the  legs  of  young  children 
is  one  of  the  difficulties  against  which  we  have  to  contend,  and  it  is 
necessary  to  insist  firmly  that  recovery  is  impossible  as  long  as  the 
legs  are  allowed  to  be  bare.  This  precaution  applies  to  in-door  life 
as  well  as  out-of-door  exercise.  For  their  walks,  indeed,  the 
children  in  cold  weather  are  usually  dressed  warmly  enough  with 
long  thick  gaiters,  but  when  they  return  to  the  house  these  are  at 
once  thrown  aside.  It  is  necessary  to  explain  that  the  patients  are 
far  more  likely  to  get  chilled  in  the  house,  exposed  as  they  are  with 
uncovered  limbs  to  cold  staircases  and  draughts  from  doors  and 
windows,  than  in  the  open  air,  where  care  is  taken  that  they  are 
fully  and  warmly  clothed. 

But  in  addition  to  the  obvious  precautions,  which  apply  equally 
to  all  subjects  of  the  complaint,  we  must  be  careful  not  to  disregard 
exceptional  sources  of  chill  which  may  be  peculiar  to  the  individual 
sufferer.  These  we  can  only  discover  by  special  inquiry  into  the 
prevailing  nursery  arrangements,  for  there  are  very  many  ways  in 
which  a  sensitive  child  may  take  cold.  To  give  an  example :  in 
some  families  it  is  a  custom  to  beautify  the  heads  of  young 
children  with  a  long  and  large  curl.  This  is  done  with  a  wet  brush, 
and  leaves  the  hair  damp,  and  I  have  known  a  catarrh  of  the 
stomach  to  be  maintained  for  weeks  together  by  this  simple 
operation.  Minute  inquiry  will  often  discover  some  unsuspected 
imprudence,  which  throws  a  sudden  light  upon  a  baffling  case  and 
suggests  the  means  by  which  it  may  be  brought  to  an  end. 

By  the  above  measures  we  do  much  to  lessen  the  difficulties 
before  us  and  ensure  the  success  of  our  treatment.  It  is  one  thing 
to  cure  an  actual  catarrh  but  quite  another  thing  to  put  a  stop  to  a 
series  of  such  attacks,  for  the  latter  object  is  not  to  be  achieved  by 
means  which  are  efficient  enough  in  the  case  of  the  former.  When, 
therefore,  we  have  taken  the  necessary  care  to  lighten  our  task, 
the  next  step  must  be  to  put  the  patient  upon  a  rigid  diet.  We 
strictly  limit  the  quantity  allowed  of  carbohydrates,  such  as 
starches  and  sweets,  and  forbid  all  articles  of  food  which  are 
capable  of  undergoing  an  unwholesome  fermentation  in  the 
alimentary  canal.  Starches  and  sweets  are  especially  liable  to 
disagree,  for,  owing  to  the  excess  of  acrid  mucus  in  the  stomach,  they 


Food  Fever.  237 

quickly  undergo  a  noxious  change.  Potatoes  are  bad,  as  they  con- 
sist of  pure  starch  in  its  most  indigestible  form,  and  the  ordinary 
milk  pudding  of  the  nursery,  made  as  it  is  of  a  pure  starch  cooked 
in  the  oven  with  milk  and  sugar,  is  highly  deleterious.  The 
admixture  of  milk  with  starch  greatly  increases  the  instability  of 
the  latter,  as  is  explained  elsewhere,2  and  the  common  addition, 
when  it  comes  to  table,  of  baked  apple  composes  a  mess  which  in 
this  derangement  is  little  short  of  explosive.  Sago  and  tapioca, 
used  as  a  thickening  to  soup,  I  have  not  found  to  be  equally 
injurious,  and  plain  boiled  rice  is  usually  digested  without  difficulty. 
Acids,  such  as  oranges,  grapes,  apples  and  all  the  summer  fruits, 
are  also  to  be  avoided  ;  and  jams,  fruit  jellies  and  marmalade,  which 
all  contain  the  acid  of  the  fruit  with  a  quantity  of  added  sugar,  can 
on  no  account  be  allowed.  Pounded  white  sugar  may  be  permitted 
in  moderation,  if  added  cold  at  table,  but  sugar  cooked  as  in  sweet 
puddings  and  sponge  cakes  is  inadmissible.  The  cooking  of  sugar 
develops  in  it  a  number  of  unstable  compounds,  which  undergo  an 
unwholesome  change  when  taken  into  the  stomach  quickly.  This 
is  especially  the  case  with  beet  sugar,  which  is  much  less  to  be 
trusted  than  that  made  from  the  cane,  and  the  latter  should 
always  be  preferred  for  nursery  use. 

In  obstinate  cases  the  inclusion  of  milk  in  the  diet  is  a  matter 
which  requires  careful  consideration.  It  is  one  of  the  prevailing 
superstitions  of  the  nursery  that  milk  at  all  times  and  in  all  states 
of  health  is  a  sufficient  and  sustaining  food.  In  the  case  of  a  child 
of  normal  constitution  and  average  health  this  may  be  an  accurate 
statement  of  fact,  but  it  is  certainly  incorrect  in  the  case  of 
children  who  are  subject  to  such  digestive  derangements  as  that 
under  consideration.  Milk  is  a  fermentable  food,  and  like  other 
articles  of  the  same  class  should  never  be  given  to  these  patients 
lightly  and  as  a  matter  of  course.  In  the  treatment  of  children 
(and  I  include  infants)  it  is  a  good  rule,  whenever  the  stomach  is 
disordered,  to  regulate  with  care  the  quantity  of  milk  allowed  in 
the  diet.  Some  can  take  a  moderate  amount  without  obvious 
harm,  while  others  after  the  smallest  quantity  begin  at  once  to 
show  signs  of  discomfort,  and  in  many  cases  of  food  fever  the 
temperature  continues  to  be  subject  to  daily  alternations  as  long  as 
milk,  in  however  small  a  quantity,  is  retained  as  a  part  of  the 
patient's  daily  fare.  When  milk  disagrees  fresh  whey  is  usually 
well  borne,  but  it  must  be  clear  and  quite  freshly  made,  for  after 
only  a  few  hours,  especially  in  warm  weather,  it  becomes  stale  and 
no  longer  fit  for  use.  In  young  children  a  good  substitute  for  milk 
is  fresh  whey  diluted  with  an  equal  quantity  of  barley- water,  and 


238  Food  Fever. 

sweetened  with  white  cane  sugar.      If  thought  desirable,  it  may  be 
flavoured  with  a  spoonful  of  extract  of  malt  or  a  pinch  of  cocoatina. 
As  long  as  the  temperature  continues  high  without  any  decline 
the  diet  must  consist  of  liquid  foods,  such  as  that  just  mentioned, 
and  alternated  with  veal  or  chicken  broth  thickened  with  barley 
and  strained  ;  but  when  the  temperature  returns  to  a  normal  level, 
with  only  a  single  daily  rise,  more  solid  food  may  be  allowed,  and  if 
milk  and  the  more  fermentable  things  above  referred  to  are  put  on 
one  side,  the  digestive  disorder  is  very  quickly  brought  to  an  end. 
Mutton,  chicken,  and  white  fish,  such  as  sole,  plaice  and  whiting, 
agree  well ;  and  the  salted  things,  such  as  bacon,  thinly-sliced  ham. 
bloaters   and   all   the   salted   pastes,   are   not   only  harmless,  but 
actually  useful  to  children  of  the  age  of  six  years  and  upwards  in 
restoring  tone  to  the  relaxed  mucous  membrane.      Sardines,  if  of 
good  brand,  agree  well  in  most  cases.     If  they  do  not  it  is  probable 
that  the  oil  has  become  rancid.      Certain  fresh  vegetables,  such  as 
cauliflower,  vegetable  marrow,  stewed  cucumber  and  Spanish  onion, 
stewed  for  five  hours  with  frequent  changes  of  the  water,  are  all 
harmless  additions  to  the  diet.      Bread  may,  of  course,  be  allowed 
if  not  new  and  spongy ;  and  toast  need  not  be  forbidden  if  cut  thin 
and  toasted  through.     Fresh  butter  is  also  unobjectionable.     In  the 
matter  of  puddings,  those  made  from  flour  and  rusks  are  to  be  pre- 
ferred to  the  pure  starches,  and  therefore  as  the  patient's  condition 
improves   he   may   be   allowed   batter   pudding,  boiled   or   baked, 
bread-and-butter   pudding,  light   suet   pudding   made  with  bread- 
crumb instead  of  flour,  and  all  the  cabinet  puddings  which   are 
made  of  biscuits    and  rusks.      These,  however,  ought  not   to   be 
admitted  into  the  dietary  until  convalescence  is  advanced. 

It  is  well  in  all  cases  to  write  out  a  dietary,  and  to  caution  the 
mother  that  it  is  to  be  adhered  to  very  strictly.  Partial 
dieting  in  these  cases  is  quite  useless,  for  our  object  is  to  put  a 
stop  to  the  fermenting  process,  and  a  small  excess  of  fermentable 
material  will  prevent  this  object  being  achieved.  In  the  diet  as 
above  prescribed  the  fermentable  material  is  reduced  to  its 
narrowest  limits,  and  any  addition  to  it  can  only  be  made  at  great 
risk.  Sweet  cakes  and  sweets  and  acid  fruits,  in  however  small 
a  quantity,  keep  up  the  fermenting  process  and  prolong  the  dis- 
turbance. 

Of  the  treatment  so  far  recommended,  the  essential  part  lies  in 
the  domestic  management  of  the  patient  upon  reasonable  and 
healthy  lines.  Much  of  this  is,  of  course,  outside  our  own  personal 
control,  and  we  have  to  look  to  others  for  the  accurate  carrying  out 
of  that  for  which  we  cannot  ourselves  be  personally  responsible. 


Food  Fever.  239 

It  is  then  of  great  importance  not  to  be  slack  in  reminding  mothers 
and  nurses  of  their  duties.  The  medical  attendant  ought,  at  his 
visits,  himself  to  feel  the  patient's  feet  with  his  hand,  and  should 
never  leave  the  house  without  renewing  his  caution  against  the 
danger  of  chill.  In  bad  cases,  when  the  child  is  confined  to  his 
bed,  the  use  of  the  bed-pan  must  be  insisted  upon.  If  the  patient 
is  allowed  to  leave  his  bed  even  in  a  warm  room,  he  is  more  than 
likely  to  suffer  from  the  change  of  temperature,  for  the  attendants 
can  rarel}"  be  trusted  to  take  adequate  precautions  to  avoid  it. 
One  of  the  chief  obstacles  to  success  in  these  cases  is  the  difficulty 
we  often  find  in  getting  the  mothers  and  nurses  to  realise  the 
curious  susceptibility  to  impressions  of  cold  shown  by  these  patients 
after  they  have  suffered  for  only  a  few  months  from  a  rapid 
succession  of  acute  catarrhs. 

In  the  administration  of  drugs,  our  attention  must  be  confined  to 

the  gastric  trouble,  and  our  prescriptions  directed  to  put  an  end  to 

this  as  quickly  as  possible.     Iron  and  other  tonics  are  absolutely 

useless  until  this  primary  object  has  been  achieved.      In  the  acute 

attack,  when  the  temperature  is  high,  it  is  advisable  to  begin  with  a 

dose  of  calomel  (2  gr.)  at  night,  and  to  follow  this  up  with  an 

aperient    saline    in   the   early  morning ;    afterwards   an   alkaline 

stomachic  draught  must  be  ordered,  to  be  taken  three  times  a  day 

half   an  hour  before  food  :    3^    Sodii  Bicarb.,  gr.  5  to  9  ;    Spirit. 

Ammon.  Co.,  ni.5  to  10;  Tinct.  Aurantii,  ttj.15;  Glycerini,  iri.15  ; 

Infus.  Calumbae  Recentis,  ad  sij  to  jss.     M.  ft.  haustus.     [U.S.P. 

1^    Sodii  Bicarb.,  gr.  5   to  9 ;  Spirit.   Ammon.   Aromat.,  Tii5   to 

10;     Tinct.    Aurantii    Amari,    ir\12;    Glycerini,    fftl5;    Infusum 

Calumbae,  ad  3ij  to  5 as.] 

Another  useful  drug  is  sulphate  of  zinc  in  minute  doses.  A 
child  of  six  years  old  may  take  gr.  £  in  a  teaspoonful  of  freshly 
made  infusion  of  calumba  three  times  a  day  before  food.  This 
remedy  is  of  especial  value  when  there  is  any  tendency  to  vomiting. 
If  the  latter  symptom  is  distressing  and  any.  liquid  taken  returns  at 
once,  the  best  treatment  is  to  forbid  all  attempts  to  feed  the 
patient  and  to  allow  nothing  by  the  mouth  but  hot  water  taken 
freely  at  short  intervals,  giving  no  medicine  at  all.  At  first  the 
water  will  be  returned  almost  immediately,  but  gradually  as  the 
acrid  mucus  gets  washed  out  of  the  stomach  tolerance  becomes 
established,  and  the  patient  is  able  to  retain  iced  whey  or  thin  veal 
broth  in  very  small  quantities  at  a  time.  When  the  intake  is  thus 
restricted  to  hot  water  it  is  often  advisable,  in  order  to  satisfy  the 
relatives,  who  will  express  their  fears  that  the  child  may  be  starved, 
to  prescribe  some  nutritive  suppositories  to  be  used  several  times  a 


240  Food  Fever. 

day.  This  precaution,  although  not  required  in  the  patient's  own 
interests,  is  a  harmless  procedure,  and  will  often  render  the  task  of 
the  medical  attendant  an  easier  one.  It  is  wise  in  all  cases  where 
the  anxieties  of  the  relatives  are  aroused  to  keep  in  mind  their 
natural  apprehensions  and  misgivings,  however  groundless  these 
may  be.  It  must  be  remembered  that  to  be  successful  in  our  work 
we  have  not  only  to  manage  the  patient,  bringing  to  his  service  all 
the  skill  and  resource  at  our  command,  but  we  have  also  to  satisfy 
the  patient's  friends  ;  and  the  latter  is  often  the  more  difficult  task 
of  the  two.  If  the  vomiting  is  very  obstinate,  small  doses  of 
calomel  (gr.  ^  to  gr.  £,  given  every  half-hour  for  six  or  eight 
doses)  will  often  effect  a  remarkable  improvement. 

Severe  abdominal  pains  are  best  controlled  by  codeine  in  suitable 
quantities.  This  sedative  has  but  little  constipating  effect,  and  is, 
therefore,  greatly  to  be  preferred  to  morphia  or  opium  in  most 
cases  of  functional  abdominal  derangement.  Most  children  of  six 
years  old  will  take  gr.  -^  three  or  four  times  a  day  without  any 
feeling  of  drowsiness.  If,  however,  any  such  consequences  follow, 
the  dose  of  the  remedy  must  be  reduced,  and  the  forthcoming  dose 
held  over  until  the  effect  of  the  last  has  been  recovered  from. 

If  mucous  colitis  occurs,  with  straining  and  the  passage  of 
thin  stools  containing  mucus  and  blood,  the  disturbance  is 
usually  of  a  mild  character,  easily  controlled  by  small  doses  of 
castor  oil  and  opium:  1^  Olei  Kicini,  iri4;  Tinct.  Opii,  T»l2; 
Vini  Ipecac.,  rn.2  ;  Glycerini,  rn.15;  Aquam  Carui,  ad  5J.  M.  ft. 
haustus  (for  a  child  of  six  years).  To  be  taken  every  four 
hours. 

It  is  necessary  to  inquire  very  carefully  into  the  state  of  the 
stools,  for  unless  their  number  or  appearance  is  obviously  abnormal, 
they  are  unlikely  to  be  referred  to ;  indeed,  the  bowels  will  pro- 
bably be  described  as  "  nicely  opened."  But  the  passage  in  the  day 
of  only  one  loose  and  offensive  stool  is  a  sure  indication  that  the 
digestive  conditions  are  not  satisfactory,  and  if  the  temperature 
continues  unsettled  there  will  be  no  prospect  of  bringing  things 
back  to  a  normal  state  until  the  derangement  has  been  overcome. 
Often  the  child  in  these  cases  is  still  allowed  a  certain  quantity  of 
milk,  although  in  other  respects  very  strictly  dieted.  This  indiscre- 
tion must  be  remedied  at  once,  and  nitrate  of  silver  with  opium 
should  be  given  without  loss  of  time  :  1^  Argenti  Nitratis  Cryst., 
gr.  \;  Acidi  Nitrici  Dil.,  in2;  Tinct  Opii,  rn.1 ;  Glycerini,  in  15; 
Aquam,  ad  5j.  M.  ft.  haustus.  To  be  given  to  a  child  of  six  years 
every  four  hours. 

In  all  abnormal  stages  of  the  digestive  organs  in  the  child,  after 


Food  Fever.  .    241 

the  acute  stage  has  passed  off  and  the  derangement  is  threatening 
to  persist  in  a  modified  degree  or  to  become  chronic,  this  remedy 
may  be  turned  to  with  confident  expectations  of  a  satisfactory 
result.  The  nitrate  may  be  continued  for  ten  months  without  any 
fear  of  inducing  pigmentation  of  the  skin. 

By  the  means  thus  described  all  cases  of  food  fever  may  be 
certainly  brought  to  an  end  and  permanent  good  health  restored. 
It  is,  however,  necessary  to  warn  the  mother  that  attention  to 
all  the  points  enumerated  must  be  persevered  with  for  many 
months.  If  these  precautions  are  relaxed,  relapses  are  almost 
certain  to  follow  as  long  as  any  abnormal  susceptibility  remains, 
and  in  ordinary  cases  twelve  months  at  least  must  pass  before  we 
can  expect  the  patient  to  have  recovered  his  normal  resisting 
power  against  rapid  changes  of  temperature. 

EUSTACE  SMITH. 

REFERENCES. 

1  .See  "  General  Hygiene  and  Care  of  Young  Children,"  Vol.  I. 

2  Loc.  cit. 


S.T. — VOL.  II. 


16 


242 


ABDOMINAL  INJURIES. 

THE  subject  of  the  treatment  of  abdominal  injuries  is  a  large  and 
complicated  one.  One  or  more  of  the  various  and  numerous 
abdominal  injuries  may  be  present  in  any  one  case.  All  necessitate 
careful  treatment  and  the  great  majority  require  active  surgical 
measures  ;  therefore  part  of  the  treatment  of  abdominal  injuries 
consists  in  recognising  what  particular  injuries  are  present  and 
treating  them  accordingly.  Thus,  in  the  class  of  case  under 
consideration,  diagnosis  has  a  peculiarly  close  relationship  to  the 
treatment.  For  instance,  it  is  easy  in  theory  to  describe  the  treat- 
ment a  certain  condition  A ;  but  if  in  practice  the  condition 
diagnosed  as  A  turns  out  to  be  B,  C  or  D,  or  any  combination  of 
them,  then  the  treatment  becomes  complicated,  and  it  is  neces- 
sary to  take  into  consideration  the  various  sub-conditions  B,  C 
and  D,  and  their  recognition. 

The  Incidence  of  Abdominal  Injuries. — Experience  is  the 
only  guide  we  have  in  adjudging  to  the  various  abdominal  injuries 
their  relative  importance.  It  gives  what  may  be  called  "  clinical 
perspective,"  enabling  us  to  place  our  cases  in  due  proportion. 
Moreover,  this  method  is  eminently  practical,  la}dng  emphasis  on 
the  more  frequent  conditions  and  proportionately  less  on  the 
infrequent,  according  to  their  clinical  importance.  No  one  surgeon 
or  practitioner  has  sufficient  practice  to  gain  full  experience  of 
abdominal  injuries.  Hence  it  is  necessary  to  consult  the  method 
of  collective  investigation,  the  material  being  available  in  the 
excellent  surgical  reports  of  St.  Bartholomew's,  St.  Thomas's, 
University  College,  Middlesex  and  Westminster  Hospitals.  From 
these  sources  I  have  been  able  to  find  records  of  over  2,500 
instances  of  abdominal  injury,  the  mildest  of  which  was  sufficiently 
severe  to  necessitate  the  patient's  admission  to  hospital. 

Table  of  the  Incidence  of  Abdominal  Injuries  in  over 
2,500  Cases  : 


Contusion  of  the  Abdomen     . 
Wounds  of  the  Abdominal  Wall    . 
Injuries  to  the  Kidney 
Injuries  to  the  Alimentary  Canal. 
Injuries  to  the  Liver     . 
Injuries  to  the  Spleen   . 


65 -0  per  cent. 
8-5 
7 '8 
4-8 
4-6 


Abdominal  Injuries  243 

Injuries  to  the  Bladder          .         .         .  1 '2  per  cent. 

Injuries  to  the  Mesentery     ...  -6    ,, 

Ruptured  Rectus  Abdominis  Muscle 

Foreign  Bodies  in  the  Abdomen    . 

Injuries  to  Gall-bladder  and  Bile-ducts 

Injuries  to  the  Diaphragm,  Suprarenal  Capsule,  Pan 

creas,  and  Omentum 1  -0 

Injuries  to  Ureter,  the  most  infrequent   visceral  in 

jury,  and  to  Abdominal  Vessels         ...  -4 

Haemorrhage   into  Lesser  Sac,  Traumatic  Peritonitis, 

1  lii'inatoma  of  Abdominal  Wall,  etc.  .         .         .         .       2'2    ,,       ,, 

The  mortality  for  over  2,000  cases  of  abdominal  injury,  which 
were  severe  enough  to  be  admitted  to  hospital,  was  no  less  than 
23  per  cent.  About  30  per  cent,  of  abdominal  injuries  require 
active  surgical  intervention. 

Contusion  of  Abdomen. — A  contusion  of  abdomen  is  a  wide 
term  given  to  injuries  sufficiently  severe  to  merit  clinical  considera- 
tion, and  not  severe  enough  to  be  complicated  by  any  recognisable 
internal  injury.  In  our  table  the  contusion  was  sufficiently  severe 
in  65  per  cent,  to  demand  the  admission  of  the  patient  to  the 
hospital.  There  is  great  variety  in  the  possible  consequences  of  an 
abdominal  injury.  It  does  not  depend  only  on  the  force  of  the 
blow,  but  on  the  strength  and  preparedness  of  the  abdominal 
muscles  to  receive  it.  For  instance,  an  expert  boxer  will  allow  a 
heavy  blow  to  be  received  on  his  abdomen  without  causing  him  any 
inconvenience ;  or  a  cart  may  pass  over  the  abdomen,  leaving  the 
mark  of  the  wheel,  and  do  no  great  harm.  On  the  other  hand,  a 
trivial  blow  may  rupture  an  enlarged  liver  or  spleen ;  hence  it  is 
difficult  to  draw  any  further  conclusion  from  the  character  of  the 
injury  than  the  broad  generalisation  that  "severe  damage  may  be 
expected  to  result  from  a  severe  injury."  Every  abdominal  injury 
must  be  regarded  as  serious  until  it  has  been  proved  to  be  other  wise. 
In  order  to  treat  these  cases  it  is  necessary  to  understand  their 
possible  causation.  In  a  paper  on  spinal  concussion  in  the  Lancet, 
September,  1906,  it  was  suggested  that  some  of  the  symptoms  and 
signs  of  contusion  of  the  abdomen  are  explained  by  the  violence  or 
shaking,  producing  a  "  molecular  disturbance  "  in  the  abdominal 
ganglia,  and  consequently  a  functional  derangement,  abdominal 
concussion.  Shaking  of  the  various  abdominal  viscera  must  also 
produce  some  functional  disturbance.  Stimulation  of  the  nerve 
endings  will  also  produce  reflex  acts,  such  as  cessation  of  the  heart's 
beat  and  fainting. 

It  will  be  necessary  to  consider  the  clinical  features  in  some 
detail  because  they  form  the  fundamental  groundwork  of  rational 
treatment.  And,  in  addition,  the  diagnosis  of  contusion  of  the 

16—2 


244  Abdominal   Injuries. 

abdomen  is  only  made  if  no  definite  lesion  is  found.  Clinically 
there  are  three  stages. 

The  first  stage  consists  in  shock  and  collapse,  which  in  one 
extreme  produce  sudden  death,  in  another  fainting.  Sometimes 
there  is  tetanic  contraction  of  the  diaphragm,  as  when  an  athlete 
is  "  winded." 

In  this  stage  the  treatment  consists  in  recumbency,  wrapping  in 
warm  blankets,  hot  water  bottles  or  bricks  carefully  protected, 
raising  of  the  foot  of  the  bed,  stimulants  particularly  if  given  hypo- 
dermically,  and  warm  saline  per  rectum.  The  temperature  is  sub- 
normal and  the  pulse  rapid.  The  saline  per  rectum  can  be  given 
in  £  to  1  pint  doses  every  hour  or  every  two  hours. 

The  second  stage  is  that  of  reaction.  The  temperature  rises  and 
the  pulse  is  less  rapid.  It  is  during  this  stage  that  the  concomitant 
conditions,  such  as  the  rupture  of  a  viscus,  may  make  their  presence 
recognisable.  Everything  which  comes  from  the  "  inside  "  of  the 
patient  must  be  carefully  kept  and  inspected,  such  as  vomit,  urine, 
motions,  or  returned  saline.  During  this  stage  it  is  well  to  avoid 
giving  food  by  mouth,  except  in  small  quantities,  and  purgatives 
must  not  be  administered  unless  it  is  certain  that  there  is  no  lesion 
of  the  alimentary  canal.  Thirst  must  be  controlled  by  the  adminis- 
tration of  saline  solution  per  rectum  or  hypodermically. 

At  this  stage  there  are  four  possibilities.  Firstly,  signs  and 
symptoms  of  internal  htemorrhage  may  appear,  such  as  a  falling 
and  subnormal  temperature,  a  rising  pulse-rate,  a  softer  pulse, 
restlessness,  blanching,  the  non-secretion  of  urine,  a  clammy  skin, 
the  appearance  of  an  increasing  dull  area  in  the  abdomen,  occa- 
sionally shifting  dulness  in  the  abdomen,  etc.  Such  symptoms 
point  to  a  ruptured  spleen,  liver,  mesenteric  vessel,  etc. 

Secondly,  the  signs  and  symptoms  of  peritonitis  may  appear  ; 
such  as  a  rising  temperature,  a  small  harder  pulse,  a  rigid 
abdominal  wall,  diminution  or  cessation  or  respiratory  move- 
ments, distension,  sickness,  inactive  bowels,  etc.  Such  symptoms 
suggest  the  rupture  of  a  hollow  viscus. 

Thirdly,  the  signs  and  symptoms  of  reaction  may  pass  away 
and  convalescence  begin. 

Fourthly,  the  abdominal  signs  and  symptoms  do  not  clear  up 
satisfactorily,  but  the  patient  remains  with  slight  fever,  a  raised 
pulse-rate,  occasional  sickness,  and  bowels  which  are  difficult  to 
move ;  he  sleeps  badly,  takes  little  or  no  food,  is  querulous  and 
not  restful,  complains  of  abdominal  discomfort  rather  than  pain ; 
generally,  the  patient's  condition  is  "  not  satisfactory,"  rather  than 
"  definitely  unsatisfactory." 


Abdominal  Injuries.  .     245 

This  condition,  which  may  be  termed  chronic  peritonism,  is  not 
sufficiently  recognised,  is  not  uncommon,  and  presents  great  clinical 
difficulty.  If  such  cases  are  operated  upon  some  definite  lesion 
is  almost  always  found.  Such  lesions  are  a  "  low  "  form  of  peri- 
tonitis, bruised  mesentery  and  bowels,  a  small  amount  of  blood  in 
the  peritoneal  cavity,  etc.  But  it  is  certain  that  such  operative 
treatment  is  not  always  a  benefit  to  the  patient. 

The  treat  mi' nt  of  cases  of  abdominal  contusion  or  concussion  may 
be  easily  summed  up :  (1)  Treat  shock  and  collapse  as  already 
indicated ;  (2)  watch  very  carefully  for  early  signs  of  internal 
haemorrhage  or  peritonitis ;  both  demand  immediate  operation  ; 
(3)  watch  for  the  persistence  of  unsatisfactory  symptoms  ;  opera- 
tion is  demanded  in  the  great  majority  of  such  cases ;  (4)  the 
only  other  consequence  is  convalescence,  which  demands  common- 
sense  treatment. 

It  is  as  well  to  remember  that  abdominal  contusion  or  concussion, 
in  addition  to  the  risks  of  very  serious  internal  complications,  has  a 
mortality  of  its  own.  Such  fatal  ending  may  occur  at  once  or 
shortly  after  the  injury.  Yet  at  an  operation  or  a  post-mortem 
examination  no  cause  of  death  can  be  found.  Such  a  mortality  for 
about  1,600  cases  was  3  per  cent. 

Wounds  of  the  Abdominal  Wall. — These  cases  constituted 
8'5  per  cent,  of  abdominal  injuries,  and  were  divisible  according  to 
the  case  records  into  three  classes,  penetrating,  the  peritoneal 
cavity  being  opened  ;  non-penetrating,  the  peritoneal  cavity  not 
being  opened  ;  and  doubtful,  it  being  uncertain  if  the  peritoneal 
cavity  has  been  opened  ;  the  last  forming  almost  one-third  of  the 
cases. 

The  Treatment  of  Penetrating  Wounds  (50  per  cent,  of  cases). — 
The  treatment  must  vary  according  as  to  whether  there  is  any 
prolapse  of  viscera  or  not. 

(1)  No  prolapse  of  viscera  :  (a)  First  dressing :  Eemove  the 
clothes  and  any  obvious  uncleanliness,  and  cover  the  wound  with  a 
dry  sterilised  antiseptic  dressing,  such  as  double  cyanide  gauze,  held 
in  position  by  a  bandage,  (b)  Second  dressing  (to  be  done  as  soon 
as  can  be  arranged)  :  Anaesthetise  the  patient,  cover  the  wound 
with  a  dry  sterilised  pad,  shave  and  wash  the  skin  around  with 
soap  and  water,  followed  by  spirit  lotion,  and  paint  with  2  per 
cent,  iodine  dissolved  in  spirit.  Having  done  this,  cleanse 
the  wound  with  a  wool  pad  and  saline,  cut  away  the  soiled 
skin  edges,  enlarge  and  explore  the  wound  for  foreign  material. 
Paint  with  2  per  cent,  iodine  solution.  Enlarge  the  opening 
in  the  abdomen  sufficiently  to  allow  a  thorough  inspection  of 


246  Abdominal  Injuries. 

the  underlying  parts,  so  that  no  internal  lesion  is  overlooked. 
Sponge  away  all  blood  and  check  all  bleeding.  If  the  wound  is 
reasonably  clean  the  peritoneum  may  be  closed  with  sutures.  The 
abdominal  wall  is  then  reconstructed,  and  the  skin  wound  closed ; 
the  area  covered  with  a  dry  dressing  held  in  position  by  a  many- 
tailed  bandage.  Such  cases  must  be  watched  with  great  care  for 
the  occurrence  of  suppuration.  If  it  is  considered  undesirable  to 
close  the  wound  completely,  as  it  will  be  in  the  majority  of  cases,  a 
gauze  drain  is  introduced  into  the  peritoneal  cavity  and  the  wound 
closed  around  it.  Such  a  drain  is  removed  in  thirty- six  to  forty- 
eight  hours,  and,  all  being  well,  a  fresh  one  is  not  inserted.  But 
if  all  is  not  well  another  drain  may  be  inserted  for  twenty-four 
hours. 

In  those  wounds  which  heal  with  suppuration  the  scar  is  weak, 
and  a  ventral  hernia  may  develop  later  requiring  an  aseptic  opera- 
tion for  the  reconstruction  of  the  abdominal  wall.  An  abdominal 
belt  does  practically  nothing  to  stop  the  development  of  a  hernia. 
It  gives  support  and  confidence  to  a  patient  with  a  hernia. 

The  mortality  for  penetrating  wounds  of  the  abdomen  is  about 
30  per  cent,  when  there  is  no  concomitant  internal  injury,  death 
being  due  to  the  introduction  of  sepsis  and  the  resulting  peritonitis. 

(2)  When  prolapse  is  present :  (a)  First  dressing  :  Eemove  the 
clothes  and  obvious  uncleanliness  ;  do  not  reduce  the  prolapsed 
viscera  unless  the  patient  appears  to  be  dying  of  shock  ;  cover  with 
a  large  dry  dressing,  (b)  Second  dressing  :  Anaesthetise  the  patient 
as  soon  as  the  necessary  arrangements  can  be  made.  Wash  the 
prolapsed  viscera  carefully  with  a  plenteous  supply  of  sterilised 
saline  solution.  Reduce  the  viscera  into  the  peritoneal  cavity. 
Cover  the  wound  with  a  pad,  cleanse  and  shave  the  abdomen 
around,  remove  the  soiled  skin  edges,  paint  with  2  per  cent, 
iodine  solution,  explore  and  cleanse  the  wound.  A  drain  must 
be  introduced  into  the  peritoneal  cavity  and  the  wound  closed 
around  it.  This  drain  is  removed  within  thirty-six  to  forty- 
eight  hours,  and,  if  necessary,  another  is  inserted. 

The  Treatment  of  Xon-pcnetratnif/  Wounds. — (a)  First  dressing  : 
Remove  the  clothes  arid  all  obvious  uncleanliness ;  cover  the  part 
with  a  dry  dressing ;  as  a  rule  it  is  not  necessary  to  ligature  any 
vessels,  (b)  Second  dressing  :  Administer  an  anaesthetic.  Place  a 
pad  over  the  wound.  Wash  and  shave  the  abdomen  around. 
Cleanse  the  wound  with  saline  solution,  followed  by  spirit 
lotion  and  painting  with  2  per  cent,  iodine  solution.  Remove 
the  skin  edges  and  explore  the  wound  to  prove  it  to  be  non- 
penetrating,  remove  all  dirt,  stop  all  haemorrhage,  and  reconstruct 


Abdominal  Injuries.  247 

the  abdominal  wall,  draining  the  wound  if  it  is  unclean,  suturing 
it  if  clean.  Use  a  dry  dressing  and  a  many-tailed  bandage.  When 
a  drain  is  used  it  should  be  removed,  and  replaced  if  necessary,  in 
thirty- six  to  forty-eight  hours. 

The  object  of  most  importance  in  these  cases  is  to  restore  the 
abdominal  wall  and  make  it  as  strong  as  possible.  But  it  must  not 
be  forgotten  that  there  is  a  mortality  even  amongst  cases  of  non- 
penetrating  wounds  of  the  abdomen.  It  was  about  10  per  cent., 
the  deaths  being  due  to  sepsis  or  traumatic  peritonitis,  produced  by 
auto-infection,  most  probably  by  the  passage  of  organisms  through 
the  bowel  wall. 

Tin'  Treatment  of  Wounds  of  the  Abdomen,  tchen  it  is  uncertain  if 
tltet/  are  ]>enet  rating  or  not. — In  the  two  former  sections  there  is  no 
doubt  as  to  the  course  of  treatment  to  be  pursued,  though  opinions  on 
the  technique  may  vary.  As  a  consequence  it  was  possible  to  speak 
somewhat  dogmatically,  two  precepts  in  particular  being  emphasised ; 
when  a  wound  is  closed  watch  more  carefully  for  complications 
than  if  it  were  not  closed,  and  use  normal  saline  solution  rather 
than  antiseptic  chemicals  to  cleanse  the  peritoneum.  But  when  it 
is  uncertain  if  an  abdominal  wound  has  opened  the  peritoneum,  the 
practitioner  has  to  think  more  carefully  before  he  acts.  To  overlook 
a  "  penetration  "  is  to  make  the  patient  incur  a  serious  risk  to  life 
that  might  have  been  obviated.  To  make  a  perforation  is  to  make 
the  patient  incur  a  grave  and  additional  risk.  In  such  case  the 
line  of  treatment  must  be  to  regard  every  icound  as  penetrating 
until  it  lias  been  prored  to  be  non-penetrating.  Thus  at  the  first 
dressing  the  case  is  treated  as  has  been  recommended  for  a 
penetrating  wound  without  prolapse  of  viscera.  At  the  second 
dressing  commence  as  though  for  a  penetrating  wound,  but  be  very 
careful  not  to  convert  a  non-penetrating  into  a  penetrating  wound  ; 
when  its  real  nature  is  discovered  treat  it  accordingly.  An 
anaesthetic  should  always  be  given,  and  the  surgeon  must  be  pre- 
pared to  deal  with  a  penetrating  wound  of  the  abdomen  with 
internal  complications.  In  giving  a  prognosis  in  case  of  wound  of 
the  abdomen  it  must  be  remembered  that :  (1)  Penetrating  are  more 
fatal  than  non-penetrating  wounds  ;  (2)  an  overlooked  penetration 
is  a  grave  source  of  danger  ;  (3)  either  wound  may  be  complicated 
by  an  internal  injury  ;  (4)  the  other  immediate  complication  to  be 
feared  is  sepsis ;  (5)  a  ventral  hernia  may  occur  later. 

All  patients  with  wounds  of  the  abdomen  involving  the  abdominal 
muscles,  and  possibly  nerves,  must  be  kept  in  bed  for  at  least  three 
weeks  if  the  wound  is  perfectly  clean.  If  the  wound  is  unclean, 
the  convalescence  must  be  much  longer. 


248 


Abdominal  Injuries. 


Bullet  "Wounds  of  the  Abdomen. — For  practical  purposes 
these  may  be  regarded  as  penetrating  -wounds,  complicated  by 
multiple  internal  injuries,  such  as  injuries  of  the  vessels,  mesentery 
and  bowel.  Yet  it  was  proved  by  experiences  in  the  South  African 
War  that  such  cases  generally  recovered  if  no  operation  were  done ; 
the  entrance  and  exit  wounds  made  by  the  bullet  were  dressed,  and 
the  patient  was  only  allowed  to  take  food  and  liquid  nourishment 
very  sparingly  at  first.  This  may  be  accepted  as  a  correct  state- 
ment with  regard  to  abdominal  injuries  inflicted  with  the  modern 
small  projectile.  With  the  old-fashioned  bullet  the  wounds  are 
larger  and  more  severe,  so  that  it  is  better  in  civil  practice  to  open 
the  abdomen  through  the  "aperture  of  entrance"  and  to  deal  with 
the  injuries  found.  Still,  the  action  taken  in  a  particular  case 
must  be  decided  by  the  circumstances  of  that  case,  and  not  by  pre- 
conceived notions.  If  operation  can  be  undertaken  under  favour- 
able conditions  within  a  few  hours  of  an  injury  by  a  modern  bullet 
it  should  be  done.  Operation  should  be  performed  in  all  cases  of 
wounds  made  with  less  modern  projectiles  (see  Gunshot  Wounds, 
Vol.  I.)- 

Abdominal  Injuries  complicating  Thoracic  Injuries. — It  is 
not  generally  recognised  that  thoracic  injuries  can  give  rise  to 
abdominal  injuries.  Such  a  complication  is  more  frequent  in 
animals  than  in  man,  as  often  the  ribs  are  greater  in  number  and 
extend  further  down  towards  the  pelvis.  Amongst  300  cases  of 
broken  ribs  admitted  to  St.  Thomas's  Hospital,  there  were  thirty- 
six  with  abdominal  injuries  (12  per  cent.) .  These  abdominal  injuries 
are  extremely  important  and  commonly  fatal.  Indeed,  if  a  thoracic 
injury  is  complicated  by  an  abdominal  injury,  the  patient  is  likely 
to  die.  The  exceptions  to  this  rule  are  cases  of  abdominal  con- 
cussion or  contusion,  or  a  contusion  of  kidney. 

Abdominal  injuries  which  complicate  a  thoracic  injury,  unless 
produced  by  an  accident  which  may  affect  more  than  the  thorax, 
are  confined  to  the  viscera  in  the  upper  part  of  the  abdomen.  The 
following  table  shows  their  order  of  frequency  : 


Injury  to  Kidney  (particularly  the  right) 
Liver       .         .         ... 

Spleen 

Liver  and  Spleen     . 
Liver,  Spleen  and  Kidney 
Stomach  ..... 
Diaphragm  alone    . 


14  Cases. 
9 
6 
3 

1  Case. 
1 
1 


The  most  frequent  injury,  that  to  the  kidneys,  is  the  one  most 
amenable  to  treatment.     For  successful  treatment   the  diagnosis 


Abdominal  Injuries. 


249 


must  be  made  at  once  and  operation  performed  quickly.  For  the 
treatment  of  the  specific  injuries  reference  must  be  made  to  the 
sections  devoted  to  them. 

Injuries  to  Other  Parts  of  the  Abdominal  Parietes. — The 
abdominal  parietes  not  considered  already  are  the  hernial  rings, 
the  pelvis,  the  loins,  lumbar  spine  and  perineum.  It  is  not  usual 
for  these  to  be  included  in  abdominal  injuries.  Indeed,  no  further 
mention  will  be  made  of  the  hernial  rings,  perineum,  or  loin.  But 
fractures  of  the  pelvis  have  some 
special  interest,  as  they  may 
involve  abdominal  viscera.  In 
the  last  seventy-seven  cases  of 
fractured  pelvis  admitted  to 
St.  Thomas's  Hospital  4  per  cent, 
were  complicated  by  rupture  of 
an  abdominal  viscus,  the  bladder. 
From  time  to  time  there  are 
cases  in  which  the  violence  of 

the  accident  has  been  so  gene-  ''^^^^^m^^l 

rally  distributed  that  abdominal 
and  thoracic  injuries  occur  as 
well  as  a  fracture  of  the  pelvis. 
In  this  series  of  seventy- seven 
cases  the  urethra  was  ruptured 
in  five  of  the  cases,  the  bladder 
in  four,  the  vagina  in  one, 
the  rectum  and  bowel  not 
once. 

The  loin  is  practically  never 
injured  except  as  a  contusion, 
when  the  kidney  generally  suffers 
and  the  injury  to  the  loin  becomes 
merged  clinically  into  a  contu- 
sion or  rupture  of  the  kidney. 

Incised  "Wounds  of  the  Abdominal  Wall. — Incised  wounds,  if 
made  under  surgically  clean  conditions  and  sutured  properly,  heal 
by  first  intention,  and  never  dispose  to  hernia.  But  if  the 
reconstruction  of  the  abdominal  wall  or  the  healing  is  imperfect, 
a  hernia  is  prone  to  develop.  This  is  particularly  true  of  wounds 
in  the  loins  or  the  lower  part  of  the  abdomen.  When  the  wound  is 
unclean  from  the  beginning  and  has  to  be  drained  the  reconstruc- 
tion of  the  part  is  necessarily  imperfect,  and  a  hernia  is  prone  to 
develop. 


FIG.    1.  —  Tetanic   Rupture  of    rectus 
abdominalis. 


250 


Abdominal  Injuries. 


The  treatment  of  these  cases  consists  in  an  attempt  at  a 
surgically  perfect  reconstruction  of  the  part,  and  if  it  is  impossible 
to  do  this  the  aperture  must  be  closed  by  a  fine  metal  filigree  net- 
work or  a  silk  "  skein."  An  abdominal  belt  supports  and  gives 
comfort  to  the  patient,  but  in  no  wise  prevents  the  formation  of  a 
hernia. 

Injuries  to  the  Kidneys  (7-8  per  cent.).— Next  in  frequency  of 
occurrence  to  injuries  of  the  abdominal  walls  come  injuries  to  the 

kidneys,  for  the  treatment  of 
which  reference  must  be  made 
to  the  section  dealing  with  them. 
Injuries  to  the  Alimentary 
Canal  (4-8  per  cent.).— Next  in 
frequency  to  injuries  of  the  kid- 
neys come  the  injuries  to  the 
alimentary  tract,  for  the  treat- 
ment of  which  reference  must  be 
made  to  the  proper  section. 

Injuries  to  the  Liver  (4-6  per 
cent.).— Following  close  in  fre- 
quency to  the  injuries  of  the  ali- 
mentary canal  come  the  injuries 
of  the  liver.  Out  of  105  cases 
of  ruptured  liver,  in  70  per  cent, 
the  injury  (or  serious  injury) 
was  confined  to  that  viscus.  The 
viscus  most  frequently  injured 
at  the  same  time  as  the  liver  was 
the  right  kidney.  The  gravity  of 
a  ruptured  liver  depends  upon 
the  extent  of  the  rupture.  When 
the  rupture  is  single  it  is  often 
large  and  deep.  When  multiple  the  ruptures  are  usually  smaller  and 
more  superficial.  Being  a  soft  structure  the  liver  is  sometimes  practi- 
cally torn  in  half,  and  stitches  in  its  substance  cannot  be  tied  firmly 
as  they  "  cut  through."  In  consequence,  it  is  usually  impracticable 
to  suture  ruptures  in  the  liver.  Ruptures  of  the  liver  chiefly  cause 
death  from  internal  haemorrhage.  If  the  patient  escapes  this  he 
may  die  from  peritonitis  from  the  extravasation  of  infected  bile,  or 
he  may  develop  abscesses  in  the  various  subdiaphragmatic  or  sub- 
hepatic  loculi.  Ruptures  of  the  liver  practically  always  involve 
the  surfaces  of  the  organ  covered  by  peritoneum,  so  that  the  extra- 
vasation takes  place  into  the  peritoneal  cavity,  being  in  consequence 


FIG.  2.— Tear  of  Liver. 


Abdominal  Injuries. 


251 


unlimited  in  extent.  Naturally,  it  is  a  very  fatal  injury,  only  3  per 
cent,  recovering  when  the  injury  is  limited  to  the  liver,  and  none 
recovering  when  the  results  of  the  injury  are  more  widespread. 
The  death  of  the  patient  may  occur  in  the  first  clinical  stage  of  an 
abdominal  injury,  when  no  special  treatment  is  required.  In  the 
second  stage,  reaction,  the  increasing  internal  haemorrhage  may 
make  itself  obvious.  The  abdomen  is  opened  above  the  pubes,  the 
source  of  the  haemorrhage  ascertained,  a  second  opening  made  over 
the  injured  viscus,  all  blood  removed,  and  the  rupture  plugged  with 
gauze.  The  surgeon  now  returns  to  the  original  opening,  removes 
all  blood  from  the  loin  and 
pelvis,  fills  the  latter  with 
warm  saline  solution,  and 
closes  the  wound.  The 
gauze  in  the  liver  is  re- 
moved and  more  inserted 
on  the  third  day  after  opera- 
tion, the  patient  being  par- 
tially anaesthetised.  After 
this  it  is  again  changed  on 
the  fifth  day,  when  it  is 
usually  bile-stained ;  and 
daily  afterwards.  It  is  very 
disappointing  to  treat  these 
cases,  as  it  is  not  so  infre- 
quent to  save  the  patient's 
life  from  the  haemorrhage, 
and  at  the  end  of  a  week 
after  the  operation  the  tem- 
perature begins  rising,  due 
to  infection  of  the  various 
loculi  of  extravasated  blood 
and  bile  above,  under,  and  around  the  liver.  Sometimes  no  bile  is 
secreted,  as  indicated  by  the  dressings  and  pale  stools,  the  patient 
becoming  drowsy  in  a  condition  of  acholia. 

Injuries  to  the  Spleen  (2-7  per  cent.). — Injuries  to  the  spleen 
come  next  in  frequency,  and,  if  uncomplicated  by  other  injuries, 
form  one  of  the  most  readily  and  certainly  diagnosable  classes  of 
abdominal  injury,  and  are  most  amenable  to  treatment.  Of  100 
injuries  to  the  spleen  about  sixty  involve  that  viscus  alone  and 
forty  have  multiple  injuries,  rupture  of  the  liver  being  the  most 
frequent  complication,  followed  by  that  of  the  left  kidney.  The 
mortality  for  uncomplicated  rupture  of  the  spleen,  all  cases  in 


FIG.  3. — Gunshot  wound  of  liver. 


252  Abdominal  Injuries. 

hospital  practice  being  considered,  is  about  65  per  cent.,  whilst 
in  the  hands  of  some  operators  the  mortality  is  as  low  as  34  per 
cent. 

For  the  details  of  treatment  of  ruptures  of  the  spleen  reference 
must  be  made  to  Surgical  Affections  of  the  Spleen. 

Injuries  to  the  Bladder  (1-2  per  cent.). — These  may  be  intra- 
peritoneal  or  extra-peritoneal,  the  latter  being  usually  associated 
with  fractures  of  the  pelvis.  For  the  treatment  of  these  injuries 
reference  must  be  made  to  Affections  of  the  Bladder. 

Injuries  to  the  Mesentery  (-6  per  cent.). — These  injuries  are 
quite  undiagnosable  before  operation  and  are  found  on  exploration 
of  the  abdomen  for  haemorrhage,  peritonitis,  or  an  "  unsatisfactory 
condition "  of  the  patient  as  mentioned  below.  The  dangers 
are  haemorrhage  or  necrosis  of  the  bowel,  of  which  the  former  is 
the  greater ;  indeed,  on  several  occasions  it  has  been  my  fortune  to 
find  the  mesentery  of  the  small  intestine  distended  by  a  huge 
haematoma  on  the  top  of  which  the  bowel  is  placed.  Under  such 
conditions  the  source  of  the  haemorrhage  is  unknown  and  the 
bleeding  uncontrolled,  yet  the  abdomen  has  been  closed  and,  in 
the  instances  I  have  seen,  the  patient  has  always  recovered,  the 
bowel  failing  to  necrose  in  spite  of  the  impairment  of  its  vascular 
supply.1 

Rupture  of  Abdominal  Muscles  (-5  per  cent.). — The  rupture 
of  an  abdominal  muscle  by  its  own  contraction  is  only  seen  in 
the  recti  muscles.  The  rupture  usually  occurs  in  the  lower 
part  of  the  muscle,  but  occasionally  near  the  ribs.  It  is  accom- 
panied by  pain  and  swelling ;  later  the  rupture  may  be  felt. 
It  is  rarely  necessary  to  operate  on  account  of  haemorrhage. 
Occasionally  it  is  necessary  to  incise  the  haematoma  to  evacuate 
clot  and  expedite  the  healing.  Attempts  to  sew  up  the 
muscle  are  not  made  often,  as  it  is  generally  understood 
that  stitches  do  not  hold  in  muscular  tissue.  This  is  perfectly 
true  of  inflamed  muscle,  such  as  that  undergoing  repair,  but  it  is 
not  true  of  freshly  divided  muscle  sutured  aseptically ;  hence  the 
treatment  for  a  ruptured  rectus  abdominis  should  consist  of  the 
immediate  suture  of  the  muscle,  provided  that  the  circumstances 
allow  of  it  being  done  with  surgical  cleanliness.  If  this  cannot  be 
done  apply  an  ice-bag,  or  ice  in  a  sponge-bag  wrapped  in  flannel. 
When  the  bleeding  has  ceased  order  massage  with  dry  starch 
powder  and  dry  heat  in  between  times.  It  is  unusual  for  a  ventral 
hernia  to  develop,  but  owing  to  the  injury  the  protective  valvular 
mechanism  of  the  inguinal  canal  is  apt  to  be  destroyed  and  the 
patient  may  develop  an  inguinal  hernia  on  the  affected  side. 


Abdominal   Injuries.  253 

Wounds  of  the  Diaphragm. — Except  in  cases  of  stab  or  bullet 
wounds  abdominal  injuries  are  not  often  complicated  by  wounds 
of  the  diaphragm.  The  abdominal  injuries  complicated  by  wounds 
of  the  diaphragm  are  of  necessity  severe,  and  are  further  com- 
plicated by  wounds  of  viscera  adjacent  to  the  diaphragm.  Thus,  in 
two  cases,  both  the  loin  and  the  right  kidney  were  ruptured,  and  in 
one  case  the  spleen  was  ruptured.  These  injuries  are  naturally 
very  fatal,  death  being  caused  by  the  concomitant  lesion  rather 
than  the  injury  to  the  diaphragm  ;  hence,  if  these  patients  are 
too  ill  for  operation,  the  treatment  must  be  directed  to  that  of  the 
viscera  injured.  Eecovery  from  such  extensive  injuries  must  be 
very  rare. 

With  incised  or  stab  wounds  of  the  chest  or  abdomen  recovery  is 
not  infrequent,  although  the  diaphragm  may  have  been  pierced. 
Such  patients  are  liable  to  develop  a  diaphragmatic  hernia  when 
the  lesion  is  on  the  left  side,  the  most  commonly  herniated  viscera 
being  the  stomach,  omentum  and  transverse  colon.  The  presence 
of  a  scar  low  down  on  the  left  side  of  the  chest  or  high  up  on  the 
left  of  the  abdomen  should  give  rise*  to  the  suspicion  of  the  presence 
of  a  diaphragmatic  hernia.  The  liver  prevents  the  formation  of 
similar  herniae  on  the  right  side. 

Wounds  of  the  omentum,  suprarenal  capsule  and  the  pancreas 
are  found  from  time  to  time  at  operation  or  post-mortem  examina- 
tion on  patients  who  have  sustained  an  abdominal  injury.  The 
most  infrequently  injured  structure  in  the  abdomen  is  the  ureter. 

A  blow  on  the  abdomen  may  so  bruise  and  injure  the  bowel  as 
to  allow  the  passage  of  organisms  from  its  interior,  starting  a 
traumatic  peritonitis,  the  infective  organism  almost  always  being 
the  Bacillus  coli  communis. 

A  further  group  of  cases  must  be  mentioned  in  which  blood  and 
clots  are  found  in  the  abdomen,  the  source  of  their  origin  never 
being  discovered.  It  may  be  bruised  bowel,  mesentery,  a  small 
peritoneal  rupture  in  the  parietal  or  visceral  peritoneum,  or  small 
rupture  of  liver,  etc.  As  a  rule  it  is  useless,  and  sometimes  indeed 
harmful,  to  the  patient  to  make  a  prolonged  search  for  the  point 
which  has  bled. 


GENERAL  CONSIDERATIONS  AND  RULES  FOR  THE  TREATMENT 
OF  ABDOMINAL  INJURIES. 

Cases  of  abdominal  contusion  should  begin  to  recover  as  soon  as 
the  initial  shock  and  collapse  have  passed  off ;  that  is  to  say,  in  the 
period  of  reaction.  In  this  same  period  of  reaction  after  an 


254  Abdominal  Injuries. 

abdominal  injury  the  signs  of  internal  haemorrhage  or  peritonitis 
begin  to  appear.  Hence  it  is  in  this  period,  usually  three  or  four 
hours  after  the  injury,  that  the  patient  must  be  most  carefully  and 
repeatedly  examined,  so  that  it  can  be  decided  whether  the  patient 
is  improving  (recovery),  getting  rapidly  worse  (free  internal 
haemorrhage),  getting  slowly  worse  (slow  internal  haemorrhage  or 
peritonitis),  or  remaining  in  an  unsatisfactory  condition  (still 
slower  haemorrhage,  a  low  form  of  peritonitis,  prolonged  peritoneal 
shock  and  other  peritoneal  functional  disturbances).  If  surgical 
interference  is  indicated  the  following  procedure  should  be  adopted  : 
Operation. — (1)  Open  the  abdomen  in  the  middle  line  between 
the  umbilicus  and  the  symphysis  pubis.  This  incision  will  always 
be  required  for  cleansing  the  pelvis  and  perhaps  for  drainage. 

(2)  On  incising  the  peritoneum  look  for  free  gas,  debris  of  diges- 
tion, blood  and  urine.     If  the  former  two  are  found  examine  the 
bowel,  beginning  with  caecal  end  of  the  ileum,  as  the  ileum  is  the 
part  most  often  injured,  and  working  upwards  to  the  duodenum. 
The  small  bowel  is  more  frequently  injured  than  the  large  bowel, 
and  the  extravasated  contents  are  likely  to  be  liquid  in  the  former 
case  and  solid  in  the  latter.     If  no  rupture  is  found  in  the  small 
bowel   examine  the   large  bowel,  beginning  at  the  rectal  end,  as 
injuries  are  more  frequent  there  and  get  progressively  less  frequent 
higher  up  in  the  colon. 

(3)  If  blood   is   found   on   incising  the  peritoneum  see  if  it  is 
coming  from  the  lower  or  upper  part  of  the  abdomen.     If  from  the 
lower  part  of  the  abdomen  in  a  woman  the  injury  is  probably  a 
ruptured   tubal  gestation.     If  from  above  and  the  right  side  of  the 
abdomen  suspect  a  ruptured  liver.     If  it  comes  from  the  upper  and 
left  side  of  the  abdomen  suspect  ruptured  spleen. 

.  (4)  If  on  incising  the  peritoneum  blood-stained  urine  is  found  in 
the  pelvis  feel  for  an  intra-peritoneal  rupture  of  the  bladder. 

(5)  An  injured  kidney  is  dealt  with  most  easily  through  the  loin, 
when  operation  is  required. 

The  above  rules  will  suffice  as  guides  for  about  93  per  cent,  of 
the  cases  met  with  in  practice.  The  remaining  7  per  cent,  consist 
of  unusual  occurrences  which,  as  a  rule,  are  not  benefited  by 
treatment. 

(6)  The  abdominal   wounds   are   then  closed  or  drained  as  is 
thought  best. 

(7)  In  cases  where  the  mischief  has  been  in  the  upper  part  of 
the  abdomen  the  patient  had  better  remain  recumbent. 

(8)  When  the  injury  is  in   the   lower  half  of  the  abdomen  sit 
the  patient  up  in  the  semi-erect  Fowler  position  and  administer 


Abdominal  Injuries.  255 

saline  per  rectum,  either  by  continuous  irrigation  (p.  635)  or  by 
the  administration  of  ^  to  1  pint  through  a  tube  and  funnel  at 
hourly  intervals. 

(9)  In  abdominal  injuries  the  infective  organism  to  be  feared  is 
the  Bacillus  coli  communis,  so  that  25  cubic  centimetres  of  the 
anticolon  serum  may  be  administered  shortly  after  the  patient  has 
returned  to  bed. 

(10)  Do  not  press  food  by  mouth  or  increase  it  rapidly. 

(11)  Open  the  bowels  by  enema  on  the  third  day  after  opera- 
tion ;  a  purgative  may  be  given  by  mouth  on  the  fifth  day. 

(12)  All  abdominal  plugs  and  drains  should  be  removed,  and  if 
advisable  replaced,  within  forty-eight  hours  of  insertion.     On  the 
first  occasion  the  patient  should   have    an  ansesthetic,  only  light 
anaesthesia  is  required  to  enable  the  surgeon  to  do  his  work  expe- 
ditiously  and  well  without  paining  the  patient,  who  should  not  be 
allowed  to  return  to  consciousness  until  the  bandages  have  been 
replaced. 

(13)  When  closed  the  wounds  should  be  sealed  with  a  "  gauze 
and  collodion  "  dressing,2  the  whole  abdomen  being  covered  with 
wool  maintained  in  position  by  a  many-tailed  bandage.     This  allows 
the  practitioner  to  examine  the  abdomen  freely  without  fear  of 
infecting  the  wounds  and  with  a  minimum  of  disturbance  to  the 
patient. 

COMPLICATIONS. 

It  may  be  mentioned  that  in  popular  and  many  professional 
minds  abdominal  injuries  are  responsible  for  many  more  troubles 
than  have  been  already  narrated,  such  as  appendicitis.  Whilst  it 
is  perfectly  true  that  an  injury  may  have  been  the  final  factor  which 
enabled  the  infective  agent  to  start  the  appendicitis  it  must  be  very 
rare  for  the  injury  to  be  so  beautifully  timed  and  graduated  as  to 
do  no  further  harm. 

Of  the  more  chronic  abdominal  conditions  which  may  demand 
treatment  a  few  days  after  the  injury,  intestinal  obstruction  is  the 
chief  guise  under  which  they  appear.  Ruptured  spleens  have  come 
under  treatment  as  cases  of  intestinal  obstruction  or  peritonitis 
some  days  after  the  apparently  slight  injury. 

Badly  fitting  trusses  allow  the  bowel  or  omentum  to  come  down 
so  that  they  lie  between  the  truss  and  the  pubes.  If  a  blow,  such 
as  the  kick  of  a  horse,  is  given  to  the  truss  the  bowel  or  omentum 
is  compressed  against  the  pubic  bone  and  grossly  injured,  after 
which  and  when  the  patient  is  in  bed  it  returns  to  the  abdomen. 
I  have  met  with  two  such  cases,  both  fatal ;  only  being  diagnosed 


256  Abdominal  Injuries. 

after  the  incidence  of  a  fatal  peritonitis.  If  the  practitioner  takes 
the  trouble  to  examine  patients  before  the  truss  they  wear  is 
touched  it  is  astonishing  how  very  frequently  the  truss  is  found  to 
be  resting  on  a  piece  of  omentum,  although  the  patient  thinks 
that  the  "  rupture  is  up." 

EDRED  M.  CORNER. 

BEFERENCES. 

1  Corner,  E.  M.,  "  Clinical  and  Pathological  Observations  in  Acute  Abdominal 
Diseases,"  Lond.,  1904. 

*  Corner,  E.  M.,  and  Pinches,  H.  I.,  "Operations  of  General  Practice," 
3rd  edition  (Oxford  Medical  Publications),  Lond.,  1910,  pp.  17 — 19. 


257 


THE    PREPARATION    OF    PATIENTS    FOR 
ABDOMINAL  OPERATIONS. 

THE  details  of  the  preparation  of  a  patient  for  an  abdominal 
operation  vary  with  the  practice  of  the  operator.  This  section 
will  deal  with  the  main  principles  and  with  procedures  in  common 
use. 

The  cases  may  be  divided  into  two  groups  :  (1)  Those  in  which 
the  surgeon  is  able  to  fix  the  time  for  operation  ;  and  (2)  "  emer- 
gency "  cases,  in  which  the  operation  must  be  performed  as  early 
as  possible. 

CASES    IN   WHICH   THE   SURGEON   IS    ABLE    TO    FIX    THE 
TIME   FOR   OPERATION. 

In  fixing  the  day  and  time  for  an  abdominal  operation, 
the  surgeon  must  take  several  matters  into  consideration.  As 
a  rule,  when  an  operation  has  been  decided  upon,  the  patient 
is  anxious  to  have  it  arranged  for  as  early  as  possible.  The 
minimum  time  to  be  devoted  to  preparation  is  thirty-six  hours, 
and  during  this  time  the  patient  should  be  in  bed.  For 
instance,  if  an  operation  is  arranged  for  a  Wednesday  morning, 
the  patient  should  go  into  the  nursing  home  or  hospital  not  later 
than  the  preceding  Monday  evening,  and  even  before  this  prepara- 
tion should  be  commenced  by  attention  to  diet  and  to  the  action 
of  the  bowels.  If  the  operation  is  likely  to  be  severe,  the  patient 
should  be  kept  in  bed  for  at  least  three  or  four  days  beforehand, 
and  defects  in  the  general  health,  such  as  those  mentioned  below, 
may  make  an  even  longer  period  of  preparation  advisable.  Much, 
however,  depends  on  the  temperament  of  the  patient  and  the 
nature  of  his  trouble. 

Certain  climatic  conditions  are  unfavourable  to  the  performance 
of  abdominal  operations,  especially  when  the  upper  part  of  the 
abdomen  is  to  be  opened,  and  when  the  patient  is  elderly  or  liable 
to  bronchitis.  These  conditions  are  fog,  cold  damp  weather, 
and  very  hot  weather.  Operations  performed  under  these 
conditions  involve  an  increased  risk  from  pulmonary  complica- 
tions. 

In  women  laparotomies  should  not  be  undertaken  shortly  before 

S.T. — VOL.  II.  17 


258     Preparation  for  Abdominal  Operations. 

or  during  menstruation  ;  the  most  convenient  time  is  about  a 
week  after  menstruation. 

The  general  health  of  the  patient  should  be  as  good  as 
possible.  When  several  days  are  to  elapse  before  operation, 
fresh  air,  regular  exercise,  and  careful  feeding  should  be  insisted 
upon.  In  many  cases  a  fortnight  or  so  may  be  well  spent  in 
improving  the  general  health.  An  examination  of  the  heart, 
lungs,  and  urine  should  always  be  made  ;  if  there  is  any  doubt  as 
to  the  patient's  ability  to  stand  the  anaesthetic,  the  anaesthetist 
should  be  asked  to  examine  him  before  the  final  decision  is  made. 

If  the  patient  has  a  cough,  its  cause  should  be  ascertained  and 
treated  ;  this  precaution  applies  especially  to  elderly  subjects 
with  trouble  in  the  upper  half  of  the  abdomen.  If  bronchitis  is 
present,  it  is  usually  advisable  to  postpone  operation  until  the 
condition  has  been  cleared  up  or  ameliorated.  Ancemia  should 
be  treated  as  far  as  possible,  and  it  is  often  well  to  delay  operation 
until  the  anaemia  has  been  lessened  by  treatment,  for  anaemic 
patients  stand  shock  badly.  Jaundice,  especially  if  of  long 
standing,  may  cause  diminished  coagulability  of  the  blood,  and, 
as  a  result,  persistent  oozing  during  and  after  the  operation. 
This  tendency  to  haemorrhage  may  be  minimised  or  prevented 
by  giving  calcium  lactate  in  10-gr.  doses  three  times  a  day  for 
three  days  before  the  operation. 

Preparation  of  the  Alimentary  Canal. — It  is  important 
that  the  alimentary  canal  should  be  as  far  as  possible  empty  and 
sterile.  Emptiness  greatly  facilitates  operation,  and  relative 
sterility  reduces  the  risk  of  intestinal  infection  to  a  minimum. 
It  has  been  proved  that  suitable  preparation  renders  the  stomach 
and  the  upper  part  of  the  intestine  sterile,  and  it  is  clear  that 
this  preparation  will  also  render  the  lower  part  of  the  intestine 
less  septic. 

The  teeth  require  special  attention,  and  whenever  practicable 
they  should  be  overhauled  by  a  dental  surgeon.  All  stumps 
should  be  extracted,  carious  teeth  should  be  removed  or  stopped  ; 
dental  plates  to  be  worn  before  the  operation  should  be  thoroughly 
and  regularly  cleaned.  A  toothbrush  and  antiseptic  tooth  powder 
should  be  used  after  each  meal,  and  the  mouth  well  rinsed  with  a 
mouth  wash,  such  as  glycothyxnoline  or  listerine,  at  least  three 
times  a  day. 

A  few  days  should  be  devoted  to  the  regulation  of  the  diet  and 
bowels.  The  diet  should  be  light,  and  foods  which  are  likely  to 
leave  much  debris  in  the  intestine  should  be  avoided  ;  it  is, 
however,  important  that  a  patient  should  not  be  starved  during  the 


Preparation  for  Abdominal  Operations.     259 

days  preceding  an  operation,  for  starvation  is  especially  conducive 
to  shock.  On  the  day  before  operation  meals  must  be  light  and 
easily  digestible  ;  milk  and  starchy  foods  should  be  avoided  ;  it 
is  not  necessary  as  a  rule  to  restrict  the  patient  to  fluids.  Three 
hours  before  operation  a  cupful  of  strong  beef-tea  or  coffee 
may  be  given. 

In  operations  upon  the  stomach,  all  foods  taken  during  the 
preceding  forty-eight  hours  should  be  sterilised  and  should  be 
la  ken  from  sterilised  vessels.  It  is  not  necessary  to  wash  out  the 
stomach  in  all  cases,  and  as  a  rule  recent  haematemesis  and  acute 
inflammatory  troubles  contra-indicate  lavage.  If,  however,  there 
is  any  degree  of  pyloric  obstruction,  the  stomach  must  be  washed 
out ;  boiled  water  is  used  for  this  process,  which  is  best  carried 
out  in  the  latter  part  of  the  day  before  operation,  and  after 
this  nothing  is  given  by  the  mouth  except  sterilised  water  or  tea. 
If  the  stomach  is  greatly  dilated,  it  may  be  well  to  wash  it  out 
daily  for  three  or  four  days  before  operation. 

The  bowels  should  act  freely  for  a  few  days  before  operation,  and 
in  those  who  are  constipated  it  is  well  to  start  with  a  full  dose 
of  salts  or  Liquid  extract  of  cascara.  Discretion  is  needed  as  to 
the  amount  of  medicine  and  the  number  of  enemata  to  be  given, 
for  whilst  it  is  important  that  the  intestines  should  be  well 
emptied,  it  is  equally  important  to  avoid  setting  up  diarrhoea  ; 
the  exhaustion  which  follows  excessive  purgation,  especially  in 
elderly  patients,  is  the  worst  possible  preparation  for  an  abdominal 
operation.  On  the  other  hand,  in  cases  of  habitual  constipation, 
free  purgation  is  necessary,  and  this  process  should  be  carried 
out  over  a  period  of  three  or  four  days,  and  should  not  be  left  to 
the  twenty-four  hours  preceding  the  operation. 

At  6  a.m.  on  the  day  before  the  operation  castor  oil  should  be 
given  ;  this  usually  acts  satisfactorily  within  a  few  hours  ;  if  not, 
1  pint  of  soap  and  water  should  be  injected  into  the  bowel. 
The  dose  of  castor  oil  must  vary  with  different  patients  :  in 
healthy  adults  1  oz.  is  given,  but  for  elderly  and  feeble 
subjects  4  to  6  drachms  is  usually  quite  sufficient.  Patients 
should  not  be  allowed  to  choose  the  purgative,  for  it  frequently 
happens  that  the  drug  selected  proves  quite  ineffectual  on  this 
particular  occasion.  A  common  enema  is  administered  in  the 
evening,  and  again  two  or  three  hours  before  the  operation. 

The  Bladder  must  be  emptied  a  short  time  before  operation . 
In  most  cases  the  passage  of  a  catheter  is  unnecessary,  but  if 
there  is  any  doubt  as  to  the  bladder  being  empty,  or  if  the  operation 
is  to  involve  the  pelvic  organs,  a  catheter  should  be  passed. 

17—2 


26o     Preparation  for  Abdominal  Operations. 

The  Preparation  of  the  Skin  is  discussed  in  the  chapter  on 
Surgical  Technique.  It  is  very  important  that  a  sufficiently 
wide  area  of  skin  should  be  prepared.  The  preparation  should 
extend  from  the  nipple  line  above  to  the  pubes  and  upper  part  of 
the  thighs  below,  whatever  region  of  the  abdomen  is  to  be  opened, 
and  all  hair  on  this  area  should  be  shaved  off.  Particular  atten- 
tion should  be  paid  to  the  cleansing  of  the  umbilicus,  especially 
in  stout  subjects. 

Clothing. — When  the  operation  is  likely  to  be  prolonged  or  to 
be  attended  with  shock,  warm  clothing  is  essential.  The  limbs 
and  the  upper  part  of  the  chest  should  be  enveloped  in  wool  or 
woollen  coverings  ;  long  woollen  stockings  reaching  to  the  upper 
parts  of  the  thighs  are  most  convenient  for  the  lower  limbs,  and  a 
woollen  jersey  may  be  used  for  the  arms  and  chest. 

Nervousness  must  be  prevented  as  far  as  possible,  and  much 
may  be  done  by  cheerful  re-assurance  on  the  part  of  the  medical 
man  and  the  nurse  :  preparations  for  the  operation  should  not 
be  obvious.  A  good  night's  rest  before  operation  is  of  great 
importance.  Nervous  patients  may  be  given  a  dose  of  bromidia 
(5ij),  or  bromide  by  the  rectum,  or  a  hypodermic  injection  of 
morphia  (gr.  I  or  gr.  £),  and  atropine  (gr.  ji^). 

Many  operators  make  a  practice  of  giving  morphia  and 
atropine  shortly  before  operation,  chiefly  in  cases  in  which  ether 
"  by  the  open  method  "  is  to  be  given.  Morphia  diminishes  the 
amount  of  anaesthetic  necessary,  and  is  especially  useful  for 
patients  who  are  very  nervous.  Atropine  checks  the  secretion  of 
mucus  and  counteracts  the  inhibitory  action  of  the  vagus  ;  it 
has  the  disadvantage  of  increasing  thirst  after  operation.  If  the 
use  of  these  drugs  is  decided  upon,  they  should  be  injected 
subcutaneously  one  hour  before  the  time  fixed  for  operation  ; 
morphia  (gr.  £  to  |)  and  atropine  (gr.  T|o  to  T<^).  (See 
Anaesthetics,  Vol.  III.) 

EMERGENCY    CASES. 

Many  acute  abdominal  affections,  such  as  perforation  of  a 
gastric  ulcer  and  acute  intestinal  obstruction,  are  accompanied 
by  considerable  shock  and  collapse.  These  conditions  must  be 
treated  by  the  application  of  warmth,  in  the  shape  of  warm 
blankets  and  hot-water  bottles,  and  unless  there  are  signs  of 
internal  haemorrhage,  by  a  rectal  injection  of  \  pint  of  saline 
solution  and  \  oz.  of  brandy.  In  severe  cases  it  is  well  to  post- 
pone operation  for  three  or  four  hours,  by  which  time  some 
improvement  will  usually  have  occurred. 


Preparation  for  Abdominal  Operations.     261 


ti  of  the  Skin.  —  For  these  emergency  cases  the  iodine 
method  of  preparation  is  usually  best  ;  the  solution  of  iodine 
(2  per  cent,  in  rectified  spirit)  should  therefore  be  in  readiness 
for  urgent  cases.  The  skin  should  be  dry-shaved  and  swabbed 
over  with  acetone  ;  the  solution  of  iodine  is  then  painted  on 
and  a  dry  sterilised  dressing  applied.  The  iodine  is  again  applied 
immediately  before  the  operation  is  commenced.  If  the  iodine 
solution  is  not  available,  the  skin  should  be  prepared  in  the 
ordinary  way.  When  there  is  acute  tenderness  the  preparation 
may  be  carried  out  after  the  patient  has  been  anaesthetised. 

An  enema  is  advisable  in  most  cases  if  there  is  time,  whilst  other 
preparations  for  operation  are  being  made  ;  a  soap-and-  water 
enema  is  usually  best. 

In  cases  of  intestinal  obstruction  with  persistent  vomiting  the 
stomach  should  be  washed  out  before  the  administration  of  the 
anaesthetic,  unless  the  patient's  condition  is  so  serious  that  the 
proceeding  is  likely  to  cause  shock  and  great  distress. 

The  details  of  the  operation  must  be  so  planned  that  no  time 
is  wasted  when  once  the  patient  has  been  anaesthetised.  All 
instruments  that  may  possibly  be  required  must  be  ready;  for 
instance,  a  Paul's  tube  with  rubber  tubing  should  be  at  hand  in 
case  it  is  needed.  All  ligatures  and  sutures  must  be  prepared 
before  the  anaesthetic  is  commenced. 

In  connection  with  this  subject,  the  following  sections  should 
also  be  consulted  :  Surgical  Technique,  Vol.  I.  ;  The  Prevention 
of  Shock,  Vol.  I.  ;  The  Management  of  the  Sick  Room,  Vol.  I.  ; 
Anaesthetics,  Vol.  III. 

T.  CRISP  ENGLISH. 


262 


THE   TREATMENT   OF    PATIENTS    AFTER 
ABDOMINAL  OPERATIONS. 

UNCOMPLICATED  CASES. 

SATISFACTORY  progress  after  abdominal  operations  depends 
largely  upon  careful  after-treatment,  which  also  contributes 
greatly  to  the  patients'  comfort. 

There  are  three  very  important  principles  in  the  treatment  of 
those  recovering  from  abdominal  operations  : 

(1)  Patients  who  are  doing  well  after  an  operation  should  as 
far   as   possible   be   left   without   active    treatment.     The   best 
recoveries  take  place  in  those  cases  in  which  stimulants,  hypo- 
dermic injections,  rectal  infusions  and  so  on,  are  not  necessary 
and  are  not  given. 

(2)  Patients  who  are  doing  badly  should  not  receive  too  much 
treatment.     When  patients  are  acutely  ill,  their  strength  may  be 
exhausted,  and  sleep  may  be  prevented  by  the  administration 
of  many  medicines,  frequent  enemata,  and  constant  changing  of 
dressings. 

(3)  If   a  patient  is   sleeping,  he  should  not  be   disturbed  for 
any  purpose  whatever. 

When  the  operation  has  been  completed,  the  patient  is  carried 
carefully  to  bed,  and  in  most  cases  it  is  best  to  place  him  on  his 
back  with  a  pillow  under  the  knees.  The  head  is  turned  to  one 
side,  and  if  vomiting  occurs  the  nurse  must  carefully  support  the 
wound  with  her  hand,  to  prevent  undue  strain  upon  the  stitches. 
If  the  abdominal  wound  is  a  large  one,  as  in  ovariotomy,  a  flat 
sandbag  about  4  inches  by  8  inches  by  1  inch,  and  weighing  about 
5  lb.,  placed  over  the  line  of  the  wound  and  lying  on  top  of  the 
dressings,  is  of  great  value  as  a  support  to  the  wound.  These 
sandbags  are  often  very  comforting  to  the  patient,  so  much  so 
that  when  removed,  as  they  should  be  after  forty-eight  hours, 
the  patient  frequently  complains  of  the  loss  of  support.  After 
the  drainage  of  an  appendix  abscess  it  is  better  from  the  beginning 
to  keep  the  patient  turned  slightly  on  to  the  right  side  by  means 
of  a  pillow  placed  under  the  left  flank  and  hip,  as  this  assists  in 
the  escape  of  the  pus  from  the  abscess  cavity.  As  soon  'as  the 
effects  of  the  ansesthetic  have  passed  off,  one  or  two  pillows  placed 
under  the  head  and  shoulders  will  materially  add  to  the  patient's 
comfort.  A  cradle  is  unnecessary  unless  the  weight  of  the  clothes 


Treatment  after  Abdominal  Operations.     263 

causes  discomfort  or  unless  the  weather  is  hot.  The  room  should 
be  darkened  and  quiet,  its  temperature  65°  to  70°  F. 

Pain  in  varying  degree  is  usually  complained  of  during  the 
first  twenty-four  hours.  An  attempt  should  be  made  to  discover 
the  cause  of  the  pain  or  discomfort,  for  attention  to  some  small 
detail  or  a  slight  change  of  position  will  often  put  matters  right. 
The  loosening  of  a  tight  bandage,  the  emptying  of  a  distended 
bladder,  or  the  re-adjustment  of  pillows  may  at  once  relieve  the 
discomfort. 

General  abdominal  pain  should  be  treated  by  the  administration 
of  10  gr.  of  aspirin  or  phenacetin,  repeated  in  two  or  three  hours  if 
necessary  ;  if  pain  is  severe,  a  hypodermic  injection  of  morphia 
may  be  given,  ^  gr.  being  usuaUy  sufficient.  In  fact,  in  many 
cases  in  which  complications  are  not  expected,  such  as  gastro- 
enterostomy  and  appendicectomy  in  the  quiescent  stage,  ^  gr. 
of  morphia  may  be  given  in  the  evening,  and  will  considerably 
lessen  the  discomforts  of  the  first  night  after  the  operation  : 
atropine  (gr.  T^)  should  be  given  with  the  morphia. 

Pain  in  the  back  is  a  common  cause  of  distress.  It  may  be 
treated  by  change  of  position,  and  by  tucking  in  small  pillows 
against  unsupported  parts,  or  by  the  application  of  hot-water 
bottles,  or  by  gently  rubbing  the  painful  region  with  rectified 
spirit.  These  measures  judiciously  used  will  almost  always  give 
relief. 

Thirst  is  another  symptom  which  is  often  very  prominent. 
It  shows  that  the  body  requires  fluid ,  and  as  a  rule  there  is  no 
harm  in  allowing  the  patient  to  swallow  a  moderate  amount  of 
fluid  within  twelve  hours  of  operation.  If  the  patient  wishes  it, 
weak  freshly-made  tea  may  be  given,  and  this  will  often  do  a 
great  deal  to  make  a  patient,  especially  if  a  female,  more  comfort- 
able. After  most  severe  abdominal  operations  the  administration 
of  saline  solution  by  the  rectum  can  be  adopted  with  great  advant- 
age, and  is  very  effectual  in  preventing  the  distressing  thirst, 
which  was  formerly  so  common  when  fluids  were  withheld. 
Half  a  pint  of  saline  solution  (1  teaspoonful  of  salt  to  1  pint  of 
water)  should  be  allowed  to  run  slowly  into  the  bowel  every  four 
or  six  hours  ;  or,  better  still,  continuous  rectal  infusion  may  be 
employed  (see  Proctoclysis). 

If  anaesthetic  vomiting  is  troublesome,  the  best  plan  is  to 
allow  the  patient  to  drink  freely  a  solution  of  bicarbonate  of 
soda  (1  drachm  to  1  pint).  This  quickly  and  effectually  clears 
the  stomach  and  usually  stops  the  vomiting.  The  treatment 
of  persistent  vomiting  is  discussed  later. 


264     Treatment  after  Abdominal  Operations. 

The  mouth  should  be  frequently  washed  out  with  weak 
solutions  of  glycothymoline  or  listerine  ;  freshly  made  tea  also 
forms  an  excellent  mouth  wash,  and  later  grape- juice  or  orange- 
juice  will  be  found  refreshing.  The  teeth  should  be  regularly 
cleansed. 

Flatulence  is  a  frequent  cause  of  complaint  after  abdominal 
operations,  especially  when  there  has  been  much  manipulation 
of  the  intestines.  If  it  is  chiefly  gastric,  bicarbonate  of  soda 
solution  in  frequent  sips  should  be  tried,  or  a  carminative  such 
as  tincture  of  ginger  may  be  given  ;  a  sodamint  tabloid  or  a 
peppermint  lozenge  crushed  and  given  in  a  teaspoonful  of  milk 
is  often  effectual.  Granulated  charcoal,  given  a  few  granules 
at  a  time  up  to  2  drachms  in  the  day,  will  relieve  both  gastric 
and  intestinal  flatulence,  and  maybe  given  as  a  routine  in  abdominal 
cases.  When  the  larger  bowel  is  involved,  or  in  any  case  in  which 
there  is  much  flatulent  distension,  the  long  rectal  tube  should  be 
used  for  fifteen  or  twenty  minutes  every  four  hours. 

Bladder. — A  careful  watch  should  be  kept  for  retention  of 
urine,  and  on  no  account  should  the  bladder  be  allowed  to  become 
over-distended,  since  this  may  cause  subsequent  atony.  The 
application  of  a  hot-water  bag  to  the  hypogastrium  or  slight 
changes  in  position  are  often  effectual  in  overcoming  retention. 
If  these  measures  fail,  a  catheter  must  be  passed  under  strict 
antiseptic  precautions,  twice  a  day  or  more  often  if  necessary. 
Persistent  retention  of  urine  after  an  operation  is  often  overcome 
by  giving  ergot  (ext.  ergotae  liquidum,  nt5,  ter.  in  die). 

Bowels. — If  a  patient  is  doing  well  after  an  operation,  and  if 
there  is  no  abdominal  distension,  the  bowels  may  be  left  alone 
until  the  morning  of  the  third  day,  when  a  common  enema  with 
2  oz.  of  olive  oil  should  be  given,  and  until  the  fifth  or  sixth  day 
enemata  are  perferable  to  aperients,  especially  when  any  part  of 
the  bowel  has  been  sutured,  for  purgatives  may  excite  harmful 
peristalsis  and  throw  undue  strain  upon  the  sutured  area.  After 
the  sixth  day,  mild  aperients  such  as  cascara  and  salines  should 
be  given. 

For  constipation  during  the  later  stages,  abdominal  massage, 
fruit,  and  suitable  aperients  should  be  used.  It  is  always  well 
to  consult  the  patient  upon  the  subject,  as  he  is  often  the  best 
judge  of  the  most  suitable  drug  ;  but  it  must  be  remembered  that 
larger  doses  will  be  required  than  those  which  the  patient  is  in 
the  habit  of  using  when  in  normal  health.  Useful  preparations 
in  addition  to  stock  Pharmacopoeal  mixtures  are  purgen,  one 
tablet  (adult  size),  at  night,  and  Burroughs,  Wellcome  &  Co.'s 


Treatment  after  Abdominal  Operations.     265 

laxative  tabloids,  one  at  night.  Purgatives  must  be  used  with 
special  care  after  abdominal  operations  upon  old  people,  since 
their  abuse  may  *et  up  a  diarrhoea  which  rapidly  exhausts  the 
patient. 

Feeding. — Fluids  only  should  be  allowed  during  the  first  two 
or  three  days.  Any  of  the  following  may  be  given :  Albumen  water, 
broths,  beef-tea,  whey,  tea,  coffee,  Vichy  water,  soda  water, 
barley  water  ;  the  patient's  tastes  may  be  consulted  in  the  matter. 
If  it  is  essential  that  he  should  have  as  much  nourishment  as 
possible  at  the  earliest  moment,  plasmon  in  small  doses  may  be 
mixed  with  the  feeds  of  albumen  water,  etc. 

Personally,  I  do  not  believe  that  milk  should  be  given,  until 
the  bowels  have  acted  and  any  distension  has  disappeared  ; 
patients  with  thickly  furred  tongues  cannot  digest  milk,  and 
under  these  circumstances,  milk,  even  if  peptonised,  causes 
flatulence,  loads  the  intestines  and  produces  constipation.  As 
soon  as  the  bowels  have  acted  and  the  tongue  has  become 
moderately  clean,  milk,  diluted  with  barley  water  or  soda  water, 
may  be  given. 

On  the  fourth  or  fifth  day,  if  all  is  going  well,  the  patient  may 
have  thin  bread-and-butter,  custard,  jelly,  Benger's  food,  lightly 
boiled  pounded  fish,  toast ;  a  day  or  two  later,  pounded  chicken 
and  fruit  may  be  given.  Rectal  feeding  is  quite  unnecessary  in 
the  majority  of  abdominal  cases,  and  its  value  at  any  time  is 
doubtful.  Water  or  saline  solution  is,  however,  freely  absorbed 
by  the  rectum  and  colon,  and  if  there  is  difficulty  in  giving 
a  sufficient  amount  of  fluid  by  the  mouth,  it  should  be  given 
by  the  rectum. 

Insomnia. — Many  patients  complain  that  they  are  unable  to 
sleep.  In  all  such  cases  a  careful  note  should  be  made  of  the 
actual  time  during  which  the  patient  has  slept,  and  if  the  amount 
of  sleep  is  less  than  normal,  or  if  the  sleep  is  broken  and  disturbed, 
steps  should  be  taken  to  remedy  this. 

Insomnia  is  often  due  to  a  definite  cause  which  is  removable. 
A  change  in  position,  or  reassurance  on  some  point  about  which 
the  patient  is  worrying,  may  be  all  that  is  necessary ;  any  such 
cause  as  flatulence  or  pain  in  the  back  should  be  treated  on  the  lines 
indicated  above.  When  there  is  no  such  definite  cause,  warm 
sponging  of  the  face  and  hands  will  often  send  the  patient  to 
sleep  ;  re-arrangement  of  the  pillows,  a  fresh  cool  sheet  or  pillow- 
case to  replace  those  which  are  hot  and  uncomfortable,  may  be 
effectual. 

If  these  measures  fail,  and  the  patient  is  evidently  becoming 


266     Treatment  after  Abdominal  Operations. 

distressed  from  want  of  sleep,  drugs  should  be  tried.  It  is  usually 
wise  to  keep  from  the  patient  the  knowledge  of  what  drug  he  is 
having,  and  in  most  cases  to  give  it  in  milk  or  other  food,  so  that 
he  does  not  know  when  it  is  given.  The  most  generally  useful 
drug  in  these  cases  is  aspirin  (in  10-gr.  doses),  or  one  of  the  follow- 
ing drugs  may  be  given  :  Chloralamide,  gr.  30  ;  trional,  gr.  10 ; 
bromidia,  3J.  Chloralamide  may  be  given  in  whisky,  but  the 
taste  is  very  difficult  to  disguise  ;  the  other  drugs  can  be  readily 
given  in  warm  milk.  Morphia  should  be  avoided  if  possible  ;  if 
it  is  given,  a  small  dose  is  usually  sufficient,  unless  actual  pain  is 
the  cause  of  the  insomnia  :  |  gr.  may  be  given  hypodermically, 
or  ^  gr.  in  a  suppository.  The  paralysing  effect  of  morphia  on 
peristalsis  may  be  minimised  by  the  addition  of  T^  to  T£Q  gr.  of 
atropine. 

Position  in  Bed. — After  recovery  from  an  anaesthetic,  the 
most  comfortable  position  for  the  patient  (provided  there  is  no 
marked  shock)  is  the  semi-recumbent  position,  piUows  being 
placed  behind  the  shoulders  and  back,  and  a  bolster  beneath  the 
knees.  After  operations  upon  the  stomach  and  in  cases  with  any 
tendency  to  chest  complications,  the  patient  should  be  well 
propped  up  in  a  sitting  position  as  soon  as  possible  ;  in  cases  of 
diffuse  peritonitis  this  position  (the  Fowler  position)  forms  an 
important  part  of  the  treatment. 

The  lateral  position  may  be  adopted  to  facilitate  drainage,  as 
in  cases  of  appendicitis  with  abscess  ;  pillows  are  placed  under 
the  shoulder  and  hip  of  the  opposite  side. 

If  there  is  much  shock  the  patient  must  be  kept  absolutely  flat 
in  bed,  with  the  foot  of  the  bed  well  raised  on  blocks  or  chairs. 

It  is  quite  unnecessary  to  restrict  the  movements  of  the  patient 
after  an  abdominal  operation,  as  was  formerly  the  practice.  As 
a  rule  the  position  of  greatest  comfort  should  be  chosen,  and 
change  of  position  should  be  made  from  time  to  time  ;  this  is  of 
especial  importance  in  enabling  the  patient  to  sleep. 

Visitors. — In  most  cases  no  visitors  should  be  allowed  for  the 
first  twenty-four  hours.  On  the  second  and  third  days  the 
patient  may  see  a  relative,  but  on  no  account  should  he  be  allowed 
to  become  over- tired  or  excited. 

Men  may  smoke  after  operations,  as  soon  as  they  have  the 
inclination  to  do  so.  They  should  be  encouraged  to  shave  or  to 
be  shaved  as  soon  as  possible,  on  account  of  the  self-respect  and 
comfort  which  this  proceeding  induces. 

Dressings. — In  cases  in  which  the  wound  is  closed  without 
drainage  the  dressings  as  a  rule  should  not  be  disturbed  until  the 


Treatment  after  Abdominal  Operations.     267 

removal  of  the  stitches.  If,  however,  they  are  causing  discomfort , 
they  may  be  changed  on  the  third  or  fourth  day.  Of  course,  full 
antiseptic  precautions  must  be  taken. 

Bandages  applied  firmly  at  the  end  of  the  operation  often 
become  uncomfortably  tight  owing  to  flatulent  distension ;  if  so, 
the  margin  may  be  cut,  but  care  must  be  taken  that  they  are  not 
so  loosened  that  the  underlying  dressing  can  be  displaced. 

Stitches  which  involve  only  the  skin  and  superficial  tissues 
should  be  removed  on  the  seventh  day;  stitches  which  pass 
through  the  whole  thickness  of  the  abdominal  wall  are  left  undis- 
turbed until  the  tenth  to  fourteenth  day;  if  they  are  taken  out 
earlier  than  this,  there  is  a  risk  of  some  sudden  effort,  such  as 
coughing,  causing  the  wound  to  burst  open.  In  those  who  are 
stout  or  have  a  cough,  it  is  well  to  apply  broad  pieces  of  strapping 
to  support  the  sides  of  the  wound  after  removal  of  the  stitches. 

In  cases  in  which  the  wound  is  drained,  e.g.,  after  the  opening 
of  an  abscess,  the  dressings  should  be  changed  four  or  five  hours 
after  operation  ;  then  they  should  be  changed  two  or  three  times 
daily  for  the  first  few  days,  according  to  the  amount  of  discharge. 
If  a  tube  has  been  inserted  into  an  abscess  cavity,  it  is  better  not 
to  move  it  for  three  or  four  days,  as  there  may  be  difficulty  in 
replacing  it,  especially  if  the  cavity  extends  deeply  into  the  pelvis  ; 
it  may,  of  course,  be  shortened  from  above  if  necessary.  After  the 
fourth  day  the  tube  may  be  removed  daily  for  cleaning.  Dis- 
cretion must  be  used  as  to  when  it  may  be  replaced  by  a  smaller 
one  or  be  dispensed  with. 

Gauze  plugging,  if  used,  should  be  removed  gradually;  if  care 
has  not  been  used  in  its  insertion,  the  removal  may  be  a  very 
painful  proceeding.  Gauze  which  has  been  used  to  pack  off  the 
general  peritoneal  cavity  should  not  be  removed  before  the  sixth 
or  seventh  day,  by  which  time  it  will  have  become  loosened  ;  if 
removed  earlier,  there  is  a  risk  that  adhesions  will  be  broken  down 
and  clean  surfaces  infected.  Gauze  which  has  been  used  to  drain 
an  abscess  cavity  should  be  taken  out  earlier  ;  its  withdrawal 
should  be  commenced  after  twenty-four  hours,  the  last  piece 
being  removed  by  the  third  or  fourth  day.  Irrigation  with 
solution  of  hydrogen  peroxide  (10  volumes)  assists  in  the  loosening 
of  gauze. 

Duration  of  Confinement  to  Bed. — This  depends  upon  a 
great  variety  of  circumstances,  and  especially  upon  the  age  and 
muscular  tone  of  the  patient,  the  character  and  size  of  the  incision, 
the  question  of  drainage  and  primary  healing.  In  the  absence  of 
complications,  most  cases  may  be  allowed  to  get  up  on  the 


268     Treatment  after  Abdominal  Operations. 

fourteenth  day,  and  may  leave  the  hospital  or  nursing  home  on 
the  twenty-first  day. 

After  appendicectomy  in  the  quiescent  period  patients  with 
ordinary  muscular  development  may  be  allowed  up  in  eight  to 
twelve  days,  and  may  leave  the  home  or  hospital  in  fourteen  to 
eighteen  days  ;  those  with  feeble  abdominal  muscles,  such  as 
multipart,  should  be  kept  in  bed  for  at  least  a  fortnight.  In  an 
acute  case  of  appendicitis  the  patient  should  be  kept  in  bed  for 
fourteen  days  if  the  wound  is  not  drained,  and  if  the  wound  is 
drained  he  should  be  kept  in  bed  until  healing  has  occurred  ;  if 
he  is  allowed  to  get  up  earlier  than  this,  final  healing  is  often 
delayed  and  ventral  hernia  is  apt  to  follow.  Such  a  patient, 
however,  may  be  moved  on  to  a  couch  and  wheeled  up  to  the 
window  or  into  another  room  after  ten  to  fourteen  days. 

Massage  to  the  extremities  is  a  most  excellent  measure  during 
convalescence,  especially  for  a  patient  who  has  had  a  long  illness 
and  whose  muscles  have  become  wasted.  Massage  very  con- 
siderably hastens  progress  when  the  patient  begins  to  get  up,  and 
greatly  diminishes  the  feeling  of  weakness  which  is  usually 
complained  of. 

A  belt  should  be  ordered  when  an  abdominal  wound  has  been 
drained  or  when  a  primary  union  has  failed ;  it  is  also  advisable 
in  very  stout  patients  and  in  those  with  lax  abdominal  muscles. 
The  belt  should  be  worn  for  six  months,  after  which  time  the 
operator  should  examine  the  scar,  to  decide  whether  the  wearing 
of  a  belt  should  be  continued.  In  women  with  weak  abdominal 
muscles  a  carefully  made  surgical  corset  is  often  better  than  the 
ordinary  abdominal  belt.  For  healthy  muscular  subjects,  in 
whom  the  wound  is  not  unusually  long  and  has  healed  well,  a  belt 
is  quite  unnecessary  and  in  fact  may  do  harm. 

"Final  Directions  to  Patients. — Careful  directions  should 
always  be  given  to  patients,  especially  to  those  who  have 
been  treated  in  hospital.  The  nature  of  the  operation  which  has 
been  performed  should  be  explained  to  them  ;  for  instance,  after 
operations  for  acute  appendicitis  it  is  very  important  that  they 
should  be  told  whether  or  not  the  appendix  has  been  removed. 
In  general  they  should  ,be  advised  as  to  the  importance  of  avoiding 
constipation  and  should  be  instructed  as  to  the  best  means  of 
doing  this  ;  they  should  also  be  warned  that  they  may  for  a  time 
have  occasional  abdominal  pain,  which  is  most  likely  caused  by 
nothing  more  serious  than  adhesions.  They  should  also  be 
informed  as  to  what  they  may  or  may  not  do  in  the  way  of  diet 
and  exercise. 


Treatment  after  Abdominal  Operations.     269 

THE  TREATMENT  OF  CERTAIN   COMPLICATIONS. 

Most  of  the  complications  which  may  follow  abdominal 
operations  are  dealt  with  in  other  parts  of  this  System.  This 
>cction  will  be  devoted  to  the  treatment  of  certain  post-operative 
complications  which  require  special  mention,  or  which  are  not 
dealt  with  elsewhere. 

Shock. — The  treatment  of  post-operative  shock  is  fully 
described  in  the  chapter  on  Shock.  Prophylaxis  is  obviously  of 
the  greatest  importance  ;  careful  preparation,  quick  operating, 
gentleness  in  manipulation,  a  minimum  amount  of  exposure,  and 
the  careful  control  of  haemorrhage,  are  the  main  points. 

After  severe  and  prolonged  operations,  the  patient  should  be 
very  carefully  carried  back  to  bed,  the  head  being  kept  low. 
The  foot  of  the  bed  should  be  well  raised  and  warm  blankets  and 
hot-water  bottles  should  be  applied ;  care  should  be  taken  that 
the  bandages  are  not  so  tight  that  they  interfere  with  respiratory 
movements.  Proctoclysis  (continuous  rectal  infusion  of  saline) 
is  one  of  the  most  effectual  methods  of  combating  shock,  and 
this  may  be  commenced  as  soon  as  the  patient  has  been  returned 
to  bed.  If  shock  is  expected,  rectal  infusion  may  be  started 
whilst  the  patient  is  on  the  operating  table  ;  it  can  be  carried 
out  without  interfering  with  the  operator,  and  is  only  contra- 
indicated  when  considerable  oozing  is  expected  or  is  occurring. 

Persistent  Vomiting. — Vomiting  which  persists  after  the  first 
twenty-four  hours  is  very  exhausting  and  distressing  to  the 
patient,  and  may  cause  damage  to  the  abdominal  wound.  Active 
steps  must  be  taken  to  arrest  it. 

Satisfactory  treatment  depends  mainly  upon  the  recognition 
of  the  cause  of  the  vomiting.  Inquiry  should  be  made  as  to  the 
effects  of  any  previous  anaesthetics,  and  also  as  to  any  liability  to 
sea-sickness.  It  must  never  be  forgotten  that  persistent  vomiting 
may  be  a  symptom  of  intestinal  obstruction  or  of  peritonitis 
following  upon  or  continuing  after  the  operation  ;  under  these 
circumstances  it  is  often  an  indication  for  reopening  the  abdomen. 
Very  rarely  copious  vomiting  may  be  a  symptom  of  acute 
dilatation  of  the  stomach. 

When  the  vomiting  is  due  to  the  irritative  effect  of  the 
anaesthetic,  the  stomach  should  be  thoroughly  cleared  by  allowing 
the  patient  to  drink  as  much  as  he  likes  of  a  solution  of  bicarbonate 
of  soda  (  1  drachm  to  1  pint) :  this  induces  copious  sickness,  and  is 
often  successful  in  completely  getting  rid  of  the  irritating  material. 
In  more  obstinate  cases  the  stomach  may  be  freely  washed  out 
with  the  same  solution,  and  this  step  is  especially  indicated  when 


270     Treatment  after  Abdominal  Operations. 

large  quantities  of  bilious  fluid  are  being  ejected.  No  food 
should  be  given  by  the  mouth,  and  if  necessary  rectal  injections 
may  be  used. 

If  the  trouble  appears  to  be  of  nervous  origin,  a  hypodermic 
injection  of  J  or  |  gr.  of  morphia  should  be  ordered,  or  2  drachms 
of  potassium  bromide  in  3  oz.  of  water  may  be  adminis- 
tered by  the  rectum.  Early  action  of  the  bowels  will  frequently 
stop  the  sickness  ;  a  large  soap-and-water  enema  is  best,  and  a 
purgative  may  be  given  at  the  same  time. 

The  following  remedies  are  sometimes  successful  :  (1)  Tincture 
of  iodine  (1-min.  doses  in  a  teaspoonful  of  water  every  half  hour 
for  six  doses)  ;  (2)  10-min.  doses  of  a  2  per  cent,  solution  of 
cocaine  ;  (3)  bismuth  subnitrate  (in  30-gr.  doses)  ;  (4)  the 
application  of  a  mustard  plaster  or  blister  to  the  epigastrium. 

Hiccough. — Persistent  hiccough  is  even  more  distressing  and 
exhausting  to  the  patient  than  vomiting.  It  should  be  treated 
on  similar  lines. 

When  not  due  to  any  serious  complication,  frequent  sips  of 
hot  water  may  stop  it,  especially  if  this  results  in  thorough 
clearing  of  the  stomach  ;  small  doses  of  tincture  of  iodine  or 
cocaine  may  prove  successful,  and  nitroglycerin  (T^  gr.  three 
times  daily)  is  recommended.  A  spoon  pressed  firmly  on  the 
dorsum  of  the  tongue  as  far  back  as  not  to  excite  retching  some- 
times has  the  desired  effect.  In  more  severe  cases,  a  large  dose 
of  potassium  bromide  or  a  hypodermic  injection  of  morphia  should 
be  given. 

Distension. — This  may  be  due  to  a  great  variety  of  causes, 
and  before  treatment  is  commenced  an  attempt  should  be  made 
to  determine  the  cause  and  the  part  of  the  alimentary  canal 
affected.  The  surgeon  must  quickly  decide  whether  the  condition 
is  due  to  obstruction  or  to  peritonitis,  for  successful  treatment  of 
these  complications  depends  entirely  upon  prompt  recognition.  A 
moderate  degree  of  flatulent  distension  is  common  in  those  who  are 
stout  and  who  suffer  from  chronic  constipation.  Undue  handling  or 
exposure  of  the  intestines  will  certainly  be  followed  by  distension, 
and  this  is  most  marked  in  the  colon.  Gastric  distension  often 
accompanies  irritative  vomiting. 

When  the  stomach  is  the  seat  of  the  distension,  it  is  usually 
best  to  empty  it  by  giving  a  large  drink  of  bicarbonate  of  soda 
solution,  or  by  washing  it  out  through  a  stomach  tube.  Simple 
remedies  which  often  afford  great  relief  are  strong  peppermint 
lozenges,  ginger,  and  three  or  four  drops  of  turpentine  on  sugar ; 
placing  the  patient  well  on  the  left  side  is  sometimes  effectual. 


Treatment  after  Abdominal  Operations.     271 

When  the  lower  bowel  is  involved,  a  small  turpentine  enema 
and  the  use  of  the  long  rectal  tube  for  twenty  minutes  every 
three  hours  should  be  tried.  It  is  important  that  the  nurse  should 
make  certain  that  the  tube  is  acting  effectually,  and  this  is  done 
by  placing  the  free  end  of  the  tube  in  a  bowl  of  carbolic  lotion, 
when  the  appearance  of  bubbles  is  an  obvious  indication  of  the 
escape  of  flatus.  The  rectum  should  be  emptied,  if  necessary, 
by  a  common  enema  before  the  tube  is  first  passed. 

In  Paralytic  Distension  prompt  measures  must  be  taken,  for 
otherwise  the  condition  may  pass  on  to  complete  obstruction.  If 
the  rectal  tube  proves  ineffectual,  a  large  enema  containing 
i  oz .  turpentine  should  be  given  ;  in  obstinate  cases  the  following 
enema  will  sometimes  succeed  when  others  fail  :  Magnesium 
Sulphate,  =jss  ;  Glycerine,  jij  ;  Turpentine,  jss ;  Water,  to 
5vj.  At  the  same  time,  a  purgative  should  be  given.  The  best 
plan  is  to  order  4  or  5  gr.  of  calomel,  to  be  followed  by  sodium  and 
magnesium  sulphate  (1  drachm  of  each),  every  two  hours  until  the 
bowels  act. 

Drs.  Berkeley  and  Bonney1  strongly  recommend  a  rectal  wash- 
out. "  A  tube  is  passed  into  the  rectum  with  a  funnel  fitted  to 
its  free  end  :  2  pints  of  soap  and  water  at  a  temperature  of  105° 
are  mixed  with  1  oz.  of  turpentine,  and  10  oz.  of  this  solution 
are  passed  into  the  funnel,  which  is  held  as  high  as  possible.  The 
fluid  is  allowed  to  remain  in  the  rectum  for  a  few  minutes,  after 
which  the  funnel  is  lowered  and  the  injection  is  allowed  to  run 
out,  with  the  consequent  aspiration  of  flatus  from  the  intes- 
tine. Another  10  oz.  is  then  run  in  until  the  two  pints  are 
used  up." 

If  these  measures  fail  to  reduce  the  distension,  T^0  to  ^  gr. 
of  eserine  salicylate  should  be  given  hypodermically  every  three 
hours,  or  ^  gr.  of  strychnine  may  be  given  three  hourly. 
Pituitary  extract  (20  per  cent.)  is  highly  recommended  by  some 
authorities2 :  it  is  given  intra-muscularly  in  doses  of  1  cubic 
centimetre,  and  is  said  to  strongly  stimulate  intestinal  peristalsis 
and  to  cause  the  expulsion  of  flatus  in  a  short  time. 

The  bandages  should  be  kept  tight  in  order  that  firm  pressure 
may  be  maintained,  and  in  certain  cases  gentle  massage  is 
indicated. 

If  the  condition  of  paralytic  distension  passes  on  to  actual 
obstruction,  as  shown  by  the  occurrence  of  vomiting,  the  abdomen 
should  be  at  once  reopened.  It  will  often  be  found  that  the 
distension  is  in  part  due  to  mechanical  causes,  and  the  freeing  of 
adhesions  may  be  all  that  is  necessary  ;  in  most  cases,  however, 


272     Treatment  after  Abdominal  Operations. 

the  intestine  must  be  opened  and  drained,  the  most  distended 
coil  being  chosen  for  this  purpose. 

Retention  of  Urine. — Retention  is  not  uncommon  after 
abdominal  operations,  owing  to  the  dorsal  position  of  the  patient, 
nervousness,  and  the  pain  caused  by  contraction  of  the  abdominal 
muscles  ;  inflammatory  conditions  in  the  pelvis  and  operations 
upon  the  pelvic  organs  especially  predispose  to  retention.  It 
must  be  remembered  that  retention  may  be  partial,  a  few  ounces 
of  urine  remaining  in  the  bladder,  and  this  condition  if  not 
attended  to  may  give  rise  to  cystitis. 

The  amount  of  urine  secreted  during  the  twenty-four  hours 
after  an  operation  is  always  less  than  under  normal  conditions, 
especially  if  fluids  by  the  mouth  or  by  the  rectum  are  restricted. 
If  urine  is  not  passed  within  eighteen  hours  and  the  patient  feels 
no  desire  to  pass  urine,  the  hypogastrium  should  be  examined  to 
ascertain  whether  the  bladder  is  distended. 

Catheterisation  should  be  avoided  if  possible,  but  it  is  equally 
important  to  avoid  over-distension  of  the  bladder,  for  this  often 
leads  to  atony.  In  female  patients,  much  depends  on  skilful 
management  by  the  nurse  ;  hot  fomentations  to  the  hypogastrium 
and  perineum,  syringing  the  vulva  with  warm  water  over  a  bedpan, 
change  of  position  and  encouragement,  are  measures  to  be  tried  ; 
encouragement,  however,  must  never  verge  upon  bullying,  for 
this  does  more  harm  than  good.  Patients  are  more  likely  to  pass 
urine  if  left  alone  than  if  watched.  Small  doses  of  ergot  (ext. 
ergotse  liq.,  KY[5,  t.d.)  are  sometimes  useful  in  cases  of  persistent 
post-operative  retention.  If  the  passage  of  a  catheter  becomes 
necessary,  there  is  no  reason  in  the  great  majority  of  cases  why 
there  should  be  any  risk  of  exciting  cystitis.  Full  instructions 
for  the  passage  of  a  catheter  in  the  case  of  a  female  patient  are 
given  in  the  article  on  the  Management  of  the  Sick  Room. 

The  amount  of  urine  passed  during  each  period  of  twelve  hours 
should  be  measured  and  registered  on  the  chart.  Scanty,  high- 
coloured  urine  is  always  an  indication  that  fluid  is  needed,  and 
sometimes  points  to  impending  suppression  of  urine. 

Complications  Involving  the  "Wound.  —  Hcematomu.  —  A 
hsematoma  is  apt  to  form  in  the  wound  if  haemorrhage  is  not  care- 
fully arrested  before  the  wound  is  closed.  Haemorrhage  is  most 
easily  overlooked  when  resulting  from  puncture  of  a  vessel  by  a 
needle  carrying  a  stitch.  In  closing  the  wound  after  an  operation 
for  appendicitis,  the  deep  epigastric  vessels  and  their  branches 
are  especially  liable  to  be  injured. 

Unless  the  heematoma  is  very  small,  it  should  be  emptied  by 


Treatment  after  Abdominal  Operations.     273 

removing  a  stitch,  passing  a  grooved  director  into  the  cavity,  and 
pressing  out  the  blood  ;  a  small  scoop  will  materially  help  in 
getting  out  clot ;  a  firm  pad  of  sterile  gauze  is  then  applied.  An 
anaesthetic  is  not  necessary  as  a  rule,  but  the  most  rigid  precau- 
tions must  be  taken  as  regards  asepsis,  for  haematomata  are  very 
prone  to  become  infected,  in  which  case  healing  is  considerably 
delayed  and  a  weak  scar  results.  As  a  precaution  against  infec- 
tion from  the  surrounding  skin,  a  2  per  cent,  solution  of  iodine  in 
rectified  spirit  may  be  applied  to  the  wound  each  time  the  dress- 
ings are  changed. 

Suppuration. — This  is  shown  by  a  rise  of  the  temperature  and 
by  pain  about  the  wound  ;  when  the  dressings  are  removed, 
inflammatory  induration  is  obvious. 

The  removal  of  one  or  two  stitches  is  usually  indicated  ;  a  pair 
of  sinus  forceps  is  then  gently  passed  between  the  skin  edges  to 
allow  drainage,  and  a  small  tube  may  be  inserted.  Fomentations 
are  applied  to  the  wound  every  four  hours  until  the  temperature 
is  normal.  The  tube  may  then  be  left  out  and  the  cavity  packed 
with  a  small  strip  of  ribbon  gauze,  so  that  it  may  granulate  from 
the  bottom.  Not  more  than  one'  or  two  stitches  should  be 
removed,  for  if  more  are  removed  there  is  a  risk  of  the  whole 
wound  gaping. 

The  patient  should  not  be  allowed  to  get  up  until  the  wound 
has  firmly  healed,  and  a  well-fitting  abdominal  belt  should  be 
ordered,  for  ventral  hernia  is  especially  likely  to  follow  in  cases 
in  which  suppuration  has  occurred. 

Sloughing  of  the  Abdominal  Wall. — This  complication  is  for- 
tunately very  rare,  but  is  occasionally  seen  after  prolonged 
operations  upon  feeble  subjects,  in  whom  the  abdominal  wall  has 
been  strongly  retracted  and  bruised  ;  it  may  occur  also  in  cases 
of  gangrenous  appendicitis,  the  skin  edges  and  superficial  tissues 
being  involved. 

Fomentations  should  be  applied  every  three  hours  and  the 
patient's  strength  maintained  by  stimulants  and  frequent  feeding. 
Free  drainage  must  be  provided  for,  but  most  of  the  stitches  must 
be  left  in  situ,  even  if  there  is  considerable  irritation  about  them, 
for  otherwise  wide  gaping  of  the  wound  will  occur.  The  wound 
should  be  irrigated  twice  daily,  peroxide  of  hydrogen  (5  volumes) 
being  particularly  useful  for  this  purpose. 

Complete  recovery  usually  follows,  although  the  period  of 
convalescence  may  be  very  prolonged.  The  scar  is  invariably 
weak,  and  an  abdominal  belt  must  be  worn. 

Bursting   of  the    Wound. — It   occasionally   happens   that   the 

S.T. — VOL.  ii.  18 


274     Treatment  after  Abdominal  Operations. 

recently  closed  wound  bursts  open,  in  which  case  omentum  or 
intestines  prolapse.  The  causes  of  this  accident  are  imperfect 
suturing  or  suture  material,  excessive  vomiting,  coughing,  or 
straining  as  the  result  of  purgation,  too  early  removal  of  the 
stitches,  suppuration  in  the  wound,  and  great  distension,  such  as 
that  occurring  in  ileus  and  unrelieved  obstruction. 

Except  in  cases  in  which  this  accident  is  the  result  of  suppura- 
tion, an  anaesthetic  should  at  once  be  given  ;  the  prolapsed  parts 
are  bathed  with  warm  saline  solution  and  are  returned  to  the 
abdomen  ;  the  wound  is  then  carefully  re-sutured  and  a  firm 
abdominal  bandage  is  applied,  elastic  cotton  bandages  being 
especially  useful  in  these  cases.  Cough  and  any  other  condition 
which  may  cause  strain  on  the  abdominal  wall  should  be  vigorously 
treated.  If  the  accident  is  the  result  of  extreme  distension,  as 
in  peritonitis,  it  may  be  necessary  to  empty  the  bowel  by  puncture 
or  incision  before  it  can  be  returned. 

When  suppuration  has  occurred  and  there  is  partial  protrusion 
of  the  intestine,  the  protruded  parts  should  be  gently  pushed  back 
and  kept  in  place  by  a  gauze  pack  ;  the  sides  of  the  wound  are  then 
approximated  as  well  as  possible  with  broad  pieces  of  strapping. 

Thrombosis. — Thrombosis  of  the  femoral  vein  occasionally 
follows  abdominal  operations.  Mr.  Warrington  Haward  3  quotes 
thirty-four  instances  in  3,774  collected  cases  of  operation  for 
appendicitis  ;  pulmonary  embolism  occurred  in  eight  cases.  The 
condition  is  seen  almost  entirely  in  cases  in  which  there  is  some 
septic  focus  and  in  those  who  are  anaemic. 

Prophylaxis. — Potassium  or  sodium  citrate,  in  doses  of  10  gr., 
may  be  given  to  patients  who  seem  likely  to  develop  thrombosis. 
Regular  change  of  position  in  bed  is  also  important  for  those  whose 
circulation  is  sluggish  and  who  are  anaemic. 

Treatment. — The  main  object  of  treatment  is  the  prevention  of 
pulmonary  embolism.  The  affected  limb  is  placed  on  a  splint, 
all  movements  are  made  with  the  greatest  gentleness,  and  the 
patient  is  warned  of  the  importance  of  keeping  the  limb  absolutely 
still.  Lead  lotion  or  hot  fomentations  are  laid  along  the  course 
of  the  inflamed  vein,  or  glycerine  and  belladonna  may  be  applied. 
Pain  is  often  severe  in  the  early  stages,  and  small  doses  of  morphia 
are  very  beneficial  in  relieving  the  pain  and  keeping  the  patient 
quite  quiet.  Best  in  the  recumbent  position  for  at  least  six  weeks 
from  the  date  at  which  the  last  spread  of  the  thrombosis  occurred 
is  necessary,  and  after  this  firm  bandaging  will  be  required  for  a 
long  period,  for  re-establishment  of  the  venous  circulation  is  a 
tedious  process.  (See  also  Thrombosis,  Vol.  I.) 


Treatment  after  Abdominal  Operations.     275 

If  pulmonary  embolism  occurs,  as  a  rule  little  can  be  done. 
Oxygen  should  be  administered,  and  hypodermic  injections  of 
brandy,  camphor,  or  ether  should  be  given.  If  breathing  stops, 
artificial  respiration  should  be  performed. 

Post-operative  Hsematemesis.  —  Haematemesis  after  an 
abdominal  operation  may  be  due  to  one  of  many  causes.  When 
following  operations  upon  the  stomach,  it  is  the  result  of  imperfect 
control  of  divided  vessels  by  the  sutures,  or  of  manipulation  of  an 
ulcer  or  growth  for  which  the  operation  has  been  performed. 
After  other  operations  it  may  be  the  result  of  thrombosis  of  gastric 
vessels,  or  of  toxaemia,  or  of  irritation  of  an  unsuspected  gastric 
ulcer  by  the  effects  of  the  anaesthetic. 

The  cause  of  the  bleeding  should  be  determined,  if  possible. 
No  food  should  be  given  by  the  mouth  ;  stimulants  and  any  other 
measures  which  raise  the  blood-pressure  should  be  avoided.  A 
hypodermic  injection  of  |  gr.  of  morphia  should  be  ordered,  and 
an  icebag  applied  to  the  epigastrium  will  help  to  keep  the  patient 
quiet.  As  a  rule  no  drugs,  except  morphia,  should  be  given.  In 
persistent  haemorrhage,  however,  the  following  remedies  may  be 
tried,  although  their  action  is  very  uncertain  :  Adrenalin  chloride 
(1  in  2,000),  10  minims  in  1  drachm  of  water  every  half  hour  for 
four  doses  ;  turpentine,  5  minims  in  an  emulsion  ;  silver  nitrate, 
\  gr.  in  |  oz.  of  water  for  four  doses  ;  fresh  serum  or  albumen 
water. 

Thirst  must  be  treated  by  rectal  injections  of  saline,  |  pint 
every  four  or  six  hours.  If  the  patient  becomes  profoundly 
anaemic,  the  foot  of  the  bed  must  be  well  raised,  and  infusion  of 
saline  into  a  vein  or  subcutaneously  should  be  carried  out. 

Intra-peritoneal  Haemorrhage. — This  accident  is  usually  due 
to  faulty  control  of  haemorrhage  during  the  operation,  and  is  chiefly 
met  with  after  operations  upon  the  pelvic  organs.  Clinically  it 
is  shown  by  acute  pain,  pallor,  a  small  quick  pulse,  cold  limbs  and 
a  subnormal  temperature,  sweating  and  restlessness.  In  some 
cases  the  haemorrhage  is  sudden  and  severe,  and  the  patient  dies 
after  a  short  period  during  which  his  condition  has  been  too 
serious  to  allow  re-opening  of  the  abdomen.  In  most  cases  the 
onset  is  more  gradual. 

Prompt  measures  must  be  taken.  A  hypodermic  injection  of 
\  gr.  of  morphia  is  given,  and  the  patient  is  carried  carefully  back 
to  the  operating  theatre,  where  the  wound  is  reopened.  A  good 
light  and  adequate  assistance  are  essential.  Blood  clot  is  rapidly 
sponged  out,  and  the  bleeding  point  is  secured  as  quickly  as 
possible.  If  the  bleeding  comes  from  several  points,  ligatures 

18—2 


276     Treatment  after  Abdominal  Operations. 

should  be  applied  to  as  many  as  possible,  and  a  firm  gauze  plug 
is  then  inserted.  After  closure  of  the  wound,  the  patient  is 
returned  to  bed  ;  warmth  is  applied,  and  the  foot  of  the  bed  is 
well  raised.  No  stimulants  or  saline  injections  are  given,  unless 
it  is  certain  that  haemorrhage  has  ceased,  or  unless  the  bloodless- 
ness  is  so  profound  that  recovery  is  doubtful. 

T.  CRISP  ENGLISH. 

KEFEB.ENCES. 

1  Berkeley,  0.,  and  Bonney,  V.,  "  Gynaecological  Surgery,"  1911. 

2  Bell,  W.  Blair,  "  Principles  of  Gynaecology,"  1910. 

3  Ha  ward,  Warrington,  "Phlebitis  and  Thrombosis":  Hunteriau  Lectures, 
1906. 

See  also   McKay,   W.  J.    Stewart,  "The   Preparation   and   After-treatment 
of  Section  Cases,"  1905. 


277 


AFFECTIONS  OF  THE  UMBILICUS. 

THE  umbilicus,  representing  as  it  does  the  point  of  closure  of 
the  abdominal  cavity  of  the  foetus  and  the  point  of  entrance  or 
emergence  of  all  those  structures  which  pass  between  the  embryo 
and  the  placenta,  is  naturally  liable  to  many  congenital  or  develop- 
mental errors.  Three  important  blood-vessels  and  two  viscera  pass 
through  the  umbilical  ring.  The  two  hypogastric  arteries  (from  the 
internal  iliacs)  take  the  foetal  blood  to  the  placenta,  whilst  the 
umbilical  vein  returns  the  placental  blood  through  the  round 
ligament  of  the  liver  to  the  portal  circulation.  In  the  adult,  these 
three  vessels  are  represented  by  mere  fibrous  cords,  but  the 
ligamentum  teres  is  richly  supplied  with  lymphatics  along  which 
inflammatory  or  malignant  processes  readily  make  their  way  from 
the  interior  of  the  abdomen  to  the  umbilicus.  The  foetal  viscera 
connected  with  the  umbilicus  are  the  yolk  sac  and  the  allantois, 
both  of  which  normally  disappear  before  birth,  but  by  their 
abnormal  persistence  may  give  rise  to  a  great  variety  of  tumours, 
cysts  or  fistulas. 

CONGENITAL   MALFORMATIONS   OF    THE   UMBILICUS. 

(1)  Failure  of  complete  closure :  hernia ;  (2)  persistence  of 
vitelline  remains  ;  (3)  persistence  of  urachal  remains.  The  subject 
of  congenital  umbilical  hernia  is  treated  elsewhere. 

Vitelline  Remains. — In  early  foetal  life,  a  small  yolk  sac  lies 
in  the  substance  of  the  umbilical  cord,  connected  by  a  tubular 
stalk  with  the  primitive  intestine.  If  this  vitelline  duct  persists, 
it  gives  rise  to  the  intestinal  diverticulum  known  as  "Meckel's." 
But  the  connection  of  this  with  the  umbilicus  usually  disappears. 
In  rare  cases,  however,  the  duct  may  not  only  persist,  but  its 
opening  at  the  navel  may  remain  patent. 

Congenital  Umbilical  Anns. — In  this  condition  there  is,  in  addition 
to  a  patent  Meckel's  diverticulum  opening  at  the  umbilicus, 
a  stenosis  of  the  ileo-caecal  valve  or  atresia  of  some  part  of  the 
large  intestine,  so  that  practically  all  the  intestinal  contents  pass 
by  the  umbilicus.  Such  a  condition,  usually,  will  permit  of  no 
treatment,  owing  to  the  absence  or  atrophy  of  the  bowel  below  the 
patent  duct.  The  point  of  importance  is  that  in  any  case  where 


278  Affections  of  the  Umbilicus. 

the  faecal  discharge  from  an  umbilical  fistula  is  copious  no  attempt 
should  be  made  to  close  it  until  it  has  been  ascertained  that  there 
is  no  obstruction  to  the  bowel  below. 

Vitello-intestinal  Fistula. — In  this  there  is  a  small  quantity  of 
mucous  or  faecal  discharge  from  the  umbilicus,  and  a  probe  can  be 
passed  for  a  short  distance  down  a  fistulous  track.  Such  a  fistula 
tends  to  close  spontaneously,  but  this  closure  may  be  greatly 
hastened  by  destroying  the  mucous  lining  with  a  cautery  wire. 

Umbilical  Tumours  due  to  Vitelline  Remains. — A  small,  bright 
red,  mucous  adenoma  is  comparatively  common.  A  section 
shows  it  to  be  composed  of  glands  similar  to  those  of  the  small 
intestine.  It  may  be  of  larger  size  and  present  the  appearance  of 
a  prolapsed  mucous  duct,  being,  indeed,  the  vitelline  duct  bulging 
outwards.  This  form  is  sometimes  known  as  an  entero-teratorna. 
Lastly,  there  may  occur  various  degrees  of  prolapse  of  the  duct 
and  the  gut  to  which  it  is  attached.  The  treatment  of  all  these 
conditions  should  be  conducted  with  considerable  caution,  in  view 
of  the  fact  that  the  tumour  of  mucous  membrane  may  contain  a 
peritoneal  pouch  or  be  connected  with  the  intestine.  When  the 
growth  is  small  and  solid  it  only  needs  to  be  cut  off  by  scissors  or 
cautery.  When  evident  bulging  exists,  it  is  better  to  cut  cautiously 
round  the  tumour  and  carefully  ligature,  sew  over  its  connection 
with  the  intestine  and  then  close  the  parietes,  as  in  dealing  with 
a  hernia. 

Persistence  of  Urachal  Remains. — The  stalk  of  the  placenta 
is  formed  in  early  embryonic  life  by  a  hollow  cord,  the  dilated  end 
of  which  is  the  urinary  bladder.  At  various  stages  of  this  growth 
development  may  be  arrested,  giving  rise  to  extroversion  of  the 
bladder  or  different  kinds  of  urinary  fistula  opening  from  the 
umbilicus  to  the  bladder. 

From  the  practical  point  of  view  these  urinary  umbilical 
fistulas  may  be  divided  into  three  classes,  that  of  infancy,  adult 
life,  and  certain  rare  cystic  conditions. 

The  Urinary  Fistula  at  the  Umbilicus  of  Infants. — This  con- 
sists of  a  narrow  track  lying  behind  the  linea  alba,  in  front  of 
the  peritoneum  opening  into  the  fundus  of  the  bladder  at  one  end 
and  on  to  the  navel  at  the  other.  A  little  leakage  of  urine  at  the 
navel  and  the  passage  of  a  probe  will  indicate  the  diagnosis. 
There  is  a  tendency  to  spontaneous  closure  of  this,  which,  together 
with  the  patient's  tender  age,  makes  operative  treatment  inad- 
visable. But,  in  any  case,  the  passage  of  an  electro-cautery  wire, 
so  as  to  destroy  the  mucous  lining  of  the  canal,  will  be  all  that  is 
required. 


Affections  of  the  Umbilicus.  279 

ACQUIRED    AFFECTIONS    OF    THE    UMBILICUS. 

Urinary  Fistulae  at  the  Umbilicus  in  Adults. —  When  a 
urinary  fistula  forms  and  discharges  at  the  umbilicus  of  an  adult, 
it  is  usually  the  result  of  some  obstructive  and  inflammatory 
condition  in  the  bladder.  A  partially  patent  urachal  duct  has 
remained  connected  with  the  bladder,  and  along  this  the  infected 
urine  finds  its  way  to  the  navel.  In  such  a  case,  it  is  necessary  to 
remove  any  obstruction  from  the  natural  outflow  channel  of  the 
bladder  and  to  cure  the  cystitis  before  attempting  to  close  the  urinary 
fistula.  When  this  has  been  done,  the  fistula  must  be  dissected 
out  from  the  mid-line  without  opening  the  peritoneum.  But  if 
the  fistula  is  associated  with  some  condition  which  necessitates 
opening  the  bladder,  e.g.,  a  large  prostate  or  a  vesical  growth,  then 
it  can  be  dealt  with  in  the  first  stage  of  the  operation  of  suprapubic 
cystotomy.  An  incision  is  made  from  the  navel  to  the  pubes,  the 
fistula  dissected  out  from  above  downwards,  and  the  upper  part  of 
the  wound  closed.  The  bladder  can  then  be  opened  by  cutting  off 
the  fistula  where  it  joins  that  viscus. 

Urachal  Cysts. — These  are  really  tubulo-dermoids  developed 
in  the  remains  of  the  urachus.  They  may  form  tumours  of 
moderate  or  large  size  which  are  fixed  to  the  deep  surface  of  the 
parietes  below  the  umbilicus.  The  treatment  is  excision. 

Inflammatory  Conditions  of  the  Umbilicus. — These  are 
comparatively  common  in  infants  and  old  people. 

///  infants  the  inflammation  is  usually  set  up  by  a  septic  infection 
of  the  cord  during  the  process  of  its  separation.  This  may 
cause  a  slight  local  soreness  with  weeping  granulation  tissue  and 
an  encircling  patch  of  eczema.  Such  a  condition  will  be  cured 
by  touching  the  granulations  with  silver  nitrate  caustic  and 
dusting  the  skin  with  zinc  oxide  powder.  But  of  far  greater 
importance  is  the  general  septic  disease  set  up  by  infection  of 
the  cord.  Thrombosis  of  the  umbilical  vessels,  general  septicaemia 
marked  by  jaundice,  haemorrhage  and  diarrhoea,  and  tetanus  in 
the  new-born,  are  all  due  to  this  portal  of  infection.  It  is 
impossible  to  be  certain  of  the  actual  infant  mortality  from  these 
sources,  but  it  is  highly  probable  that  many  cases  of  death  from 
convulsions,  diarrhoea,  vomiting,  etc.,  are  in  reality  due  to  this 
cause.  Of  course,  the  prophylactic  treatment  is  nothing  more  or 
less  than  the  observance  of  asepsis  in  tying,  cutting  and  dressing 
the  cord. 

Inliammatwn  of  the  Umbilicus  in  the  Adult. — This  is  generally  a 
dirt  eczema  in  obese  persons  in  whom  the  navel  has  become 


280  Affections  of  the  Umbilicus. 

sunk  in  a  deep  pit.  In  this,  dirt,  sweat  and  foreign  bodies  collect 
and  set  up  a  skin  irritation  ;  or  an  inspissated  mass  may  be 
formed  by  the  agglutination  of  various  debris  with  sebum  and  an 
umbilical  calculus  will  be  the  result.  This  must  be  released  by 
slitting  open  the  orifice  of  the  umbilical  canal,  and  instructing 
the  patient  to  wash  out  the  cavity  daily. 

Acquired  Umbilical  Fistulse. — There  is  a  marked  tendency 
for  many  intra-abdominal  diseases  to  burst  through  the  parietes  at 
the  umbilicus,  and  hence  the  number  and  variety  of  umbilical 
fistulae  is  very  great. 

They  may  conveniently  be  divided  up  as  follows : 

(1)  Peritoneal,  from  acute  peritonitis,  local  peritonitis,  tuberculous 
peritonitis,  cancerous  peritonitis,  ascites  ;  (2)  gastric,  from  trauma, 
ulcers,  cancer  or  operations ;  (3)  intestinal,  from  a  gangrenous 
umbilical  hernia,  foreign  body,  wound,  or  operations  (also  see 
above  for  vitello-intestinal  fistulse) ;  (4)  biliary,  from  the 
adhesion  of  the  gall-bladder  to  the  parietes,  with  direct  bursting 
through  the  navel  or  more  often  through  a  sub-umbilical  abscess ; 
(5)  vesical,  usually  congenital  (see  above). 

The  nature  of  the  fistulae  may  be  made  quite  evident  by  the 
character  of  the  discharge,  gastric,  intestinal,  biliary  and  vesical 
contents,  all  being  so  very  distinctive  from  one  another.  When 
the  fluid  has  none  of  these  definite  characters  but  is  clear  or 
purulent,  the  inference  is  that  the  fistula  communicates  with  the 
peritoneum. 

Peritoneal  Fistula. — If  these  are  secondary  to  cancer  or  ascites, 
nothing  of  a  directly  curative  nature  can  be  done.  If  any  diffuse 
peritonitis,  e.g.,  that  due  to  the  pneumococcus  or  tubercle,  has 
burst  through  the  navel,  there  need  be  no  hesitation  in  freely 
opening  the  abdomen  and  evacuating  the  fluid  contents.  But  if,  as 
is  most  often  the  case,  the  fistula  leads  into  an  irregular  abscess 
cavity,  the  utmost  caution  is  required  in  dealing  with  it.  A 
grooved  director  is  passed  into  the  fistulas  and  the  abscess  cavity 
opened  by  cutting  along  this  and  then  packed  and  drained.  The 
other  varieties  of  fistulse  opening  at  the  umbilicus  must  be  treated 
according  to  the  general  principles  described  under  the  headings  of 
the  diseases  of  stomach,  intestines,  gall-bladder  or  urinary  bladder. 

Tumours  of  the  Umbilicus. — The  following  tumours  occur  in 
connection  with  the  umbilicus  : 

Innocent:  Granuloma,  papilloma,  fibroma,  myxoma,  angeioma, 
adenoma  (from  vitelline  remains) ;  cysts,  vitelline,  sebaceous, 
urachal,  and  dermoid.  Malignant:  Sarcoma,  carcinoma,  primary 
and  secondary.  It  seems  scarcely  necessary  to  add  anything  to  what 


Affections  of  the  Umbilicus.  281 

has  already  been  said  about  the  innocent  tumours.  If  they  cause 
any  discomfort  they  should  be  removed. 

Sarcoma  growing  at  the  navel  is  a  deeply  placed  and  well-defined 
ovoid  tumour  covered  with  large  veins.  It  does  not  grow  very 
fast  and  is  only  of  comparatively  slight  malignancy.  The  mere 
fact  of  any  tumour  steadily  growing  should  be  enough  to  demand 
its  removal  without  waiting  for  details  to  clear  up  the  diagnosis. 

Primary  Epithelioma  of  the  umbilicus  may  begin  as  a  warty 
mass  or  as  an  epithelioma  with  hard  everted  edges.  It  may  be 
caused  by  a  patch  of  chronic  eczema  in  the  pit  of  the  navel.  Early 
excision  with  a  generous  margin  of  healthy  tissue  is  the  necessary 
treatment.  The  peritoneum  need  not  be  opened  in  this  operation. 

Secondary  Cancer  of  the  umbilicus  is  a  very  frequent  sequela 
of  any  form  of  intra-abdominal  malignant  disease,  but  especially 
that  of  the  liver,  stomach  and  female  genital  organs.  A  hard  red 
nodule  occurs  at  the  navel,  and  this  soon  gives  rise  to  an 
ulcer  or  fungating  sore.  Usually  the  evidence  of  the  primary 
disease  is  so  obvious  that  no  unnecessary  operative  treatment  will 
be  undertaken. 

Umbilical  Hernia  (see  Chapter  on  Hernia). 

ERNEST  W.  HEY  GROVES. 


282 


INJURIES    OF    THE    STOMACH. 

EXTERNAL   INJURIES   ASSOCIATED   WITH   WOUND. 

(1)  Stab-wound  over  Stomach  Region. — It  is  first  necessary 
to  ascertain  by  means  of  a  clean  finger  or  probe  whether  the 
abdominal  wall  has  been  actually  pierced  or  merely  wounded.  If 
the  weapon  has  actually  pierced  the  peritoneum  it  will  be  necessary 
to  perform  abdominal  section  and  then  to  repair  the  stomach  or  any 
other  viscus  that  may  be  injured. 

The  skin  for  some  distance  round  the  wounds  must  therefore  be 
thoroughly  cleansed  by  washing  with  ether  soap  and  water  and 
then  painted  with  a  solution  of  iodine  in  chloroform  (15  gr.  to  the 
ounce).  All  instruments  having  been^oiled,  the  wound  having  been 
surrounded  with  sterilised  towels  and  the  hands  of  the  surgeon 
having  been  thoroughly  cleansed  and  if  practicable  gloved  with 
rubber,  the  wound  must  be  enlarged  in  such  a  way  as  to  inflict  the 
least  injury  on  muscular  fibres,  vessels  or  nerves,  for  instance, 
vertically  if  over  the  recti,  or  obliquely  if  external  to  the  recti. 
Through  the  wound,  which  must  be  large  enough  to  permit  of 
examination  of  the  viscera  (say  3  or  4  inches),  the  stomach, 
omentum,  colon,  etc.,  can  be  examined  and  repaired  if  injured. 

The  presence  of  gas  in  the  peritoneum  will  point  to  puncture  of 
a  hollow  viscus.  If  the  gas  is  odourless  it  will  indicate  stomach 
injury.  If  the  puncture  of  the  stomach  is  small  and  not  bleeding 
the  readiest  repair  is  effected  by  a  purse-string  suture,  which  can  be 
applied  very  quickly. 

If  the  wound  is  bleeding,  a  through-and-through  continuous 
stitch,  taking  up  all  the  coats,  will  at  the  same  time  effect  approxi- 
mation and  haemostasis,  and  the  wound  can  be  made  secure  either 
by  a  Lembert's  or  a  purse-string  suture. 

If  the  wound  is  extensive  the  continuous  through-and-through 
suture  covered  in  by  a  Lembert's  suture  will  prove  effectual.  The 
abdomen  must  then  be  cleansed  of  blood  clots  and  stomach  contents 
and  either  drained  by  a  rubber  tube  containing  a  strip  of  gauze 
brought  through  the  wound,  or  if  the  peritoneal  cavity  has  not  been 
soiled  the  abdominal  wound  can  be  closed  without  drainage. 

A  dressing  of  sterilised  gauze  or  of  double  cyanide  gauze  covered 


Injuries  of  the  Stomach.  283 

with  sterilised  wool  and  held  in  place  by  strapping  and  a  many- 
tailed  bandage  is  simple  and  efficient. 

(2)  Gunshot  Injuries. — If  the  injury  is  inflicted  by  a  non- 
expanding  bullet  from  a  modern,  high  velocity  rifle  and  occurs  on  the 
battlefield  or  where  treatment  cannot  be  efficiently  carried  out,  it  is 
better  to  keep  the  patient  quiet  and  avoid  giving  anything  by  the 
mouth. 

A  subcutaneous  injection  of  morphia  to  relieve  pain  and  arrest 
the  peristaltic  movement  of  the  viscera  is  usually  called  for,  and  the 
external  wounds  must  be  dressed  with  cyanide  or  simple  sterilised 
gauze.  If,  however,  the  injury  should  occur  where  it  is  possible  to 
obtain  skilled  help  and  the  advantages  of  a  properly  equipped  hospital 
or  nursing  home,  it  is  better  not  to  trust  to  chance,  but  to  treat  the 
case  as  just  described  for  a  stab  wound,  following  up  the  track 
of  the  bullet,  repairing  any  injuries  to  viscera,  ligaturing  injured 
vessels  and  carefully  cleansing  the  track  of  the  missile,  removing 
any  foreign  bodies,  such  as  pieces  of  clothing,  and,  if  it  can  be 
readily  found,  removing  the  bullet. 

On  no  account  must  a  prolonged  search  be  made  for  the  bullet, 
and  it  is  not,  as  a  rule,  wise  to  wash  out  the  abdomen  or  to  use 
anything  but  hot  sterilised  normal  saline  solution  for  the  swabs 
employed  for  cleansing  the  injured  parts. 

INJURIES   WITHOUT   EXTERNAL   WOUND. 

(1)  Injuries  of  the  stomach  caused  by  a  kick  or  blow  with  a 
fist  or  blunt  instrument  are  usually  accompanied  by  such  pro- 
found shock  that  even  instant  death  may  result. 

The  treatment  for  shock  will  in  any  case  be  the  first  care,  and 
until  a  diagnosis  of  the  extent  of  the  injury  has  been  made  it  is 
better  not  to  give  anything  by  the  mouth  but  to  administer  an 
enema  of  hot  normal  saline  fluid  (about  1  pint)  containing  1  oz. 
of  brandy,  this  to  be  repeated  in  half  an  hour  or  less  if  required. 
The  patient  must  be  wrapped  in  blankets  and  have  hot  bottles 
applied  to  the  extremities.  A  subcutaneous  injection  of  morphia 
may  do  good,  but  the  disadvantage  of  cloaking  symptoms  must  be 
borne  in  mind.  A  subcutaneous  injection  of  5  min.  of  solution  of 
strychnine  [U.S.P.  strychnin,  hydrochlor.  gr.  -£%]  is  to  be  preferred, 
and  this  can  be  repeated  in  an  hour  or  two  if  required. 

If  the  symptoms  of  shock  do  not  yield  to  treatment  the  occurrence 
of  haemorrhage  from  ruptured  vessels  must  be  considered,  and  if 
there  is  a  fluid  thrill  to  be  elicited  across  the  abdomen  or  in  the 
loins,  or  if  liver  dulness  is  diminished  or  absent,  the  question  of 
immediate  abdominal  section  must  be  considered. 


284  Injuries  of  the  Stomach. 

Only  a  very  small  incision  is  required  for  diagnostic  purposes,  as 
the  escape  of  gas  or  blood  will  at  once  tell  if  it  is  necessary  to  extend 
the  opening  for  the  repair  of  any  laceration  or  for  the  arrest  of 
haemorrhage. 

If  the  stomach  is  found  to  be  lacerated  the  tear  must  be  sutured 
by  a  through-and-through  continuous  catgut  suture,  taking  up  all 
the  coats,  this  to  be  covered  in  by  a  continuous  serous  suture  of 
silk  or  Pagenstecher's  thread.  The  abdominal  toilet  must  then  be 
completed  as  described  under  gun-shot  injury. 

(2)  Rupture  from  within,  so-called  "  Spontaneous  Rupture  " 
from  over-distension,    is  an  extremely  rare  event  which  demands 
immediate  laparotomy  with  repair  of  the  laceration  and  cleansing 
of  the  abdominal  cavity. 

(3)  Puncture  from  within,  as  in  the  case  of  a  sword-swallower, 
is  also  extremely  rare,  and  as  the  accident  will  be  immediately 
recognised  no  time  need  be  lost  in  performing  immediate  laparotomy 
and  repair  of  the  punctured  viscus. 

Should  haemorrhage  occur  without  puncture  of  the  visceral  wall, 
as  in  a  case  under  my  care  in  which  the  patient  had  swallowed 
nails,  the  stomach  must  be  opened  and  the  foreign  body,  "  knife, 
nails  or  whatever  it  may  be,"  must  be  removed,  any  bleeding  points 
ligatured  and  the  stomach  wall  closed  by  visceral  and  peritoneal 
sutures. 

In  the  after-treatment  of  these  cases  rectal  feeding  for  two  or 
three  days  will  be  advisable,  only  water,  albumen  water,  plasmon 
and  barley-water  or  weak  tea  being  given  by  the  mouth ;  unless  the 
pain  is  severe  morphia  is  best  avoided,  especially  as  5  to  10  gr.  of 
aspirin  repeated  if  needful  will  usually  give  relief.  On  the  third  or 
fourth  day  the  bowels  should  be  moved  by  enema,  but  it  is  not 
advisable  to  give  an  aperient  until  the  end  of  the  week. 

INJURIES   DUE    TO  SWALLOWING  OF  CAUSTIC  FLUIDS. 

As  the  shock  is  profound  and  the  pain  is  intense,  morphia  subcu- 
taneously  will  be  necessary,  and  at  the  same  time  the  caustic 
swallowed  must  be  neutralised  by  acid  or  alkali  according  to  the 
nature  of  the  fluid  taken.  Emesis  may  be  induced  if  the  case  is 
seen  at  once  by  the  administration  of  salt  and  water,  which  will 
serve  to  dilute  the  poison. 

All  feeding  for  some  days  must  be  by  rectum.  The  mouth  and 
throat  must  be  kept  clean  by  spraying  or  washing  with  some  mild 
antiseptic,  such  as  boric  solution.  When  feeding  is  begun  the  food 
must  be  liquid  and  non-irritating,  and  only  when  epigastric  pain 
and  tenderness  have  subsided  must  soft  solids  be  allowed. 


Foreign  Bodies  in  the  Stomach.  285 

If  there  is  extensive  ulceration  and  sloughing  of  the  mouth, 
pharynx,  resophagus  and  stomach  the  operation  of  jejunostomy 
may  be  required,  so  as  to  be  able  to  feed  the  patient  without  causing 
irritation  of  the  ulcerated  surfaces.  At  a  later  stage  further  surgical 
treatment  may  be  demanded  for  stricture  of  the  cardiac  or  pyloric 
orifices  of  the  stomach. 

FOREIGN   BODIES   IN   THE   STOMACH. 

The  removal  of  foreign  bodies  lodged  in  the  stomach  by  means 
of  the  operation  of  gastrotomy  has  been  attended  with  considerable 
success  when  performed  by  surgeons  of  experience.  It  is  the  only 
method  of  treatment  available,  and  in  this  way  nails,  knives, 
spoons,  forks,  razors,  false  teeth,  safety  pins,  ordinary  pins  and 
needles,  coins,  keys,  hair  balls,  gall  stones  and  other  substances 
have  been  successfully  removed. 

The  indications  for  the  operation  are  the  presence  of  a  foreign 
body  which  can  neither  be  safely  dissolved  nor  allowed  to  pass 
through  the  bowel,  and  which  is  actually  producing  or  likely  to 
produce  serious  symptoms. 

The  mortality  under  improved  technique  ought  not  to  exceed  5  per 
cent.,  though  of  seventy-one  cases  collected  from  all  sources  by 
Friedenwald  and  Rosenthal  and  reported  in  July,  1903,  seven 
died.  The  earlier  the  operation  the  greater  had  been  the  success 
attending  it. 

Operation  of  Gastrotomy. — After  opening  the  abdomen  as 
described  under  gastro-enterostomy  the  stomach  is  brought  for- 
ward into  the  wound  and  surrounded  by  sterile  gauze  ;  the  anterior 
wall  of  the  viscus  is  incised  transversely  to  its  axis  so  as  to  avoid 
unnecessarily  wounding  blood-vessels,  the  foreign  body  or  bodies 
are  then  removed  by  fingers  or  forceps  and  the  wound  in  the 
stomach  is  repaired  by  a  continuous  chromic  catgut  suture  which 
takes  up  all  the  coats.  The  line  of  suture  is  buried  by  a  second 
continuous  stitch  of  silk  or  Pagenstecher's  thread,  which  takes  up 
the  serous  coat.  The  exposed  part  of  the  stomach  and  the  line  of 
suture  are  carefully  wiped  with  normal  saline  solution  and  returned 
to  the  abdomen,  which  is  then  closed. 

A.  W.  MAYO-ROBSON. 


286 


DISEASES    OF    THE    STOMACH    AND 
DUODENUM. 

THE  stomach  is  more  prone  to  disturbances  of  function  than  any 
other  viscus  of  the  body,  and  the  symptoms  with  such  derange- 
ments are  accompanied  closely  resemble  those  that  ensue  from 
organic  lesions  of  its  structure.  Moreover,  the  digestive  apparatus 
is  of  such  delicate  construction  and  perfect  equipoise  that  failure  of 
one  portion  is  invariably  followed  sooner  or  later  by  disturbance  of 
the  whole,  while  its  vicarious  functions  are  so  numerous  and 
diverse  that  it  is  injuriously  affected  by  disease  of  any  other 
important  organ.  It  is,  therefore,  obvious  that  no  form  of  treatment 
can  be  undertaken  with  assured  success  unless  the  primary  dis- 
order has  been  accurately  determined,  and  that  the  selection  of 
medicinal  remedies  must  be  influenced  by  the  state  not  only  of 
the  stomach  itself,  but  also  of  those  other  viscera  upon  which  the 
conservation  of  the  general  health  invariably  depends.  In  the 
following  pages  the  various  disorders  and  diseases  of  the  stomach 
are  considered  under  their  appropriate  titles,  and  due  reference  is 
made  to  the  prevention  and  management  of  the  principal  complica- 
tions that  are  apt  to  ensue  during  their  progress  :  (1)  Atony ; 
(2)  Atrophy ;  (3)  Cancer ;  (4)  Dilatation ;  (5)  Displacements ; 
(6)  Haemorrhage ;  (7)  Inflammations ;  (8)  Nervous  disorders ; 
(9)  Parasites,  Concretions,  etc. ;  (10)  Secretory  disorders  ;  (11)  Sym- 
ptoms of  gastric  diseases ;  (12)  Ulcer  of  stomach  and  duodenum ; 
(13)  Sea- sickness. 


ATONY    OF   THE    STOMACH. 

ATONY,  or  myasthenia  as  it  is  more  appropriately  termed,  implies 
an  enfeeblement  of  the  musculature  of  the  stomach,  combined  with 
a  notable  loss  of  elasticity.  It  seldom  occurs  as  a  primary  com- 
plaint, but  is  either  associated  with  a  similar  condition  of  the  entire 
digestive  tract  or  ensues  from  inflammations  or  displacements  of 
the  stomach,  fatty  or  lardaceous  diseases  of  its  muscular  tissue  or 
from  an  obstruction  to  the  passage  of  food  through  the  pylorus. 

Prophylaxis. — Gastric  myasthenia  is  very  apt  to  develop  during 
convalescence  from  a  febrile  malady  and  in  the  course  of  debili- 
tating diseases.  Under  these  conditions  special  precautions  must 
be  taken  to  preserve  the  motor  power  of  the  stomach.  Overfeeding 


Atony  of  the  Stomach.  287 

with  fluid  nourishment  must  be  avoided,  and  milk  should  not  be 
given  in  quantities  exceeding  6  oz.  at  a  time,  while  concentrated 
meat  juices,  essences  and  jellies  are  to  be  preferred  to  beef-tea, 
soups  and  broths.  Poached  eggs,  ham,  bacon,  lightly-cooked  fish, 
chicken  and  game  which  have  been  passed  through  a  sieve,  sheep's 
brains,  calf's  head,  tripe  and  sweetbreads  may  be  allowed,  while 
raw  meat  pulp  mixed  with  its  own  juice  is  easily  digested.  Bread 
and  starchy  materials  are  apt  to  ferment,  and  should  be  omitted  in 
favour  of  toast,  plain  biscuits,  or  one  of  the  patent  cereal  prepara- 
tions. Uncooked  vegetables  and  fruits  are  especially  injurious,  but 
a  baked  apple  may  be  allowed  occasionally.  Excess  of  fluid  with 
the  meals  must  be  prohibited,  and  only  a  little  hot  water  should  be 
taken  with  the  food.  The  application  of  a  firm  belt  or  binder  to 
the  abdomen  prevents  sagging  of  the  viscus  in  the  erect  position, 
and  both  massage  and  electricity  are  of  value  in  improving  the 
tone  of  the  abdominal  walls. 

Massage  is  employed  in  the  treatment  of  gastric  myasthenia 
with  three  objects  :  (1)  To  promote  the  evacuation  of  the  contents 
of  the  stomach  and  to  increase  its  peristaltic  activity  ;  (2)  to  relieve 
the  associated  condition  of  intestinal  atony ;  (3)  to  strengthen  the 
abdominal  wall. 

(1)  Gastric  peristalsis  may  be  excited  by  gentle  stimulation  of 
the  cutaneous  nerves  of  the  abdomen  in  the  following  manner : 
The   tip  of  the  right  thumb  of  the  operator  is  placed  upon  the 
abdominal   wall   over   the   centre   of  the  stomach,  and  by  rapid 
rotatory  movements  of  the  wrist,  the  tips  of  the  fingers  are  allowed 
to   describe   a   series    of   circles   upon   the  skin.     No   pressure  is 
exercised,  a  light  brushing  movement  being  all  that   is  required. 
At  intervals  of  a  minute  the  thumb  is  moved  to  an  adjoining  spot 
over  the  region  of  the  stomach  and  the  process  repeated.     This 
treatment  is  practised  night  and  morning  for  ten  minutes  when  the 
organ  is  empty,  and  is   particularly  useful  when   myasthenia   is 
accompanied  by  stagnation  of  food.     Patients  soon  learn  to  per- 
form it  for  themselves.     It  has  been  claimed  by  some  authorities 
that  the  contents  of  the  stomach  may  be  squeezed  through   the 
pylorus  by  the  adoption  of  the  following  method  :  The  ulnar  border 
of  the  operator's  left  hand  is   firmly   pressed   into  the  abdomen 
along  the  lower  border  of  the  stomach,  so  that  the  pyloric  end  lies 
in  the  palm  of  the  hand.     The  fingers  and  thumb  of  the  right  hand 
are  then  pressed  deeply  into  the  fundus,  and  by  a  series  of  pushing 
movements   the  contents   of   the   viscus   are   forced    toward    the 
pylorus. 

(2)  If   the  motions    are    hard    and    constipation    troublesome, 


288  Atony  of  the  Stomach. 

massage  of  the  lower  bowel  should  be  undertaken  first,  but  if  the 
stools  are  fluid  the  rubbing  may  be  begun  over  the  caecum.  In  the 
former  case,  the  right  hand  is  laid  flat  over  the  upper  part  of 
the  descending  colon,  with  the  fingers  of  the  left  hand  super- 
imposed upon  it,  the  two  hands  being  slowly  moved  downward  and 
inward  and  being  made  to  dip  deeply  into  the  pelvis.  The  right 
is  then  placed  upon  the  caecum,  with  the  ulnar  border  pressing 
more  deeply  than  the  radial ;  the  little  finger  and  thumb  are  then 
slightly  approximated,  and  with  the  fingers  in  this  position  the 
whole  hand  is  moved  along  the  course  of  the  colon  ;  the  procedure 
being  repeated  three  or  more  times  a  minute. 

(3)  To  increase  the  tone  of  the  abdominal  muscles  massage  is 
applied  to  the  abdominal  wall,  and  the  patient  performs  regular 
daily  exercises  with  active  and  resisted  movements. 

Electricity. — It  was  formerly  the  custom  to  employ  a  continuous 
current  to  the  stomach  by  means  of  an  intragastric  electrode.  This 
method,  which  is  always  distasteful  to  the  patient,  has  been 
superseded  by  the  polyphase  alternating  current.  When  applied 
percutaneously,  the  triphase  current  produces  contraction  of  the 
stomach  and  intestines,  strengthens  their  peristalsis  and  promotes 
the  evacuation  of  chyme  into  the  duodenum.  The  electrodes  should 
each  possess  the  same  area  and  must  be  well  wetted  before  being 
applied  to  the  skin.  The  patient  lies  upon  a  couch  with  one  elec- 
trode at  the  side  of  the  dorsal  spine  and  the  other  placed  over  the 
epigastrium.  The  current  is  applied  for  fifteen  minutes  each  day 
for  a  fortnight,  and  then  on  alternate  days  for  another  month. 
Many  of  the  most  obstinate  cases  lose  their  symptoms  after  a 
course  of  this  character  (see  Herschell's  "  Manual  of  Intragastric 
Technique  "). 

Lavage. — This  is  only  of  value  when  myasthenia  is  accompanied 
by  retention  of  food  and  gastrectasis,  and  should  then  be  performed 
in  the  early  morning  before  breakfast.  As  a  rule  warm  water  con- 
taining 1  gr.  of  bicarbonate  of  sodium  to  the  ounce  is  all  that  is 
required,  but  if  gastric  fermentation  is  active  some  antiseptic 
solution  may  be  used,  such  as  salicylic  acid  (1  in  1;000)  ;  sodium 
salicylate  (1  per  cent.),  potassium  permanganate  (1  in  1,000), 
boracic  acid  (1  per  cent.),  or  borax  (5  per  cent.).  Some  authorities 
recommend  that  after  the  stomach  has  been  washed  out,  a  pint  of 
boro-salicylic  solution  (boracic  acid  60  gr.,  salicylic  acid  20  gr.,  dis- 
solved in  a  pint  of  water)  should  be  introduced  into  the  organ  and 
allowed  to  remain  for  five  minutes.  A  teaspoonful  of  glycerine 
administered  after  lavage  completes  the  process  of  antisepsis  and 
also  acts  as  a  useful  aperient.  The  inner  surface  of  the  stomach 


Atony  of  the  Stomach.  289 

may  be  sprayed  by  means  of  the  needle-douche  invented  by  Turck. 
By  the  alternate  use  of  hot  and  cold  water,  an  important  tonic 
effect  is  said  to  be  produced  upon  the  secretory  and  muscular 
structures  of  the  organ. 

Climate  and  Baths. — When  a  change  of  air  is  considered  advis- 
able, a  dry  bracing  place  should  be  selected  in  preference  to  a  low- 
lying  or  enervating  locality.  For  this  reason  Scotland,  Yorkshire, 
Malvern  and  the  east  and  south-east  seaboard  usually  agree,  while 
the  southern  and  south-western  parts  of  England  almost  invariably 
increase  the  symptoms  of  the  complaint.  If  the  water  is  impreg- 
nated with  lime,  Malvern  water,  Salutaris,  or  some  other  pure  water 
should  alone  be  drunk.  A  visit  to  Switzerland  is  often  attended  by 
good  results.  When  myasthenia  is  accompanied  by  neurasthenia 
or  gastroptosis,  Egypt  or  Algiers  may  be  selected  as  a  winter  resort 
with  advantage. 

Mineral  waters  are  chiefly  indicated  when  constipation  or  anaemia 
is  a  prominent  feature  of  the  complaint,  but  should  be  prescribed 
with  caution  when  the  disorder  is  accompanied  by  gastric  dilata- 
tion. In  the  former  case,  Kissengen  or  Brides-les-Bains  may  be 
recommended,  or  if  a  more  bracing  climate  is  deemed  necessary, 
Tarasp  may  be  tried ;  while  in  the  latter,  the  iron  springs  of 
St.  Moritz  often  afford  good  results.  Carlsbad  and  Marienbad 
should  be  avoided ;  but  a  course  of  the  waters  of  Harrogate  or 
Llandrindod  is  sometimes  beneficial. 

Diet. — The  quantity  of  the  food  as  well  as  the  frequency  with 
which  it  is  administered  must  be  adjusted  to  meet  the  requirements 
of  each  case.  Owing  to  the  fact  that  liquids  stagnate  in  the 
inyasthenic  stomach,  many  authorities  recommend  an  entirely  dry 
diet,  and  only  permit  a  small  amount  of  fluid  to  be  taken  before  or 
after  meals.  As  a  matter  of  fact,  however,  water  is  an  important 
excitant  of  gastric  secretion,  and  when  given  in  moderate  quan- 
tities along  with  the  food  it  also  stimulates  peristalsis.  Unless 
hyperacidity  exists,  milk  usually  disagrees  and  should  never  be 
given  in  bulk.  Tea  and  coffee  should  be  prohibited, but  cocoa  made 
from  the  nibs  or  husks  may  be  allowed.  In  most  instances,  a  little 
stimulant  taken  at  meal-times  tends  to  relieve  the  subsequent  dis- 
comfort, and  for  this  purpose  a  tablespoonful  of  good  brandy  or 
whisky  mixed  with  4  oz.  of  hot  water  may  be  given  at  the  end 
of  the  meal  twice  a  day.  Malt  liquors  always  disagree  and  wines 
can  rarely  be  tolerated.  During  the  early  stages  of  the  complaint 
when  food  stagnation  alone  exists,  a  meal  may  be  allowed  every  four 
hours ;  but  when  retention  is  present  five  hours  should  be  allowed 
to  intervene  between  each  meal. 

S.T. — VOL.  n.  19 


290  Atony  of  the  Stomach. 

An  excess  of  sweets  must  always  be  prohibited,  and  when  the 
stomach  is  dilated  these  substances  should  be  eliminated  from  the 
dietary.  On  the  other  hand,  well-cooked  rice  or  cornflour  or  one 
of  the  patent  digested  cereal  foods  may  be  allowed,  while  toast  or 
the  Brusson-Jeune  rolls  are  preferable  to  wheaten  bread  or  biscuit. 
Green  vegetables  and  fruits  should  be  entirely  avoided  in  severe 
cases,  but  in  mild  instances  a  little  well-cooked  asparagus,  celery  or 
spinach  may  be  allowed.  Meat-fat,  fat  bacon,  ham  and  salad  oil 
are  all  injurious,  since  they  hinder  the  secretion  of  gastric  juice  and 
favour  food  retention ;  but  cream  and  butter  may  be  permitted  in 
moderation.  Lightly-boiled  or  poached  eggs  usually  agree  unless 
some  form  of  biliary  or  pancreatic  disturbance  exists.  The  white 
kinds  of  fish,  such  as  whiting,  sole,  cod,  turbot,  plaice,  haddock  and 
hake,  are  to  be  preferred  to  the  heavier  and  oily  varieties,  like 
mackerel,  salmon  or  herring,  and  should  be  boiled  rather  than  fried. 
Smoked  and  dried  fish  are  inadmissible.  Sweetbreads,  tripe, 
sheep's  head  and  brains,  calf's  head  and  feet,  chicken,  pheasant, 
partridge  and  tongue  are  all  easy  of  digestion,  but  venison,  hare, 
duck,  goose,  pigeon,  sausages,  pork,  veal,  curries  and  meats  twice 
cooked  usually  excite  discomfort.  Meat  essences,  powders  and 
jellies  may  be  given  with  impunity,  but  soups  and  broths  must  be 
prohibited.  Raw-meat  pulp  often  agrees  when  all  other  meats  give 
rise  to  indigestion,  and  in  certain  cases  of  uncomplicated  my  asthenia 
the  so-called  "  Salisbury  treatment"  maybe  pursued  with  advantage. 
Milk  curdled  by  means  of  lactobacilline  is  chiefly  indicated  when  the 
disorder  is  accompanied  by  a  notable  deficiency  of  free  hydrochloric 
acid,  but  it  always  disagrees  when  hyperacidity  exists.  When  it 
agrees  half  a  pint  should  be  taken  twice  a  day  for  a  period  of  three 
months.  In  the  tablet  form  the  bacilli  are  useless. 

Medicinal  Treatment. — The  objects  of  medicinal  treatment 
are :  (1)  To  prevent  fermentation  of  the  contents  of  the  stomach ; 
(2)  to  stimulate  the  muscular  structure  of  the  organ  ;  (3)  to  augment 
the  digestive  powers  of  the  gastric  juice ;  (4)  to  promote  the  evacua- 
tion of  the  bowels. 

1.  Antiseptic  treatment  should  always  be  adopted  at  the  outset 
and  no  stimulating  remedies  be  employed  until  the  tongue  is  clean. 
The  best  plan  is  to  administer  a  mixture  containing  carbonate  of 
bismuth,  bicarbonate  of  sodium,  glycerine  of  carbolic  acid  and 
peppermint  water,  twice  a  day  between  meals.  If  the  tongue  is  foul 
1  drachm  of  the  compound  tincture  of  rhubarb  or  2  drachms  of 
the  infusion  may  be  added  with  advantage,  with  1  drachm  of  pure 
glycerine  should  the  stomach  be  dilated.  Some  authorities  prefer 
resorcin  (10  gr.);  bismuth  salicylate  (20  gr.)  ;  beta-naphtbol  (3gr.); 


Atony  of  the  Stomach.  291 

salicylic  acid  (10  gr.) ;  creosote  or  guaiacol  (3  min.) ;  sodium 
benzoate  (5  gr.) ;  sodium  hyposulphite  (20  gr.)  ;  sodium  sulphocar- 
bolate  (15  gr.) ;  a  mixture  of  iodoform  and  charcoal,  or  the  carbolic 
acid  pill.  Charcoal  biscuits  and  the  Biscols  Fraudin  are  sometimes 
of  use  when  the  eructated  gases  are  offensive.  Excessive  flatulence 
may  be  relieved  by  peppermint,  chloroform,  ether,  oil  of  cajuput  or 
the  essence  of  Ricqles. 

2.  The  chief  drugs  that  stimulate  the  musculature  of  the  stomach 
are  strychnine,  hydrastin,  quinine,  ergot,  ipecacuanha,  and  formate 
of  sodium.     The  first  named  is  the  most  reliable  and  may  con- 
veniently be  given  in  combination  with  quinine  and  phosphoric 
acid,  while  in  some  instances  the  tincture  of  nux  vomica  with  a 
bitter  infusion  is  serviceable.     Hydrastin  and  ergot  are  very  variable 
in  their  action  and  are  liable  to  produce  nausea  and  impair  the 
appetite.    Many  practitioners  favour  powdered  ipecacuanha  in  doses 
of   £  gr.  three  or  four  times  a  day  after  meals,  but  several  weeks 
usually  elapse  before  any  signs  of  improvement  manifest  themselves. 
Latterly  formate  of    sodium  has  come  into  fashion.     It  is  most 
conveniently  prescribed  in  the   form  of  the  compound  syrup  or 
of   the  tablets  of  the  polyformates  (Roberts  &  Co.).     When  the 
nayasthenia  is  associated  with  anaemia  a  cautious  trial  should    be 
made  of  one  of  the  salts  of  iron.     As  a  rule  the  ammonio-citrate 
combined  with  the  solution  of  bismuth  agrees  best,  but  the  dialysed 
solution  or  the   pill   of   reduced   iron   may   be   given   if   desired. 
Zambelleti's  hypodermic  injections  of  soluble  arsenic  and  iron  are 
a  most  valuable  method  of  treatment  in  refractory  cases,  but  care 
must  be  taken  to  wash  out  the  syringe  with  rectified  spirit  imme- 
diately after  use.     If  general  neurasthenia  exists,  valerianate  of  zinc, 
either  alone  or  combined  with  dioxide  of  manganese,  or  the  syrup 
of  the  glycerophosphates  (Robin)  may  be  prescribed. 

3.  The  adjuvants  of  the  gastric  secretion  are  pepsin,  pancreatin, 
papain,  diastase  and  hydrochloric  acid.     Theoretically  the  adminis- 
tration of  pepsin  and  hydrochloric  acid  should  relieve  the  symptoms 
of  indigestion,  which  depend  upon  a  deficiency  of  gastric  juice,  but 
as  a  matter  of  fact  almost  every  disease  of  the  stomach,  with  the 
exception  of  achylia,  is  capable  of  producing  sufficient  ferment  if  the 
secretion  of  the  mineral  acid  is  sustained,  and  hence  the  success  of 
pepsin  in  clinical  practice  is  not  commensurate  with  its  reputation 
in  the  laboratory.     Of  the  various  preparations,  the  pure  powder, 
the  glycerine  extract  and  Liebreich's  essence  are  the  most  reliable 
and  should  be  given  immediately  after  meals. 

The  wines  of  pepsin  have  no  therapeutic  value ;  indeed,  according 
to   the   experiments   of   Hugouenenq,   the   addition  of   alcohol  to 

19-2 


292  Atony  of  the  Stomach. 

pepsin  greatly  interferes  with  its  action.  Papain  is  able  to  convert 
proteid  into  peptone  in  an  alkaline  medium,  but  its  use  is  chiefly 
confined  to  cases  of  achylia.  Pancreatin  is  of  little  value  unless 
the  myasthenia  is  secondary  to  atrophic  gastritis. 

In  the  myasthenia  of  childhood  maltine  given  after  meals  is 
sometimes  of  value ;  but  in  adults  takadiastase  or  diastase  setterie 
is  often  recommended  with  a  view  of  promoting  the  digestion  of 
starches  in  the  stomach.  The  tabloids  of  pentenzyme,  which 
consist  of  a  mixture  of  all  the  digestive  glands,  are  occasionally 
of  use. 

As  compared  with  the  ferments,  dilute  hydrochloric  acid  is  often 
of  considerable  value  when  the  gastric  secretion  is  much  reduced. 
As  a  rule,  15  min.  of  the  dilute  solution  may  be  given  immediately 
after  meals,  but  sometimes  half  a  tumblerful  of  0'05  per  cent, 
solution  taken  with  the  food  proves  more  efficacious.  The  addition 
of  a  teaspoonful  of  pure  glycerine  appears  to  increase  its  digestive 
activity.  The  acid  should  never  be  prescribed  if  the  myasthenia  is 
accompanied  by  hyperacidity  or  secondary  gastritis.  The  value  of 
lactic  acid  has  already  been  mentioned. 

4.  No  medicinal  remedy  exerts  any  permanent  influence  upon 
the  digestive  disorder,  unless  care  is  taken  to  procure  a  daily 
evacuation  of  the  bowels.  Saline  aperients  usually  do  more  harm 
than  good,  unless  gastritis  is  present,  and  the  mildest  aperient  is 
usually  the  most  efficacious.  In  ordinary  cases  a  large  enema  or 
an  injection  of  glycerine  two  or  three  times  a  week  may  alone  be 
necessary,  or  the  patient  may  be  directed  to  take  a  home-made 
infusion  of  senna-pods  each  night.  In  more  advanced  cases,  a 
combination  of  liquid  extract  of  cascara  with  maltine  and  glycerine 
taken  each  evening  before  the  last  meal  will  procure  an  easy 
evacuation  on  the  following  morning,  or  a  pinch  of  Turkish 
rhubarb,  a  dose  of  confection  of  senna  or  a  cup  of  Garfield's  tea 
at  night  will  be  found  sufficient.  Obstinate  constipation  requires 
the  exhibition  of  rhubarb  and  euonymin,  aloes  and  iron,  or  some 
other  aperient,  pill,  the  dose  of  which  may  be  reduced  as  the  case 
improves. 

W.   SOLTAU   FENWICK. 


293 


ATROPHY    OF   THE    STOMACH. 

A  DIMINUTION  or  actual  suppression  of  the  gastric  secretion  is 
an  invariable  result  of  an  extensive  atrophy  of  the  mucous  mem- 
brane of  the  organ,  while  a  similar  condition  occasionally  presents 
itself  as  a  congenital  nervous  disorder  (achylia,  p.  368).  In  both 
instances  the  symptoms  of  indigestion  which  ensue  from  the  dis- 
turbance of  the  gastric  functions  are  intensified  sooner  or  later  by 
those  of  a  secondary  intestinal  derangement.  The  treatment  of 
atrophy  of  the  stomach  varies  according  to  its  causation. 

In  severe  cases  care  must  be  taken  to  preserve  the  strength, 
and  consequently  over-exertion  must  be  prohibited  and  only 
moderate  daily  exercise  be  allowed.  Sufferers  from  this  com- 
plaint are  unduly  susceptible  to  cold,  and  the  clothing  should 
therefore  be  warm  and  exposure  to  wet  carefully  avoided.  Cold 
baths  and  douches  are  sometimes  of  value  in  the  nervous  type 
of  the  disease,  but  are  not  to  be  recommended  in  cases  of  inflam- 
matory atrophy.  Lavage  is  indicated  whenever  much  mucus  is 
present  in  the  stomach  and  when  nausea  or  vomiting  are  prominent 
symptoms,  but  care  must  be  taken  not  to  distend  the  viscus,  and 
antiseptics  are  rarely  required.  In  the  inflammatory  cases  the 
bowels  should  be  regulated  by  means  of  salines,  with  the  occasional 
use  of  a  mild  mercurial  pill.  Mineral  waters,  baths,  massage  and 
electricity  are  useless. 

Atrophy,  with  Pernicious  Anaemia. — In  this  variety  both 
the  gastric  disease  and  the  anaemia  probably  arise  from  the  same 
cause.  The  meals  should  be  taken  at  intervals  of  about  three 
hours,  and  all  solid  articles  of  food  must  be  finely  minced  and  well 
masticated.  As  a  rule,  the  red  meats  are  difficult  of  solution  in 
the  stomach  and  should  be  omitted  in  favour  of  well-cooked 
chicken,  game,  sweetbreads,  tripe,  sheep's  brains,  white  fish  and 
oysters.  Farinaceous  foods  often  agree  well,  and  rice,  tapioca,  sago, 
mealy  potato,  lentils,  and  oatmeal  may  be  employed  in  the  pre- 
paration of  soups  and  puddings.  Soft-boiled  and  poached  eggs 
may  be  given  with  bread  or  toast.  Butter  and  cream  can  usually 
be  tolerated  if  the  intestines  are  healthy,  but  milk  is  apt  to  create 
discomfort  unless  peptonised  or  diluted  with  lime  water.  Beer  and 
spirits  must  be  prohibited,  but  sometimes  a  little  white  wine  taken 
with  the  meals  improves  the  appetite. 


294  Atrophy  of  the  Stomach. 

At  an  early  stage  of  the  complaint  the  administration  of  some 
bland  preparation  of  iron  by  the  mouth  almost  invariably  relieves 
the  symptoms  of  indigestion,  and  may  often  be  advantageously 
combined  with  arsenic.  In  severe  cases,  however,  both  these  drugs 
are  apt  to  excite  nausea  and  vomiting  or  diarrhoea.  Zambelleti's 
subcutaneous  injections  of  iron  and  arsenic  are  extremely  valuable 
at  all  stages  of  the  disease,  the  course  of  which  is  often  materially 
influenced  by  their  employment.  A  single  injection  of  the  weak 
solution  should  be  given  each  day  for  a  fortnight  and  one  of  the 
strong  solution  every  day  subsequently  for  three  weeks  or  a  month, 
the  course  being  repeated  when  necessary.  In  addition  to  the  use 
of  the  ordinary  antiseptic  precautions,  the  syringe  must  be  washed 
out  thoroughly  with  rectified  spirit  immediately  after  use,  since  by 
this  means  the  deposition  of  metallic  iron  upon  the  interior  of  the 
instrument  is  prevented  and  the  occurrence  of  abscesses  avoided. 
The  fluid  may  be  obtained  in  sterilised  ampoules  from  Martindale 
&  Co.  and  other  chemists  in  London,  and  is  most  conveniently 
injected  beneath  the  skin  a  few  inches  above  the  patellae. 

Atrophy  from  Chronic  Gastritis. — This  variety  is  usually  met 
with  in  the  marasmus  of  infancy  and  in  long-standing  cases  of  renal 
disease,  pulmonary  tuberculosis,  diabetes  and  cancer  of  the  breast. 
It  is  never  so  complete  as  in  pernicious  anaemia,  and  the  hydrochloric 
acid  and  ferments  seldom  disappear  completely  from  the  gastric 
secretion.  The  general  treatment  and  dietary  are  similar  to  those 
employed  in  cases  of  chronic  gastritis.  Quinine,  arsenic  and 
other  tonics  are  seldom  tolerated,  and  the  salts  of  iron  usually 
provoke  vomiting  or  diarrhoea.  If  the  secretion  of  hydrochloric 
acid  is  markedly  diminished,  15  min.  of  the  dilute  solution  of  this 
acid  may  be  administered  immediately  after  meals,  either  alone  or 
combined  with  pepsin.  As  a  rule,  however,  alkalies  agree  better 
than  acids,  and  a  bismuth  mixture  containing  glycerine  and  car- 
bolic acid  administered  between  meals  serves  to  relieve  the 
distension  and  discomfort  which  ensue  from  the  fermentation  of 
food.  Only  the  mildest  aperients  should  be  prescribed. 

Atrophy  from  the  Ingestion  of  Corrosives. — When  recovery 
occurs  after  the  ingestion  of  mineral  acids  or  caustic  alkalies, 
the  mucous  membrane  of  the  stomach  is  replaced  more  or  less 
entirely  by  fibrous  tissue  and  a  chronic  ulcer  often  persists  in  the 
neighbourhood  of  the  pyloric  or  cardiac  orifice.  Under  these  cir- 
cumstances the  diet  should  consist  for  several  months  entirely  of 
peptonised  milk,  digested  cereal  foods,  toast,  rusks,  Brusson-Jeune 
rolls,  meat  soups  or  essences  thickened  with  vermicelli,  rice  or 
sago,  eggs,  raw-meat  pulp,  chicken  cream,  well- stewed  tripe  or 


Atrophy  of  the  Stomach.  295 

sweetbreads.  A  pint  or  more  of  Metchnikoff's  curdled  milk  is 
often  a  valuable  adjunct  to  other  forms  of  food.  Owing  to  the 
extensive  destruction  of  the  tissues  and  the  possibility  of  an  open 
ulcer,  lavage  should  not  be  undertaken  unless  the  symptoms  and 
signs  of  pyloric  obstruction  exist,  and  even  then  should  be  per- 
formed with  caution.  A  large  enema  each  day  will  suffice  to  relieve 
the  bowels,  and  drastic  purgatives  must  be  avoided.  Although  the 
gastric  secretion  is  greatly  diminished,  it  should  be  remembered 
that  the  cicatricial  mucous  membrane  remains  for  a  long  time 
intersected  by  areas  of  inflamed  glandular  tissue,  and  that  con- 
sequently indications  of  atrophy  are  almost  always  associated  with 
symptoms  of  chronic  gastritis.  Hydrochloric  acid  is  therefore 
rarely  tolerated,  and  recourse  should  be  had  to  bismuth  combined 
with  alkalies.  If  much  carbohydrate  fermentation  exists,  takadias- 
tase  may  be  administered  after  meals,  and  if  an  artificial  digestive 
is  considered  advisable,  the  glycerine,  or  essence,  of  pepsin,  or  papain, 
is  preferable  to  the  acid  preparations.  Failure  of  the  general  nutri- 
tion is  very  apt  to  be  followed  by  acute  pulmonary  tuberculosis,  and 
should  intestinal  compensation  fail,  an  attempt  may  be  made  to 
stimulate  the  secretion  of  the  pancreas  by  duodenin  or  to  assist  its 
action  by  pancreatin  or  pancreatic  emulsion.  Excessive  fermenta- 
tion in  the  intestines  may  be  controlled  by  the  exhibition  of  a  suit- 
able antiseptic,  such  as  bismuth  salicylate,  iodoform  and  charcoal, 
naphthol,  or  guaiacol. 

W.  SOLTAU  FENWICK. 


296 


CANCER    OF   THE    STOMACH. 

General  Treatment. — During  the  early  stages  of  the  complaint 
the  patient  should  be  encouraged  to  perform  his  usual  work,  and 
when  this  becomes  impossible  it  is  better  that  he  should  dress  and 
lie  upon  a  couch  than  remain  in  bed.  Change  of  air  is  seldom 
advisable,  and  spa  treatments  are  useless.  When  the  stomach  is 
much  dilated,  a  firm  binder  should  be  applied  to  the  abdomen  so  as  to 
support  the  enlarged  and  heavy  viscus.  Massage  and  electricity  are 
of  no  value  when  gastrectasis  arises  from  a  growth  of  the  pylorus, 
and  recourse  to  these  and  other  so-called  "  cures  "  is  attended  by 
much  disappointment.  Up  to  the  present  time  the  employment  of 
the  Rontgen  rays  and  radium  have  not  been  attended  by  any 
permanent  benefit.  The  severe  pain  that  ensues  from  the  forma- 
tion of  metastases  or  perigastritis  may  often  be  relieved  by  stimulant 
or  sedative  applications  to  the  skin.  In  chronic  cases  the  repeated 
use  of  small  blisters  to  the  epigastrium,  followed  by  dusting  of  the 
raw  surfaces  with  a  powder  composed  of  acetate  of  morphine  (f  gr-) 
and  hydrochlorate  of  cocaine  (J  gr.)  is  of  much  value,  but  in  the  more 
acute  conditions  hot  fomentations  or  poultices  with  the  liniment  of 
belladonna  or  tincture  of  opium  sprinkled  upon  them,  are  more 
beneficial.  Lavage  may  be  employed  with  advantage  in  the 
majority  of  cases,  but  it  is  chiefly  indicated  when  obstruction  of  the 
pylorus  exists.  The  benefit  derived  from  it  is  of  a  threefold  kind. 
In  the  first  place,  stagnation  and  decomposition  of  the  food  are  con- 
trolled, the  tendency  to  secondary  gastritis  is  diminished  and  the 
progress  of  gastrectasis  retarded.  Secondly,  the  systematic  cleans- 
ing of  the  inner  surface  of  the  organ  from  the  thick  mucus  that 
adheres  to  it  tends  to  promote  secretion  and  to  stimulate  absorption. 
Thirdly,  the  periodic  removal  of  the  products  of  fermentation 
relieves  the  acidity  and  vomiting  and  greatly  improves  the  appetite. 
In  order  to  obtain  the  best  results,  lavage  should  be  commenced  as 
soon  as  possible,  and  be  performed  regularly  and  in  an  efficient 
manner.  As  a  rule,  the  stomach  should  be  washed  out  before  the 
patient  retires  to  bed,  or  about  three  hours  after  his  last  meal,  by 
which  means  retention  of  food  during  the  night  is  obviated,  and  the 
insomnia  that  arises  from  nocturnal  indigestion  is  prevented.  As 
the  disease  progresses  it  is  advisable  that  the  stomach  be  cleansed 


Cancer  of  the  Stomach.  297 

both  night  and  morning.  Warm  water  containing  bicarbonate  of 
sodium  (3  gr.  to  the  ounce)  is  usually  all  that  is  required,  but  if  an 
antiseptic  is  considered  necessary,  one  or  other  of  those  usually 
employed  for  the  purpose  may  be  used.  It  is  important  to 
empty  the  stomach  completely  at  the  termination  of  the  operation, 
since  the  retention  of  any  of  these  solutions  may  produce  toxic 
poisoning.  A  soft  tube  is  also  of  value  as  a  means  of  introducing 
food  into  the  stomach  in  cases  of  cancer  of  the  cardiac  orifice.  The 
subjects  of  this  complaint  should  not  be  permitted  to  exist  solely 
upon  food  that  they  can  manage  to  swallow,  but  from  the  onset  of 
the  dysphagia  their  nutrition  should  be  maintained  by  forcible 
feeding  and  nutrient  enemata.  The  tube  should  be  soft  and  of 
moderate  calibre,  and  must  be  inserted  with  the  greatest  caution. 
As  soon  as  it  has  entered  the  stomach  a  pint  or  more  of  peptonised 
milk,  egg  and  milk,  clear  soup,  or  other  form  of  liquid  nourishment 
is  poured  in  through  a  funnel  and  the  instrument  withdrawn.  This 
procedure  must  be  repeated  every  six  hours,  and  as  the  stricture 
becomes  more  pronounced  the  size  of  the  tube  must  be  reduced. 
Another  plan  which  is  more  particularly  of  value  when  no  ulcera- 
tion  of  the  growth  exists,  is  to  insert  a  Symonds'  oesophageal  tube 
of  convenient  size  through  the  stricture  by  means  of  a  guide,  and 
to  maintain  it  in  position  by  a  silk  thread  attached  to  the  cheek  by 
a  piece  of  sticking  plaster.  The  chief  contra-indication  to  the 
employment  of  a  tube  for  lavage  or  feeding  is  the  existence  of 
haemorrhage.  When  the  vomit  frequently  contains  altered  blood 
or  attacks  of  hsematemesis  occur  at  short  intervals,  the  neoplasm  is 
invariably  ulcerated  and  usually  extensive.  In  such  cases  the  care- 
less or  even  frequent  passage  of  a  tube  may  produce  serious  results, 
and  I  have  often  seen  dangerous  bleeding  ensue.  Eectal  feeding  is 
of  great  value  when  gastric  intolerance  exists,  and  also  where  it  is 
advisable  to  increase  the  nutrition  before  the  performance  of  an 
operation.  In  all  cases  the  lower  bowel  should  be  irrigated  with 
normal  saline  solution  each  day,  and  the  enemata  be  administered 
through  a  soft  tube  at  atmospheric  pressure. 

Diet. — The  appetite  and  powers  of  digestion  vary  so  much  in 
different  cases  that  it  is  usually  advisable  to  favour,  as  far  as 
possible,  the  patient's  natural  inclinations,  and  to  abstain  from  any 
hard-and-fast  rules  concerning  the  dietary.  The  existence  of  severe 
pain  after  meals  usually  indicates  ulceration  of  the  growth,  and 
cases  which  display  this  symptom  should  be  treated  on  the  same 
lines  as  simple  ulceration  of  the  stomach.  If  raw  milk  agrees, 
from  5  to  8  oz.  may  be  given  every  two  hours,  but  if  it  pro- 
duces nausea  or  discomfort  it  should  be  peptonised,  sterilised  or 


298  Cancer  of  the  Stomach. 

mixed  with  aa  equal  quantity  of  lime-water.  Clear  soups,  the 
Leube-Eosenthal  beef  solution,  or  the  various  meat  essences,  juices, 
jellies,  or  extracts  may  be  tried,  and  the  diet  may  be  varied  with 
eggs  beaten  up  with  milk,  poached  eggs,  soft  bread  and  butter, 
bread  and  milk,  or  milk  puddings.  In  less  severe  cases  scraped 
raw  meat,  boiled  chicken  and  fish  that  have  been  passed  through  a 
sieve,  sweetbreads,  calf's  feet  or  brains,  and  tripe  may  be  allowed. 
Green  vegetables  are  to  be  avoided,  and  in  most  cases  raw  or  even 
stewed  fruits  occasion  pain  or  acidity.  Stenosis  of  the  pylorus 
accompanied  by  vomiting  must  be  treated  by  a  light  diet,  which 
includes  a  considerable  quantity  of  peptonised  milk  and  a  limited 
amount  of  farinaceous  material.  Only  the  strongest  and  most  con- 
centrated forms  of  meat  essence  or  solution  should  be  allowed,  and 
the  animal  food  must  be  lightly  cooked  and  finely  minced.  Cocoa 
made  from  the  nibs  usually  agrees,  but  tea  and  coffee  are  apt  to 
provoke  acidity.  A  small  quantity  of  good  brandy  taken  with  the 
meals  often  aids  digestion  and  relieves  the  sensations  of  fulness  and 
distension.  In  all  cases  the  nutrition  should  be  increased  by  the 
administration  of  a  large  enema  of  peptonised  milk  each  night.  At 
a  late  period  of  the  complaint  it  may  be  necessary  to  peptonise  the 
greater  part  of  the  food  and  to  administer  it  in  small  quantities  at 
frequent  intervals. 

Although  the  sour  milk  of  Metchnikoff  has  proved  disappointing 
in  the  majority  of  gastric  disorders,  there  can  be  no  doubt  that  its 
employment  in  cancer  of  the  stomach  is  often  of  inestimable  benefit, 
and  tends  to  relieve  many  of  the  most  troublesome  symptoms  of  the 
complaint.  A  cautious  trial  should  be  made  of  it  at  first,  and  if  it 
agrees  one  or  two  pints  may  subsequently  be  given  each  day.  If 
the  curds  are  found  to  be  distasteful,  they  may  be  beaten  up  with 
fresh  milk  until  the  fluid  attains  the  consistency  of  thin  cream, 
arid  sweetened  with  sugar.  The  tablets,  chocolate  and  cheese, 
which  are  supposed  to  contain  living  lactic  acid  bacilli,  are  quite 
useless. 

SYMPTOMATIC   TREATMENT. 

In  the  absence  of  a  specific  remedy  it  is  necessary  to  direct 
treatment  to  the  relief  of  the  various  symptoms  as  they  arise. 

Anorexia. — This  may  be  combated  by  frequent  changes  of  diet 
and  by  the  use  of  lavage.  The  various  bitters  are  occasionally  of 
value  in  the  early  stages  of  the  disease,  but  they  are  apt  to  disagree 
when  secondary  gastritis  has  developed.  Condurango  is  a  favourite 
remedy  with  some  practitioners,  and  is  best  prepared  according  to 
the  directions  of  Friedreich.  Half  an  ounce  of  the  bark  is  macerated 


Cancer  of  the  Stomach.  299 

for  twelve  hours  with  12  oz.  of  water,  after  which  the  fluid  is 
reduced  to  half  its  bulk  by  boiling  and  strained.  One  tablespoonful 
of  this  fluid,  combined  with  syrup  of  orange,  is  given  three  times  a 
day  between  meals.  Occasionally  a  few  drops  of  the  solution  of 
arsenic  appears  to  improve  the  appetite  in  a  remarkable  manner. 
The  fact  that  free  hydrochloric  acid  is  usually  absent  from  the 
gastric  contents  in  cases  of  carcinoma  naturally  suggests  the 
administration  of  this  drug  as  an  aid  to  digestion.  It  is  chiefly  of 
use  when  the  growth  affects  the  central  or  cardiac  portions  of  the 
organ,  but  is  apt  to  excite  pain  and  vomiting  when  the  pylorus  is 
contracted.  Occasionally  pepsin,  lactopeptin,  or  papain  seem  to 
increase  the  powers  of  digestion  and  the  relish  for  food.  Chlorate 
of  sodium  in  doses  of  60  gr.  three  times  a  day,  as  recommended  by 
Huchard,  is  sometimes  of  value. 

Pain. — When  this  symptom  continues  severe  in  spite  of  careful 
dieting  and  lavage,  recourse  must  be  had  to  sedatives.  If  it  chiefly 
occurs  after  meals,  a  mixture  containing  carbonate  of  bismuth, 
bicarbonate  of  sodium  and  dilute  hydrocyanic  acid  will  often 
relieve  it,  or  a  pill  composed  of  belladonna,  conium  and  stram- 
monium  may  be  given  immediately  after  food.  Cocaine  is  of  use 
only  when  the  growth  is  situated  close  to  the  cardiac  orifice.  At  a 
late  period  of  the  disease  opium  is  usually  required.  Codeine, 
nepenthe,  and  the  compound  tincture  of  chloroform  and  morphine 
[U.S.P.  ^.Chloroform.,  7'50;  Morphin.  Hydrochlor.,  I'OO;  Acid. 
Hydrocyanic.  Dil.,  5'00  ;  Tinct.  Capsici,  1'25  ;  Tinct.  Cannab.  Ind., 
5-00;  01.  Menth.  Pip.,  0-15  ;  Glycerin.,  25'00 ;  Alcohol.,  ad  lOO'OO], 
are  less  apt  to  disturb  the  digestion  than  other  preparations  ;  but 
when  vomiting  prevents  the  administration  cf  drugs  by  the  mouth, 
hypodermic  injections  of  atropine  and  morphine  are  indicated. 
This  latter  method  is  also  best  adapted  to  procure  sleep. 

Vomiting. — The  treatment  of  this  symptom  varies  with  its  cause. 
If  it  arises  from  obstruction  of  the  pylorus,  daily  lavage  combined 
with  careful  dieting  is  at  once  the  most  appropriate  and  successful 
treatment.  In  all  cases  the  administration  of  antiseptics  is  valuable 
in  the  prevention  of  excessive  fermentation  of  the  food.  For  this 
purpose  carbolic  acid  is  the  most  useful,  and  may  be  given  either  in 
the  form  of  the  glycerine  preparation  (8  to  12  min.)  or  the  pill. 
Occasionally  full  doses  of  resorcin  (15  gr.),  hyposulphite  of  sodium 
(60  gr.),  or  sulphocarbolate  of  sodium  (15  gr.),  creosote  (3  rnin.),  or 
1  min.  of  the  tincture  of  iodine  every  hour,  also  afford  relief. 
Vomiting  due  to  secondary  gastritis  necessitates  daily  lavage 
and  a  diet  of  peptonised  milk  or  sour  milk.  If  retching  is  an 
urgent  symptom,  ^  gr.  of  calomel  should  be  placed  upon  the 


300  Cancer  of  the  Stomach. 

tongue  every  three  hours,  and  J  gr.  of  acetate  of  morphine 
is  given  by  hypodermic  injection  once  or  twice  a  day.  The  emesis 
which  occurs  soon  after  food,  and  is  preceded  by  pain,  usually 
indicates  severe  ulceration  of  the  growth,  and  is  best  controlled  by 
the  exhibition  of  morphine  or  nepenthe  before  meals,  and  the 
repeated  application  of  a  small  blister  to  the  epigastrium.  Chloro- 
form, hyoscyamus,  cocaine  and  glycerine  have  also  been  recom- 
mended, but  their  effects  are  uncertain  and  usually  disappointing. 
The  regurgitation  of  food  that  arises  from  a  stricture  of  the  cardiac 
orifice  must  be  treated  by  lavage  and  rectal  feeding.  The  distressing 
nausea  that  is  sometimes  a  symptom  of  cancer  of  the  body  of  the 
stomach  may  often  be  relieved  by  a  mixture  of  bicarbonate  of 
sodium,  hydrocyanic  acid  and  bromide  of  potassium. 

Acidity. — Acid  eructations  usually  arise  from  abnormal  fermen- 
tations of  the  food  and  subside  under  lavage  and  antiseptic  treatment. 
When  they  persist,  bicarbonate  of  sodium  combined  with  calcined 
magnesia,  glycerine  and  carbolic  acid  may  be  prescribed,  or  a 
bismuth  lozenge  may  be  sucked  at  intervals.  Sometimes  charcoal 
biscuits,  or  charcoal  and  iodoform  enclosed  in  a  cachet,  serve  to 
relieve  this  troublesome  symptom. 

Haematemesis. — Severe  haemorrhage  is  rarely  encountered  and 
when  it  occurs  must  be  treated  like  that  arising  from  simple 
ulcer.  The  patient  is  confined  strictly  to  bed,  fed  exclusively 
by  the  bowel,  while  an  icebag  is  applied  to  the  epigastrium  in  order 
to  control  the  movements  of  the  stomach.  If  necessary,  a  small 
dose  of  morphine  may  be  given  by  hypodermic  injection.  The 
constant  small  losses  of  blood  that  ensue  from  oozing  from  the 
surface  of  the  growth  may  be  controlled  by  the  administration  of 
ergot,  hamamelis,  gallic  acid,  perchloride  of  iron,  alum,  or  calcium 
chloride,  but  acetate  of  lead  (2  gr.),  combined  with  £  gr.  of 
extract  of  opium,  and  given  in  the  form  of  a  pill  every  four  hours  is 
the  most  efficacious  remedy.  Extract  of  the  suprarenal  gland  is 
occasionally  an  excellent  haemostatic  when  given  by  the  mouth,  the 
adrenalin  chloride  in  doses  of  15  min.  diluted  with  2  drachms 
of  water  being  the  most  useful  preparation.  As  its  effects  are 
purely  local,  the  drug  should  be  given  immediately  after  vomiting 
has  taken  place. 

Constipation. — The  tendency  to  constipation  almost  always 
requires  correction.  At  an  early  stage  of  the  disease  one  or  two 
teaspoonfuls  of  phosphate  of  sodium  dissolved  in  6  oz.  of  hot 
water  and  administered  each  morning  before  breakfast  is  an 
excellent  aperient  for  the  purpose,  or  one  of  the  natural  laxative 
waters  may  be  prescribed.  With  the  progress  of  inanition  salines 


Cancer  of  the  Stomach.  301 

are  apt  to  induce  exhaustion,  and  should  be  omitted  in  favour  of 
the  liquid  extract  of  cascara,  the  infusion  of  senna,  or  a  mild  pill 
containing  podophyllin  and  rhubarb.  Occasionally  the  daily  use  of 
a  glycerine  suppository  or  an  enema  is  to  be  preferred.  Mercury 
and  drastic  purgatives  should  as  a  rule  be  avoided. 

W.  SOLTAU  FENWICK. 


302 


THE  SURGICAL  TREATMENT  OF   CANCER  OF  THE 

STOMACH. 

IT  is  not  long  since  patients  with  cancer  of  the  stomach  were  from 
the  first  condemned  as  hopeless.  In  the  'seventies,  anyone  with 
carcinoma  of  the  stomach  was  at  once  given  up  as  doomed,  and 
only  in  1879  was  the  first  attempt  made  by  Pean  to  remove  a 
malignant  pylorus ;  the  first  successful  operation  was  performed  by 
Billroth  in  1881,  when  the  operation  was  looked  on  with  as  much 
disfavour  as  was  the  first-attempted  complete  gastrectomy  a  few 
years  ago  by  Connor  in  America,  when  his  patient  died  on  the 
table ;  yet  Schlatter's  patient  a  little  later  lived  fourteen  months 
after  complete  gastrectomy,  and  I  can  point  to  a  patient  in  complete 
and  perfect  health  on  whom  I  performed  almost  complete  gastrectomy 
nine  years  ago. 

Nor  was  the  palliative  operation  of  gastro-enterostomy  much 
better  thought  of  at  first,  for  although  Wolfler  successfully  per- 
formed the  operation  in  1881,  his  patient  surviving  for  four  months, 
yet  the  mortality  of  65'71  per  cent,  in  the  years  1881  to  1885,  of 
47  per  cent,  in  the  period  from  1886  to  1890,  of  83'91  per  cent, 
from  1891  to  1896,  though  showing  a  steadily  decreasing  death-rate, 
yet  presented  so  doleful  a  picture  as  to  deter  medical  men  from 
recommending  their  patients  to  submit  to  operation.  Even  so 
recently  as  1900,  when  I  gave  the  Hunterian  Lectures  on  the 
Surgery  of  the  Stomach,  of  the  1878  cases  of  gastro-enterostomy 
that  I  was  then  able  to  collect  from  all  sources,  the  mortality  was 
36*4  per  cent.  But  since  that  time  the  surgery  of  the  stomach  has 
made  such  rapid  progress  that  I  can  now  point  to  a  long  series 
of  posterior  gastro-enterostomies  personally  performed  in  simple 
diseases  of  the  stomach  with  a  mortality  of  1'7  per  cent.,  and  even 
in  cancer  of  only  3  per  cent. 

Moreover,  the  operation  of  partial  gastrectomy  in  cancer  is  one 
that  is  attended  with  much  more  encouraging  success  immediate 
and  remote  than  is  generally  recognised. 

I  am  firmly  convinced  that  many  deaths  are  ascribed  to  cancer 
when  the  disease  is  inflammatory  and  perfectly  curable  by  the 
operation  of  gastro-enterostomy  without  removal  of  the  tumour, 
and  this  I  can  prove  from  my  own  experience. 

No  one  has  done  more  than  Professor  Osier  in  advocating  the 


Surgical  Treatment  of  Cancer  of  Stomach.     303 

early  diagnosis  of  cancer  in  order  that  a  radical  operation  may  be 
performed  at  a  time  when  there  is  hope  of  cure ;  and  if  only  this 
truth  can  be  impressed  on  the  minds  of  those  engaged  in  general 
practice,  who  usually  see  these  cases  at  a  time  when  diagnosis  is 
doubtful,  and  when  perhaps  the  only  symptom  complained  of  is 
indigestion,  and  if  in  such  doubtful  cases  a  consultation  is  insisted 
on  in  order  that  the  matter  may  be  taken  seriously  at  the  earliest 
possible  moment,  then  we  shall  find  that  much  can  be  done  for 
these  otherwise  hopeless  cases  in  the  way  of  relief  or  even  cure. 

Medical  treatment  cannot  cure,  and  can  do  very  little  even  to 
prolong  life ;  it  therefore  applies  only  to  cases  too  advanced  for 
surgical  treatment  or  where  operation  is  declined.  It  aims  at 
nourishing  the  patient  as  much  as  possible,  and  at  relieving  pain  or 
other  symptoms  as  they  arise. 

Surgical  treatment  which  offers  the  only  chance  of  relief  and  the 
only  possibility  of  cure  may  be  considered  under  the  heading  of 
preventive,  palliative  and  curative  operations.  In  order  that  the 
best  results  may  be  attained,  the  physician  and  surgeon  must  act  in 
concert,  so  that  by  a  timely  diagnosis  an  operation  may  be  under- 
taken at  the  earliest  possible  date. 

There  is  ample  evidence  to  show  that  for  some  length  of  time 
cancer  is  a  purely  local  disease,  and  just  as  in  the  breast,  the 
tongue,  and  the  uterus  one  can  point  to  patients  living  comfortable 
and  happy  lives  years  after  the  removal  of  the  disease,  so  in 
gastric  cancer  it  can  now  be  proved  that  a  like  result  may  be 
obtained.  Here,  however,  we  are  faced  with  the  difficulty  of  a 
sufficiently  early  diagnosis  being  made,  and  it  is  not  only  necessary 
for  us  to  appeal  for  an  early  exhaustive  and  persistent  investigation 
into  suspicious  stomach  cases,  but  that  when  the  suspicions  are 
becoming  confirmed  an  early  surgical  consultation  may  be  held, 
and,  if  needful,  an  exploratory  operation  carried  out  to  complete 
the  diagnosis. 

Whenever  a  patient  at  or  after  middle  age  complains  somewhat 
suddenly  of  indefinite  gastric  uneasiness,  pain  and  vomiting, 
followed  by  progressive  loss  of  weight  and  energy  and  associated 
with  anaemia,  the  possibility  of  cancer  of  the  stomach  should  be 
recognised,  and  in  a  suspected  case,  if  no  improvement  takes  place 
in  a  few  weeks  at  the  most,  an  exploratory  operation  is  more  than 
justified. 

Let  us  remember  also  that  to  prolong  the  investigation  uselessly, 
and  to  wait  until  a  tumour  develops  into  a  recognisable  quantity, 
is  to  lose  the  favourable  time  for  a  radical  operation ;  and  although 
a  clinical  examination  of  the  stomach  contents  and  a  general 


304     Surgical  Treatment  of  Cancer  of  Stomach. 

examination  of  the  patient  may  give  us  strong  grounds  for 
suspicion,  our  diagnosis  can  only  be  rendered  certain  by  a  digital 
examination,  which  may  be  effected  through  a  small  incision  that 
can,  if  needful,  be  made  under  cocaine  anaesthesia  with  little  if 
any  risk. 

At  the  time  of  exploration  it  will  be  advisable  to  have  everything 
ready  to  follow  up  the  exploratory  procedure  by  whatever  further 
operation  may  be  called  for.  It  may  be  discovered  that  the  disease 
is  manifestly  not  malignant,  and  that  some  curative  operation  can 
be  done,  as  in  inflammatory  thickening  around  chronic  ulcer  of  the 
pylorus  leading  to  obstruction. 

Or  it  may  be  discovered  that  the  disease  resembles  malignancy 
both  in  its  history  and  physical  signs  and  in  the  form  of  the  tumour, 
and  is  yet,  if  we  may  judge  from  the  ultimate  results,  not  malignant. 

I  would  lay  particular  stress  on  this  class  of  cases,  for  I  think  it 
serves  to  explain  some  misconception  about  cancer  generally.  It 
would  be  easy  for  anyone,  looking  at  the  subject  from  a  one-sided 
point  of  view,  to  raise  a  claim  to  having  cured  a  number  of  cases  of 
cancer  of  the  stomach  by  gastro-enterostomy ;  but  I  do  not  for  a 
moment  believe  that  these  cases  were  more  than  inflammatory 
tumours  formed  round  chronic  gastric  ulcers  ;  nevertheless,  I  have 
no  doubt  that  they  would  have  proved  fatal  just  as  certainly  as  if 
they  had  been  cancer  had  no  operation  been  done.  I  feel  sure  that 
many  cases  of  this  nature  would  have  been  certified  as  death  from 
cancer  of  the  stomach  had  no  exploration  been  done  or  necropsy 
with  microscopic  investigation  made,  and  I  think  we  must  take 
such  cases  into  account  before  hastily  deciding  that  cancer  is  on  the 
increase. 

Even  though  a  tumour  is  palpable,  and  even  though  it  is  probably 
too  large  for  removal,  it  may  be  quite  worth  while  advocating  an 
exploration,  to  be  followed  by  gastro-enterostomy  if  that  be  practic- 
able, in  the  hope  that  the  disease  may  prove  to  be  wholly  or  partially 
inflammatory  which  the  physiological  rest  secured  by  gastro-ente- 
rostomy will  either  cure  or  materially  relieve. 
.  Now,  to  pass  to  the  genuine  cancer  cases,  what  can  we  do  for 
them  ?•  This  will  depend :  (1)  On  the  position  of  the  growth ; 
(2)  on  its  extent ;  (3)  on  the  presence  of  adhesions ;  and  (4)  on 
glandular  invasion  or  secondary  growths. 

First,  as  to  position.  In  irremovable  growth  at  the  cardiac  end, 
if  it  involves  the  cardiac  orifice  and  adjacent  portion  of  the  stomach, 
gastrostomy  should  be  performed  in  order  that  starvation  may  be 
staved  off.  The  view  that  gastrostomy  is  both  a  dangerous  and 
useless  operation  is,  I  know,  held  by  some,  but  I  feel  convinced  that 


Surgical  Treatment  of  Cancer  of  Stomach. 


305 


Tube   passing1) 
down  distal    arrm-- 
o?   Jejunal    loopj 


such  views  are  erroneous.     When  these  cases,  either  of  cancer  of 

the  cardiac  end  of  the  stomach  or  of  the  ossophagus,  were  handed 

over   to   the   surgeon  in  a    moribund   condition  the  mortality  of 

gastrostomy  was  of  course  terrible,  and  the  short  survival,  even  if 

successful  from  an  operative  point  of  view,  brought  discredit  on 

the  operation  ;  but  when  I  myself  can  •  point  to  a  long  series  of 

gastrostomies  performed  since  1897  not  only  without  any  mortality, 

but   with  comfort   to    all   and  great 

prolongation  of  life  to  many,  I  feel 

that  I  have  good  grounds  for  saying 

that    the    operation    is    well    worth 

doing.      The    operation    is    quite    a 

simple  one,  and,  if  necessary,  can  be 

performed  under  cocaine  anaesthesia 

in    a    very   short    time.     In   several 

cases  the  patients  have  lived  a  year 

or  more  and  have  gained  considerably 

in  weight,  even  up  to  2|  stones,  and 

have  lost  their  pain  and  the  distress- 

ing sense  of  starvation. 

Jejunostomy  is  an  operation  occa- 
sionally called  for  as  a  means  of  giving 
relief  and  prolonging  life  in  patients 
suffering  from  advanced  disease  of 
the  stomach,  when  on  exploration  it 
is  discovered  to  be  impracticable  to 
perform  gastrectomy,  gastrostomy, 
or  gastroenterostomy.  The  indica- 
tions for  operation  are  : 

(1)  Extensive  cancer  of  the  stomach 
too  advanced  for  gastrectomy,  and  in 
which  no  healthy  spot  of  sufficient 

size  on  the  stomach  wall  can  be  found  for  the  purpose  of  gastrostomy 
or  gastro-enterostorny. 

(2)  General   cicatricial  contraction  of   the   stomach,    simple    in 
character,  and  due  to  the  swallowing  of    caustic  fluid,  in  which  the 
stomach  has  been  so  far  damaged  that  it  no  longer  performs  its 
functions,  or  even  allows  of  the  proper  passage  onwards  of  food. 

(3)  Extensive    ulceration    of    the    stomach   or   duodenum,   the 
operation   being   done   in  order   to    secure   complete   rest   to   the 
ulcerated  area. 

For  the  operation  to  be  a  success  the  bowel  must  be  so  placed 
that  it  will  serve  two  purposes  :  (1)  To  permit  the  passage  onward 
S.T.—  VOL.  n.  20 


*     '  l 


306     Surgical  Treatment  of  Cancer  of  Stomach. 

of  the  bile  and  pancreatic  fluid  poured  into  the  intestine  above 
the  artificial  fistula ;  (2)  to  allow  of  food  being  introduced  through 
the  fistula  without  fear  of  regurgitation,  either  of  the  food  or  of  the 
intestinal  contents. 

The  operation  that  has  given  me  the  best  results  consists  in 
taking  a  loop  of  the  beginning  of  the  jejunum,  just  sufficiently  long 
to  reach  the  surface  without  tension ;  the  two  arms  of  the  loop  are 
short-circuited  about  3  inches  from  the  surface,  the  short- 
circuiting  being  done  by  means  of  a  continuous  suture  taking 
up  all  the  coats  and  a  continuous  serous  suture  beyond  the 
marginal  one.  . 

A  small  incision  is  then  made  into  the  top  of  the  loop  just  large 
enough  to  admit  a  No.  12  or  14  Jacques's  catheter,  which  is  inserted 
and  passed  for  3  inches  down  the  distal  arm  of  the  loop  ;  this 
is  fixed  to  the  margin  of  the  incision  in  the  gut  by  a  silk  or 
Pagenstecher's  suture,  and  the  entrance  of  the  tube  into  the  bowel 
is  further  guarded  by  two  pursestring  sutures,  one  over  the  other. 
The  top  of  the  loop  is  fixed  to  the  skin  by  one  or  two  stitches  and 
the  wound  closed.  The  patient  can  then  be  fed  at  once  with  some 
peptonised  milk  and  brandy.  The  whole  operation  can  be  done  in 
from  fifteen  to  twenty  minutes  and  with  very  little  visceral  exposure. 
Should  the  patient  be  too  ill  to  bear  the  little  extra  time  occupied 
by  the  short-circuiting,  the  tube  may  be  inserted  as  directed  and 
surrounded  by  two  or  three  pursestring  sutures,  a  proceeding 
which  can  be  accomplished  in  a  few  minutes.  In  this  case  the 
loop  of  bowel  must  not  be  brought  to  the  skin,  but  had  better  be 
fixed  by  sutures  to  the  peritoneal  margin  and  the  aponeurosis,  in 
order  to  leave  part  of  the  lumen  of  the  attached  loop  within  the 
abdomen  for  the  direct  passage  onwards  of  the  intestinal  fluid  with 
the  bile  and  pancreatic  secretion. 

The  next  class  of  cases  to  be  considered  is  where  the  disease 
involves  the  pylorus,  and  is  producing  obstruction  to  the  passage 
onwards  of  the  gastric  contents,  but  where,  on  account  of  the 
extreme  feebleness  of  the  patient,  or  because  of  extensive 
adhesions,  secondary  growths  or  involvement  of  glands,  it  is 
considered  unwise  to  attempt  pylorectomy  or  partial  gastrectomy, 
though  there  is  sufficient  free  stomach  wall  left  to  enable  a  gastro- 
enterostomy  to  be  performed.  In  such  cases  a  gastro-enterostomy, 
if  performed  with  proper  expedition  and  adequate  precautions, 
affords  the  greatest  relief  to  the  sufferer,  who  not  only  loses  the  distress 
due  to  painful  peristalsis  and  to  the  irritation  of  retained  secretion, 
but  also  becomes  freed  from  the  toxaemia  due  to  absorption  of  the 
poisonous  fermenting  stomach  contents,  which  are  drained  away  into 


Surgical  Treatment  of  Cancer  of  Stomach.     307 

the  intestine  and  there  disposed  of.  Thus  life  is  prolonged  and  made 
more  comfortable,  flesh  and  colour  are  regained,  and,  even  in  cases  of 
cancer,  the  patient  may  have  a  new  lease  of  life ;  moreover,  in  some 
cases  where  the  condition  of  the  patient,  and  not  simply  the  extent 
of  the  growth,  has  prevented  a  radical  operation,  the  speedy 
restoration  to  health  enables  a  radical  operation  to  be  subsequently 
undertaken. 

The  remaining  class  of  cases  is  of  great  interest,  and  includes 
those  where  the  disease  is  limited  to  the  stomach,  and  where  the 
lymphatic  glands  and  adjoining  organs  have  not  been  seriously 
invaded,  the  patient  being  in  a  sufficiently  good  condition  to  permit 
of  the  radical  operation  of  partial  or  complete  gastrectomy  being 
performed. 

The  cases  that  have  been  reported  by  myself  and  other  surgeons 
are  sufficient  to  show  that  removal  of  even  a  considerable  portion 
of  the  stomach  may  be  something  more  than  a  palliative  operation, 
and  I  think  it  justifies  me  in  saying  that  although  it  is  better  to 
have  cases  of  cancer  diagnosed  and  operated  on  early,  yet  we  need 
not  take  the  pessimistic  view  which  has  been,  and  which  is  still, 
held  by  some  surgeons,  that  if  a  tumour  is  manifest  it  is  too  late 
to  perform  a  radical  operation. 

I  hope  I  have  advanced  sufficient  evidence  to  prove : 

(1)  How  desirable  it  is  to  make  an  early  diagnosis  of  cancer  of 
the  stomach  in  order  that  a  radical  operation  may  be  performed  at 
the  earliest  possible  moment. 

(2)  That  it  may  be  needful  to  perform  an  exploratory  operation 
in  order  to  complete  or  confirm  the  diagnosis. 

(3)  That  such  an  exploration  may  be  done  with  little  or  no  risk 
in  the  early  stages  of  the  disease. 

(4)  That  even  when  the  disease  is  more  advanced,  and  a  tumour 
perceptible,  an  exploratory  operation  is,  as  a  rule,  still  advisable  in 
order  to  carry  out  radical  or  palliative  treatment. 

(5)  That   where   the   disease   is   too   extensive   for   any  radical 
operation  to  be  done,  the  palliative  operation  of  gastro-enterostomy, 
which  can  be  done  with  very  small  risk,  may  considerably  prolong 
life  and  make  the  remainder  of  it  much  more  comfortable  and  happy. 

(6)  That  some  cases,  thought  at  the  time  to  be  cancer  too  extensive 
for  removal,  may  after  gastro-enterostomy  clear  up  completely  and 
get  quite  well. 

(7)  That  in  cases  of  disease  of  the  cardiac  end  of  the  stomach  too 
extensive   for   removal,    the   operation  of   gastrostomy   may   con- 
siderably prolong  life,  and  prove  of  great  comfort  to  the  patient  by 
preventing  death  from  starvation. 

20-2 


308     Surgical  Treatment  of  Cancer  of  Stomach. 


(8)  That   even    when   the   disease    is   too    extensive   either   for 
removal  or  for  a  gastro-enterostomy  to  be  performed  with  a  fair 
chance  of  success,  the  operation  of  jejunostomy  may  occasionally 
prove  of  service  to  the  patient. 

(9)  That   when    a   radical   operation    can    be    performed,    the 
thorough  removal  of  the  disease  may  bring  about  as  much  relief 
to  the  patient  as  does  the  operation  for  the  removal  of  cancer  in  the 
breast,  uterus,   and  other  organs  of  the  body,  and  that  in  some 
cases  a  complete  cure  may  follow. 

Partial  gastrectomy  may  have  to  be  undertaken  for  cancer  of 
the  pyloric  end  of  the  stomach  when  an  exploratory  operation  shows 
that  the  tumour  is  free  from  adhesions  to  the  pancreas  and  that 

there  is  no  extensive  involve- 
ment of  glands.  The  operation 
is  simplified  by  extending  the 
incision  upwards  to  the  notch 
between  the  ensiforni  cartilage 
and  the  right  costal  margin  and 
by  bringing  the  stomach  nearer 
to  the  surface,  either  by  means 
of  a  table  which  can  be  raised  at 
the  liver  level  or  by  a  sandbag 
placed  under  the  back  opposite  the 
lower  ribs. 

An  opening  is  made  in  the 
lesser  omentum,  and  through  the 
slit  two  pairs  of  forceps  are  passed 
so  as  to  grasp  it.  It  is  then 
divided  between  the  forceps  and 
ligatured  above  and  below.  This 

gives  free  access  to  the  lesser  peritoneal  cavity  and  to  the  blood 
vessels  which  should  either  be  caught  up  and  tied  as  the  operation 
progresses  or  ligatured  in  their  continuity  near  their  origin. 
These  vessels  are  the  gastric,  which  is  best  ligatured  at  a  point  1 
inch  below  the  cardiac  orifice,  where  it  joins  the  lesser  curvature  ; 
the  pyloric,  which  can  be  taken  up  shortly  after  it  leaves  the  hepatic 
artery ;  the  right  gastro-epiploic  as  it  passes  down  behind  the  pylorus ; 
and  the  left  gastro-epiploic,  which  is  taken  up  below  the  greater 
curvature  of  the  stomach.  It  answers  well  to  seize  the  vascular 
trunks  in  pressure  forceps,  and  when  the  excision  has  been  performed 
to  ligature  them  separately.  The  fingers  of  the  left  hand  are  then 
passed  behind  the  growth  until  the  great  omentum  is  reached,  thus 
raising  the  mass  from  the  transverse  colic  vessels.  The  great  omentum 


FIG.  2. — Diagram  to  show  the  stomach 
after  partial  gastrectomy. 


Surgical  Treatment  of  Cancer  of  Stomach.     309 

is  then  ligatured  and  divided  in  the  same  way  as  the  lesser.  Double 
clamps  are  then  applied  to  the  duodenum  and  to  the  stomach,  the 
duodenum  being  divided  between  the  clamps  a  full  |  inch  from  the 
distal  end  of  the  growth,  and  the  stomach  being  also  divided  between 
clamps  1  inch  or  more  beyond  the  proximal  end  of  the  growth.  As 
cancer  usually  advances  further  along  the  lesser  curvature,  the 
clamps  will  have  to  be  placed  obliquely  on  the  cardiac  side.  The 
growth  which  is  then  free  can  be  lifted  away,  any  glands  removed 
and  vessels  ligatured.  The  gastric  incision  must  then  be  closed  by 
a  haemostatic  suture  of  chromic  catgut,  which  takes  up  all  the  coats, 
and  by  an  external  suture  of  silk  or  Pagenstecher's  thread,  which 
approximates  the  serous  margins.  The  duodenal  end  may  be 
ligatured  en  masse  where  the  clamp  has  crushed  it,  and  the  cut  end 
invaginated  by  a  pursestring  suture.  A  posterior  gastro-enterostomy 
is  then  performed  in  the  ordinary  way  between  the  jejunum,  just 
beyond  the  duodeno-jejunal  junction,  and  the  posterior  wall  of  the 
stomach.  I  usually  prefer  to  perform  a  gastro-jejunostomy  first,  as 
should  the  patient's  strength  fail  the  operation  need  not  be 
persevered  with  at  the  time  and  may  be  completed  later.  As  the 
parts  will  not  have  been  soiled,  drainage  is  unnecessary. 

If  adhesions  are  extensive,  especially  to  the  pancreas,  the 
operation  is  attended  with  much  more  danger  and,  as  a  rule,  is 
unjustifiable. 

A.  W.  MAYO-ROBSON. 


3io 


DILATATION    OF   THE    STOMACH. 

ENLAKGEMENT  of  the  stomach  may  arise  from  several  conditions  : 
(1)  Stenosis  of  the  pylorus  or  duodenum  from  cancerous  or  sarco- 
matous  growths,  the  contraction  of  a  simple  ulcer,  kinking  of  the 
first  part  of  the  duodenum  or  adhesions  of  the  pylorus  to  the  liver 
or  gall-bladder,  pressure  on  the  outlet  by  an  aneurysm  of  the 
hepatic  artery  or  tumour  of  the  liver,  a  papilloma  of  the  pyloric 
ring,  or  the  impaction  of  a  hair-ball  or  other  foreign  body  in  the 
pyloric  antrum  ;  (2)  diseases  of  the  muscular  coat  of  the  organ 
which  impair  its  contractility,  such  as  cirrhosis,  or  fatty  or 
lardaceous  degeneration ;  (3)  functional  loss  of  tone,  to  which  the 
term  "atony"  or  "myasthenia"  is  applied;  (4)  paralysis  of  the 
nervous  mechanism  which  gives  rise  to  an  acute  distension  of  the 
viscus  (acute  dilatation).  Many  of  these  conditions  are  discussed 
under  their  appropriate  titles,  and  it  is  only  necessary  in  the  present 
section  to  consider  the  treatment  of  acute  dilatation  of  the  stomach 
and  of  that  chronic  variety  which  ensues  from  mechanical 
obstruction  to  the  passage  of  food  into  the  intestine  (pyloric 
stenosis). 

ACUTE  DILATATION  OF  THE  STOMACH. 
Acute  dilatation  of  the  stomach  is  a  very  rare  complaint.  It 
is  easily  recognised  by  the  repeated  vomiting  of  immense  quantities 
of  bile-stained  fluid,  despite  the  fact  that  no  food  is  taken  by  the 
mouth,  and  the  sudden  development  of  an  immense  gastrectasis. 
Immediately  the  disease  is  recognised  the  organ  must  be  emptied 
by  means  of  a  soft  tube,  and  thoroughly  washed  out.  Owing  to  the 
constant  regurgitation  through  the  patulous  pylorus  of  bile  and 
intestinal  fluids,  the  procedure  is  somewhat  tedious,  and  as  much 
as  3  or  4  quarts  of  warm  water  are  usually  required  before 
the  gastric  fluid  loses  its  bilious  character.  The  lavage  must  be 
repeated  every  hour  until  fluid  no  longer  accumulates  in  the 
distended  viscus,  and  the  efforts  at  vomiting  cease.  In  the  mean- 
time, the  concomitant  symptoms  of  shock  are  combated  by  the 
hypodermic  use  of  strychnine  while  a  continuous  injection  of  warm 
saline  solution  (a  teaspoonful  to  the  pint)  is  administered  either 
beneath  the  skin  or  by  the  bowel.  In  the  latter  case  the  same 
apparatus  is  employed  as  that  used  for  large  nutrient  enemata 


Dilatation  of  the  Stomach.  311 

(p.  326),  but  instead  of  15  oz.  2  quarts  or  more  of  the  hot  saline 
are  introduced  slowly  into  the  body.  No  food  is  allowed  by  the 
mouth  until  the  size  of  the  stomach  has  diminished  and  the  pulse 
rate  fallen.  Should  the  case  prove  more  tedious  than  the  average 
(twelve  hours),  it  may  be  necessary  to  administer  10  oz.  of 
peptonised  milk  with  £  oz.  of  brandy  by  the  rectum. 
When  the  collapse  has  disappeared  and  the  gastric  dilatation 
subsides,  whey  should  be  given  by  the  mouth  and  the  amount 
rapidly  increased  until  6  or  7  pints  are  consumed  in  the 
twenty-four  hours.  The  shrunken  aspect  of  the  patient  betokens 
the  necessity  for  giving  him  this  large  amount  of  fluid.  Sub- 
sequently milk  is  substituted  for  whey,  and  the  diet  gradually 
resumed.  The  danger  of  sudden  heart  failure  must  always  be 
borne  in  mind. 

W.  SOLTAU  FENWICK. 


ACUTE  POST-OPERATIVE  DILATATION  OF  THE   STOMACH. 

Some  of  the  cases  of  ileus  after  abdominal  operations  are  due  to 
acute  dilatation  of  the  stomach  from  primary  gastric  atony,  which, 
once  initiated,  tends  to  persist  and  get  worse  owing  to  the  distended 
stomach  dragging  on  and  kinking  the  duodenum,  thus  leading  to 
shock  by  pressure  on  the  heart  without  there  being  any  sign  of 
sepsis.  In  some  cases  the  duodenum  participates  in  the  dilatation, 
apparently  owing  to  pressure  of  the  superior  mesenteric  vessels  on 
the  third  part  of  the  duodenum,  which  they  cross  transversely  ;  it  is 
in  such  cases  that  the  prone  position  may  afford  some  relief.  In  all 
cases  of  ileus  after  operation  the  use  of  the  stomach-tube  should 
not  be  neglected,  and  if  repeated  lavage,  the  prone  position  and 
general  treatment  fail  to  bring  about  relief,  the  question  of  gastro- 
enterostomy  should  be  considered,  provided  that  the  intestines  do  not 
participate  in  the  paralysis. 

A.  W.  MAYO-ROBSON. 


CHRONIC  DILATATION  OF   THE  STOMACH  (PYLORIC 
STENOSIS). 

General  Treatment. — The  retention  of  food  which  accompanies 
all  varieties  of  the  complaint  indicates  the  necessity  of  systematic 
lavage.  The  time  of  day  at  which  the  operation  should  be  per- 
formed depends  upon  the  nature  of  the  case  and  the  degree  of 
stenosis.  As  a  rule,  the  best  time  is  before  breakfast,  since  the 


312  Dilatation  of  the  Stomach. 

organ  is  then  cleansed  from  the  secretion  of  mucus  that  has 
accumulated  during  the  night  and  is  prepared  for  the  ingestion 
of  food.  When,  however,  sleep  is  prevented  by  nocturnal  indiges- 
tion or  vomiting  occurs  in  the  early  hours  of  the  morning,  it  is 
advisable  to  wash  out  the  organ  about  10  p.m.  or  even  twice  a 
day.  The  apparatus  required  consists  of  a  soft  gastric  tube  having 
an  internal  diameter  of  about  f  inch  with  a  bevelled  orifice  at  its 
extremity  and  two  or  three  small  holes  in  the  immediate  vicinity. 

A  piece  of  glass  tubing  inserted  into  the  opposite  end  serves  to 
connect  the  gastric  tube  with  2  feet  of  rubber  tubing  of  similar 
diameter  to  the  free  extremity  of  which  a  good-sized  glass  funnel  is 
attached.  Many  other  and  more  elaborate  forms  of  stomach  siphon 
have  been  invented,  but  with  the  exception  of  Gentile's  evacuator 
they  are  all  inferior  to  that  just  described.  In  the  performance  of 
lavage  the  patient  lies  upon  a  couch  with  his  head  and  shoulders 
raised  upon  a  pillow  and  removes  any  false  teeth  he  may  possess. 
The  gastric  tube  is  warmed  by  immersion  in  hot  water  and  smeared 
with  glycerine,  or,  if  preferred,  merely  moistened  with  water.  It  is 
quite  unnecessary  to  depress  the  tongue  with  the  fingers  or  to  use  a 
gag.  The  tube  is  merely  inserted  into  the  pharynx  and  the  patient 
is  instructed  to  swallow,  when  the  instrument  becomes  grasped  by 
the  pharyngeal  muscles  and  may  rapidly  be  pushed  into  the 
stomach.  It  is  only  in  very  nervous  individuals  and  in  those  who 
have  been  anticipating  the  operation  with  dread  that  an  involuntary 
retraction  of  the  tongue  prevents  the  downward  passage  of  the  tube, 
which  consequently  curls  up  in  the  mouth.  If  the  tube  causes  a 
sense  of  suffocation  or  spasm  of  the  glottis,  the  patient  should  be 
made  to  inspire  entirely  through  the  nose,  when  these  unpleasant 
symptoms  immediately  subside.  The  fluid  employed  for  lavage 
should  possess  a  temperature  of  about  70°  F.,  and  at  least 
2  quarts  should  be  ready  for  use.  As  a  rule,  warm  water  alone  is 
sufficient,  but  if  much  mucus  exists  in  the  stomach  bicarbonate  of 
sodium,  in  the  proportion  of  about  2  gr.  to  the  ounce,  may  be  added 
to  it.  When  food  decomposition  is  a  notable  feature  of  the  case,  it 
may  be  advisable  to  use  an  antiseptic,  of  which  the  following  are 
the  most  reliable:  Salicylic  acid  (1  in  1,000);  sodium  salicylate 
(0'5  per  cent.) ;  permanganate  of  potassium  (1  in  1,000) ;  boracic  acid 
(1  percent.) ;  borax  (5  per  cent.) ;  resorcin(4  in  1,000);  thymol  (5  in 
1,000);  benzol  (5  in  1,000);  or  a  solution  of  hydrochloric  acid  (1  in 
1,000).  Some  authorities  recommend  that  after  the  organ  has  been 
thoroughly  cleansed  with  boiled  water,  a  pint  of  boro-salicylic  solu- 
tion (boracic  acid,  60  gr.,  salicylic  acid, 20  gr.;  water,  1  pint)  should  be 
poured  into  it  and  allowed  to  remain  in  contact  with  the  mucous 


Dilatation  of  the  Stomach.  313 

membrane  for  five  minutes,  before  being  withdrawn.  A  teaspoonful 
of  pure  glycerine  after  lavage  completes  the  process  of  antisepsis 
and  also  acts  as  an  aperient.  It  is  always  necessary  that  the 
stomach  should  be  carefully  emptied  at  the  end  of  lavage,  lest  the 
antiseptic  be  absorbed  into  the  general  circulation  and  produce 
symptoms  of  poisoning.  In  all  cases  a  firm  binder  or  belt  should 
be  applied  to  the  abdomen  in  such  a  manner  as  to  elevate  and 
support  the  enlarged  stomach,  as  by  this  simple  measure  the 
traction  of  the  heavy  viscus  upon  its  fixed  pylorus  is  prevented  and 
the  exit  of  its  contents  into  the  duodenum  accelerated.  The  fact 
that  compensatory  hypertrophy  of  the  gastric  musculature  usually 
exists  renders  the  application  of  electricity  and  massage  superfluous. 

Diet. — This  must  vary  according  to  the  cause  of  the  pyloric 
stenosis  and  the  general  condition  of  the  patient.  As  a  rule,  a 
mechanical  obstruction  to  the  exit  of  chyme  from  the  stomach  is 
associated  with  diminished  peptic  digestion,  and  it  is,  therefore, 
necessary  to  administer  nourishment  in  a  form  which  is  capable  of 
passing  with  the  least  difficulty  into  the  duodenum.  Thin  soups 
and  broths  should  be  prohibited,  but  milk,  either  raw,  peptonised, 
sterilised  or  mixed  with  a  suitable  proportion  of  lime-water,  usually 
agrees,  and  may  be  permitted  in  considerable  amount.  Finely 
minced  fish,  chicken,  game,  sweetbreads,  tripe,  or  hashed  mutton, 
along  with  eggs,  and  a  small  quantity  of  potato,  cauliflower  or 
asparagus  may  be  allowed  in  suitable  cases,  but  the  material  must 
be  well  masticated  and  eaten  slowly.  Scraped  raw  beef  often 
answers  well.  Curdled  milk  is  only  suitable  when  the  gastric 
secretion  is  deficient  in  hydrochloric  acid.  In  these  latter  cases,  of 
which  the  best  example  is  cancerous  stricture  of  the  pylorus,  the 
increasing  tendency  to  food  stagnation  soon  renders  a  solid  diet 
inadmissible,  and  the  meals  must  consequently  be  composed  of  such 
fluids  and  semi-solids  as  are  most  easily  digested.  In  this  category 
the  various  meat  jellies,  essences  and  juices,  are  important  items. 
In  cases  of  benign  stenosis,  on  the  other  hand,  milk  should  form 
the  staple  diet.  Tea  almost  invariably  disagrees,  but  unsweetened 
cocoa  is  often  digested  without  trouble.  A  little  good  brandy  or 
whisky  given  in  hot  water  along  with  the  food  often  relieves  the 
flatulence  and  other  unpleasant  symptoms.  When  vomiting  is  a 
constant  feature  of  the  case  rectal  feeding  may  be  necessary. 

Medicinal  Treatment. — The  chief  indications  for  the  adminis- 
tration of  drugs  are  :  (1)  To  relieve  the  gastric  symptoms  ;  (2)  to 
assist  the  processes  of  digestion  and  control  excessive  fermenta- 
tion ;  (3)  to  maintain  an  efficient  action  of  the  bowels. 

1.  Severe  pain  during  the  course  of  gastric  digestion  is  either 


314  Dilatation  of  the  Stomach. 

due  to  an  excessive  secretion  of  acid,  such  as  ensues  from  cicatricial 
contraction  of  the  pylorus,  or  to  the  presence  of  an  open  sore, 
whether  simple  or  cancerous.  In  both  instances  it  is  necessary  to 
prescribe  an  alkaline  sedative  mixture  and  to  avoid  all  tonics, 
acids,  bitters  and  other  drugs  which  tend  to  augment  acidity  or  to 
irritate  the  inflamed  gastric  mucous  membrane.  The  salts  of 
bismuth  are  indispensable  in  these  conditions,  but  it  is  still  the 
usual  custom  to  prescribe  the  subnitrate  preparation  in  combination 
with  bicarbonate  of  sodium  in  a  mucilaginous  medium  to  retain 
the  heavy  powder  in  suspension.  The  subnitrate  is,  however, 
frequently  acid  in  reaction,  and  produces  decomposition  of  the 
alkaline  bicarbonate,  while  the  mucilage  favours  bacterial  fermenta- 
tion. A  better  plan  is  to  employ  15  gr.  of  the  carbonate 
of  bismuth,  with  either  a  similar  quantity  of  the  sodium  salt,  or 
12  min.  of  the  solution  of  potash,  and  a  drachm  of  pure 
glycerine  in  some  simple  excipient  like  chloroform  or  peppermint 
water.  When  hyperacidity  exists  the  bismuth  carbonate  has  the 
further  advantage  of  effecting  partial  neutralisation  of  the  gastric 
contents,  and  this  property  may  be  further  enhanced  by  the 
addition  of  10  gr.  of  carbonate  of  magnesia.  The  solution  of 
bismuth  is  only  of  use  in  mild  cases.  If  the  pain  is  severe,  10  to 
15  min.  of  the  solution  of  morphine  [U.S. P.  morphine  hydro- 
chloride,  gr.  ^  to  gr.  ^5]  may  be  incorporated  in  the  prescription, 
or  tincture  of  opium  or  chlorodyne  may  be  employed.  Nepenthe 
is  also  a  valuable  drug,  but  it  should  not  be  given  along  with 
soluble  alkalies.  Excessive  pain,  such  as  accompanies  the  exten- 
sion of  cancer  to  the  peritoneum  or  liver,  may  require  the  use 
of  opium  pills  or  the  hypodermic  administration  of  morphine. 
Cocaine,  belladonna,  chloretone  and  other  analgesics  are  occa- 
sionally prescribed,  but  they  are  not  so  reliable.  When  the  pain 
develops  within  half  an  hour  of  a  meal  the  medicine  should  be 
given  immediately  after  food ;  but  if  the  symptom  is  deferred  for 
one  or  two  hours,  its  administration  midway  between  the  meals 
proves  more  efficacious.  A  deficiency  of  hydrochloric  acid  usually 
accompanies  cancerous  stricture  of  the  pylorus,  and,  theoretically, 
demands  the  administration  of  this  mineral  acid  by  the  mouth ; 
but,  as  a  matter  of  fact,  alkalies  always  afford  greater  relief,  since 
they  serve  to  neutralise  the  acid  products  of  fermentation  and  to 
soothe  the  inflamed  mucous  surface.  The  only  acid  which  is  really 
of  use  is  lactic  acid,  administered  in  the  form  of  curdled  milk. 
Anorexia  is  chiefly  met  with  in  cancer  of  the  pylorus,  and  should  be 
treated  by  systematic  lavage  (see  Cancer  of  the  Stomach).  When 
excessive  flatulence  occurs  at  night,  thirty  drops  of  the  alcoholic 


Dilatation  of  the  Stomach.  315 

essence  of  peppermint  (Ricqles)  in  half  a  sherry-glassful  of  water 
often  affords  relief,  or  a  gingermint  tablet  may  be  sucked  at 
intervals.  Nausea  and  vomiting  usually  subside  when  the  general 
and  dietetic  measures  already  described  are  carefully  carried  out. 

2.  Efforts  to  increase  the  digestive  powers   of  the  stomach  in 
gastric  dilatation  due  to  pyloric  cancer  are  rarely  attended  by  much 
success,  the  incorporation  in  the  dietary  of  1  or  2  pints  of  the 
curdled  milk  each  day  being  of  most  service.      Occasionally,  how- 
ever, pepsin,  combined  with   dilute    hydrochloric  acid,    the    acid 
glycerine  of  pepsin  [U.S. P.  1^.  Pepsin,  9'15 ;  Acid.  Hydrochloric., 
ri5  ;  Glycerin.,  GO'OO  ;  Aquam  Dest.,  ad  lOO'OO] ,  papain,  or  one 
of  the  other  artificial  digestives,  appear  to  relieve  the  symptoms  of 
indigestion,  or  takadiastase  may  be  prescribed  before  the  meals. 
To  control  the  excessive  fermentation,  10  to  12  min.  of  the  glycerine 
of  carbolic  acid  may  be  added  to  the  alkaline  bismuth  mixture,  or 
a  pill  containing  1  gr.  of  the  acid  may  be  given  after  each  meal. 
Creosote  and  guaiacol  are  apt  -to  produce  unpleasant  eructations, 
and  should  be  prescribed  in  3-min.  capsules  after  food.     Cyllin  does 
not  give  rise  to  discomfort,  and  may  advantageously  be  used  in  the 
form   of   the    gastric  palatinoids,  each  of  which  contains  3  min. 
Yanadine,  in  doses  of  10  min.,  taken  immediately  after  meals  is 
sometimes  of  use,  while  minim  doses  of  the  tincture  of  iodine,  well 
diluted,  are  sometimes  successful  when  much  secondary  gastritis 
exists. 

3.  In  the  early  stages  of  the  complaint  the  bowels  usually  react 
to  a  full  dose  of  the  phosphate  and  dried  sulphate  of  sodium  (equal 
parts),  sulphate  of  magnesium,  sulphate  of  sodium,  Carlsbad  salts, 
or  one  of  the  natural  aperient  waters  administered  in  hot  water 
before  breakfast ;    but  at  a    later  period    the  contraction  of   the 
pylorus    causes   the   saline   to   be   retained   in  the  stomach,  and 
recourse  must  be  had  to  vegetable  purgatives  in  the  form  of  a  pill. 
Sooner  or  later  enemata  have  to   be  employed,  but  lavage  of  the 
large  intestine  is  apt  to  prove  exhausting.     For  the  treatment  of 
the   complications    of  gastric  dilatation   see   Gastric   Intolerance  ; 

Heematemesis  and  Tetany. 

W.    SOLTAU   FENWICK. 


316 


SURGICAL     TREATMENT     OF     PYLORIC     STENOSIS 
AND  OBSTRUCTIVE  DILATATION. 

THE  very  process  of  cure  in  pyloric  ulcer  can  only  result  in 
stenosis,  which  if  moderate  in  extent  is  overcome  by  hypertrophy 
of  the  gastric  muscle.  "While  this  compensation  is  maintained 
symptoms  may  be  slight  or  even  absent,  but  sooner  or  later  com- 
pensation fails  and  dilatation  occurs,  leading  to  stagnation  of  the 
stomach  contents,  with  fermentation  and  the  generation  of  acrid 
acids  and  offensive  gases,  giving  rise  to  gastritis.  Relief  is  obtained 
for  a  time  by  vomiting,  but  as  the  stenosis  increases  less  and  less 
food  passes  into  the  intestine,  and  death  from  starvation  is  the 
inevitable  result,  should  not  tetany  or  perforation  hasten  the  end. 

In  perhaps  no  other  variety  of  so-called  chronic  indigestion  are 
the  patients  so  miserable,  and  as  the  disease  may  drag  on  for 
months,  or  even  years,  the  sum-total  of  suffering  probably  exceeds 
that  from  almost  any  other  form  of  disease. 

In  the  early  stages  of  obstructive  dilatation,  when  the  symptoms 
are  slight,  relief  will  doubtless  have  been  given  by  semi-liquid  diet 
and  lavage  of  the  stomach  ;  but  as  soon  as  the  symptoms  are  pro- 
nounced it  is  a  mere  waste  of  time  to  persevere  with  the  use  of 
drugs,  massage,  electricity,  or  even  lavage. 

Surgical  treatment  is  alone  of  avail  in  order  to  remove  the 
cause  of  the  stenosis,  or  to  create  a  new  channel  by  which  the 
contents  of  the  stomach  may  pass  onwards  into  the  intestines. 

It  may  sometimes  be  possible  to  remove  the  cause  of  the 
stenosis  by  division  of  peritoneal  bands  or  adhesions,  or  by  the 
removal  of  a  tumour  obstructing  the  pylorus,  but  in  the  majority 
of  cases  it  will  be  necessary  either  to  enlarge  the  contracted  pyloric 
orifice  or  to  perform  a  gastro-enterostomy. 

The  operations  available  are  :  (1)  Pylorodiosis,  or  forcible 
dilatation  of  the  pylorus  ;  (2)  Pyloroplasty  ;  (3)  Finneys  operation  ; 
(4)  Kocher's  gastro-duodenostomy  ;  (5)  Pylorectomy  ;  (6)  Gastrolysis  ; 
(7)  Gastro-JKJunostomy. 

It  is  not  necessary  to  describe  or  dilate  on  the  various  opera- 
tions that  may  be  performed  in  case  of  dilatation  of  the  stomach  due 
to  simple  pyloric  stenosis,  as  the  greater  number  of  experienced 
surgeons  are  agreed  that  gastro-jejunostomy  is  the  procedure 
that  should  be  followed  in  such  cases,  not  only  because  it  can  be 


Pyloric  Stenosis  and  Obstructive  Dilatation.      317 

done  with  very  little  risk,  but  also  because  the  after-results  of  the 
operation  in  these  cases  are  extremely  satisfactory.  The  risk  is 
under  2  per  cent.,  and  the  cases  permanently  relieved  or  cured  are 
over  90  per  cent. 

Although  pylorectomy  or  partial  gastrectomy  is  a  much  more 
severe  operation  than  gastro-enterostomy,  yet  there  is  a  certain 
class  of  cases  of  pyloric  stenosis  associated  with  tumour  in  which 
it  is  difficult  to  say  whether  the  tumour  of  the  pylorus  is  simple  or 
malignant. 

If  the  obstruction  of  the  pylorus  is  associated  with  a  tumour  due 
to  inflammatory  disease,  in  all  probability  it  will  be  so  adherent  to 
the  under- surf  ace  of  the  liver  or  to  the  pancreas  that  pylorectomy 
will  be  extremely  difficult  and  hazardous.  In  such  cases  it  will 
probably  be  deemed  necessary  to  rest  content  with  gastro-enterostorny, 
in  the  hope  that  the  rest  induced  by  the  operation  will  cause  a 
subsidence  of  the  tumour.  I  have  found  this  to  apply  in  many 
such  cases  in  which,  at  the  time,  there  was  a  question  of  malignant 
disease,  but  in  which,  after  gastro-enterostomy,  complete  and  per- 
manent recovery  followed.  If,  however,  under  these  circumstances, 
the  pylorus  should  be  free  and  the  disease  limited,  it  may  be  quite 
justifiable  to  perform  pylorectomy  in  case  of  doubt.  As  pylorec- 
tomy, even  in  cancer,  can  be  performed  with  a  mortality  of  15  per 
cent,  or  less,  the  risk  of  operation  in  simple  ulceration  should  not 
exceed  5  per  cent. 

My  views  on  pyloroplasty  and  its  modifications  are  given  later 
(see  p.  385). 

The  operation  of  pylorodiosis,  though  recommended  and  per- 
formed by  Loreta  in  some  cases  of  cicatricial  contraction  of  the 
pylorus,  is  not  a  procedure  to  be  recommended,  as,  though  it  has 
given  good  results  in  some  cases  of  obstruction  due  to  simple 
spasm  of  the  pylorus,  the  procedure  is  attended  with  much  more 
risk  than  either  gastro-enterostomy  or  pyloroplasty,  and  the  only 
form  of  obstruction  in  which  I  should  consider  Loreta's  operation 
at  all  justifiable  is  in  congenital  hypertrophic  stenosis,  where  spasm 
is  taking  a  share  in  the  obstruction. 

A.  -W.  MAYO-ROBSON. 


DISPLACEMENTS  OF  THE  STOMACH. 

THE  stomach  may   undergo   displacement  upward,  laterally  or 
downward. 

UPWARD    DISPLACEMENT. 

Care  must  be  taken  to  correct,  as  far  as  possible,  the  con- 
ditions that  are  responsible  for  this  abnormal  position  of  the 
viscus.  In  the  case  of  abdominal  tumours  or  ascites,  the  removal 
of  the  cause  of  the  excessive  abdominal  pressure  is  at  once 
followed  by  a  descent  of  the  organ,  while  in  cases  of  meteor- 
ismus,  the  exhibition  of  suitable  aperients,  the  prohibition  of 
green  vegetables  and  fruit,  and  a  course  of  intestinal  antiseptics, 
are  usually  followed  by  improvement.  When  the  malposition 
depends  upon  an  abnormal  shape  of  the  thorax,  the  wearing  of 
tight  corsets  and  of  strings  round  the  waist  must  be  avoided,  and 
the  patient  should  practise  some  form  of  breathing  exercise  which 
augments  the  capacity  of  the  chest. 

Starches  and  sugars  should  only  be  allowed  in  strict  moderation, 
and  all  excess  of  fluid  with  the  meals  must  be  prohibited.  Efferves- 
cent drinks  are  especially  harmful.  The  food  must  be  thoroughly 
masticated,  and  green  vegetables  should  be  taken  sparingly.  A 
dose  of  euonymin,  combined  with  rhubarb  and  cascara,  forms  an 
excellent  corrective  of  constipation,  but  salines  should  be  given 
with  caution.  When  much  cardiac  or  respiratory  distress  is 
experienced  after  meals  a  carminative  and  antispasmodic  mixture 
may  be  prescribed,  and  in  the  event  of  a  severe  attack,  the  patient 
should  pass  a  tube  into  the  stomach  with  the  view  of  evacuating 
the  gas  which  is  unable  to  escape  through  the  displaced  oesophagus. 
Intestinal  fermentation  may  be  corrected  by  means  of  cyllin, 
guaiacol,  or  salicylate  of  bismuth  taken  after  meals. 

VERTICAL   DISPLACEMENT. 

The  main  indications  are  to  prevent  further  displacement  of  the 
stomach,  to  support  the  organ,  and  to  correct  any  secondary  dis- 
turbances of  digestion  that  may  occur.  Tight  corsets  must  always 
be  prohibited,  especially  in  girls  who  possess  a  long,  narrow  chest, 
and  come  of  a  tuberculous  stock.  In  such  cases  the  corset  should 
either  be  short  and  loose  or  be  replaced  by  a  band  of  some  warm 


Displacements  of  the  Stomach.  319 

and  firm  material.  Exercises  undertaken  to  strengthen  the 
muscles  of  the  arms,  chest  and  abdomen  are  extremely  valuable, 
and  the  patient  should  learn  to  inspire  deeply  through  the  nose, 
so  as  to  increase  the  capacity  of  the  thorax.  In  every  instance 
a  firm,  well-fitting  belt  should  be  worn  in  such  a  way  as  to 
elevate  and  sustain  the  stomach.  The  belt  should  be  applied  in 
the  recumbent  posture,  and  be  worn  both  night  and  day.  When 
anaemia  and  emaciation  are  prominent  features  of  the  case  rest  in 
bed  is  essential,  and  should  be  maintained  for  a  month  or  six 
weeks.  Abdominal  massage  and  electricity  are  useful  adjuncts 
in  some  cases.  The  salts  of  iron  rarely  agree,  but  arsenic,  nux 
vomica  and  gentian  are  of  value,  and  a  dose  of  hydrochloric  acid, 
administered  after  meals,  is  an  important  aid  to  digestion  when 
the  gastric  secretion  is  diminished.  Eegurgitation  of  bile  into  the 
stomach  should  be  treated  by  lavage  at  night,  while  a  full  dose  of 
sulphate  of  sodium  is  given  in  hot  water  at  an  early  hour  every 
morning.  Should  these  means  prove  ineffectual  in  relieving  the 
bilious  vomiting,  surgical  aid  must  be  invoked. 

TOTAL  DESCENT  OF  THE  STOMACH  (GASTROPTOSIS). 

Much  may  be  accomplished  in  the  prevention  of  gastroptosis  by 
careful  attention  to  the  clothing  and  to  the  early  correction  of  those 
conditions  which  are  commonly  responsible  for  its  development. 
Young  girls  should  never  be  permitted  to  wear  tight  corsets,  and 
at  all  ages  tight  lacing  is  to  be  discouraged.  For  the  same  reason, 
strings  and  bands  worn  round  the  waist  should  be  avoided  and  buttons 
substituted  for  them  when  possible.  During  the  lying-in  period 
special  attention  should  be  bestowed  upon  bandaging  the  abdomen, 
so  as  to  afford  a  firm  support  to  the  viscera  and  aid  the  belly  to 
regain  its  former  shape.  Any  attempt  subsequently  to  improve  the 
figure  by  tight  lacing  must  be  prohibited,  since  the  chief  effect  of 
the  corset  is  to  force  the  stomach  and  intestines  downward,  while 
it  fails  to  afford  any  support  to  the  parietes  below  the  waist.  Care 
should  also  be  taken  to  reduce  the  gaseous  distension  of  the  bowels 
that  usually  occurs  after  delivery,  and  to  overcome  the  natural 
tendency  to  constipation.  The  patient  should  never  be  allowed  to 
walk  before  the  tone  of  the  abdominal  muscles  has  been  restored. 
The  same  rules  apply  to  persons  who  have  undergone  abdominal 
operations,  and  to  those  cases  in  particular  where  the  intra- 
abdominal  pressure  has  been  suddenly  lowered  by  the  removal  of  a 
large  tumour  or  an  excess  of  ascitic  fluid.  The  treatment  of  the 
dislocated  stomach  itself  is  a  purely  mechanical  one.  In  mild  or 
recent  cases,  confinement  to  bed  for  a  month  is  invaluable,  as  it 


320  Displacements  of  the  Stomach. 

not  only  tends  to  cut  short  the  progress  of  the  complaint,  but 
completely  relieves  the  symptoms  that  emanate  from  it.  Rest 
cures  also  act  advantageously,  since  the  patient  is  forced  to  occupy 
the  recumbent  posture ;  while  an  excess  of  nourishment  leads  to 
the  accumulation  of  fat  in  the  abdomen.  Under  all  conditions 
persons  suffering  from  gastroptosis  should  be  advised  to  lie  down 
for  an  hour  after  meals  and  at  the  same  time  to  loosen  the  corsets 
and  clothing  round  the  waist.  By  this  simple  procedure  the 
symptoms  which  develop  during  digestion  are  rendered  much  less 
severe  and  stagnation  of  food  is  to  a  great  extent  prevented. 
Lavage  is  of  no  value  unless  the  condition  is  complicated  by 
gastrectasis  or  chronic  gastritis,  nor  in  ordinary  cases  do  massage 
and  electricity  produce  any  direct  effect  upon  the  stomach.  As  a 
means,  however,  of  strengthening  the  muscles  of  the  abdomen 
they  are  often  beneficial. 

The  essential  factor  in  the  treatment  of  gastroptosis  is  the 
application  of  a  firm  belt  to  the  abdomen,  which  will  support  the 
stomach  and  hold  it  in  position.  Many  varieties  have  been  devised 
for  the  purpose  (Glenard,  Landau,  Bardenheuer,  and  Teufel),  but  it 
must  be  remembered  that  a  belt  that  suits  one  person  will  not 
necessarily  suit  another  and  that  consequently  no  stock  pattern  can  be 
prescribed  without  previous  trial.  Many  of  the  corset-belts  now  in 
fashion  either  exaggerate  all  the  ill -effects  of  the  corset  or  fail  to 
afford  support  to  the  prolapsed  stomach.  As  a  rule,  the  binder  or 
belt  should  extend  from  the  lower  border  of  the  twelfth  rib  to  the 
symphysis  pubis,  and  should  be  made  of  some  light  but  firm  material 
that  will  not  easily  stretch.  Silk  elastic  makes  an  excellent  belt,  but 
it  requires  constant  renewal.  The  support  should  be  applied  with 
the  patient  lying  on  his  back  and  should  be  laced  or  tightened  from 
below  upward.  To  prevent  it  from  riding  up,  a  perineal  band  may 
be  worn,  or,  in  the  case  of  a  woman,  the  suspenders  of  the  stockings 
may  be  attached  to  it  on  either  side.  For  some  time  the  belt  must 
be  worn  both  by  day  and  night,  but  when  considerable  improvement 
has  taken  place  it  may  be  left  off  when  the  patient  retires  to  bed. 

Diet. — The  food  must  be  regulated  according  to  the  necessities 
of  each  individual  case  and  the  existence  of  complications. 
Gastroptosis  associated  with  healthy  intestinal  functions  and  good 
gastric  compensation  merely  requires  a  full  diet  of  substances  that 
are  easily  digestible.  Moderately  cooked  and  tender  meats,  fish, 
game,  eggs,  sweetbreads,  tripe,  sheep's  head,  calf's  head  and  feet, 
well-boiled  cereals,  farinaceous  puddings,  and  a  small  amount  of 
fruit  may  be  allowed ;  and  the  patient  should  be  encouraged  to 
drink  milk  with  her  meals  and  to  indulge  in  cream  and  fats.  Raw 


Displacements  of  the  Stomach.  321 

vegetables,  pastry,  sauces,  pickles  and  cheese  should  be  pro- 
hibited. When  emaciation  is  a  marked  feature  of  the  case  and 
is  attended  by  neurasthenia,  a  milk  diet  wis  often  of  great  value, 
5  pints,  mixed  with  a  small  proportion  of  lime-water,  being  given  in 
divided  doses  during  the  course  of  the  day. 

Gastroptosis  accompanied  by  myasthenia  requires  a  diet  suited 
to  this  important  complication.  The  great  principles  to  be  borne  in 
mind  are  to  supply  the  stomach  with  those  forms  of  food  which  are 
most  easy  of  digestion,  to  avoid  over-distension  of  the  organ,  and  to 
permit  a  sufficient  interval  to  elapse  between  the  meals  in  order  that 
the  viscus  may  completely  empty  itself  on  each  occasion.  Sugars 
and  fats  in  excess  are  always  injurious,  owing  to  the  tendency  of  the 
former  to  ferment  and  of  the  latter  to  stagnate  in  the  stomach. 
Butter  and  cream  may  be  allowed  in  moderation,  as  well  as  rice 
and  oatmeal  porridge.  Lean  meats,  white  fish,  fowl,  game,  and  eggs 
may  be  given,  but  soups  and  broths  must  be  avoided.  Spinach  and 
asparagus  may  be  taken  in  small  quantities,  but  raw  and  coarse 
vegetables  are  difficult  of  digestion.  An  exclusive  milk  diet  is 
seldom  advisable,  owing  to  the  distension  of  the  stomach  which 
ensues  from  the  introduction  of  large  quantities  of  fluid,  and  at 
most  8  oz.  should  be  taken  at  a  meal.  Tea  and  coffee  rarely 
agree  and  most  varieties  of  cocoa  are  unsuitable,  owing  to  the 
sugar  they  contain.  A  decoction  of  cocoa  husks  or  cocoa  nibs  forms 
a  palatable  drink  and  is  free  from  the  disadvantages  that  pertain 
to  the  other  preparations.  If  the  patient  is  accustomed  to  take 
alcohol,  a  little  good  brandy  or  whisky  may  be  allowed ;  but  as  a 
rule  a  claret-glassful  of  hot  water  sipped  at  the  end  of  the  meal  is 
more  beneficial. 

When  colitis  complicates  the  gastric  displacement  the  diet  should 
consist  entirely  of  finely  minced  fish,  poultry,  tripe,  sweetbreads  and 
sheep's  brains,  dry  toast,  meat  juice,  clear  soups  without  vegetables, 
potatoes  and  plain  milk  puddings.  Green  vegetables  and  fruits  are 
particularly  harmful,  and  red  meats  should  usually  be  avoided. 
Vichy  or  Contrexeville  water  may  be  drunk  with  the  meals. 

Medicinal  Treatment. — In  uncomplicated  cases  drugs  are  seldom 
of  much  value  and  the  treatment  is  chiefly  symptomatic.  If  the 
appetite  is  bad  a  dose  of  dilute  phosphoric  or  nitro-hydrochloric 
acid  combined  with  a  bitter  infusion  may  be  given  between  meals. 
Occasionally,  the  sense  of  extreme  weakness  may  require  the  exhibi- 
tion of  strychnine,  nux  vomica,  cinchona  or  •  other  tonic ;  while  in 
many  instances  cod-liver  oil,  the  compound  syrup  of  the  hypophos- 
phites,  the  elixir  of  phosphorus  or  formate  of  sodium  produce  a  bene- 
ficial effect  upon  the  symptoms  of  neurasthenia.  Pain  after  food  and 

S.T.— VOL.  II.  21 


322  Displacements  of  the  Stomach. 

flatulence  usually  depend  upon  some  morbid  condition  of  the  gastric 
secretion  or  an  increased  sensibility  of  the  gastric  mucous  membrane, 
and  in  such  cases  the  compound  bismuth  mixture,  with  or  without 
morphine,  affords  relief.  Sometimes  a  preparation  of  pepsin  or 
pancreatin,  or  the  tablets  of  pentenzyme,  appear  to  aid  the  processes 
of  digestion.  The  development  of  gastric  rnyasthema  requires  the 
addition  of  carbolic  acid  to  the  bismuth  mixture,  while  in  cases 
complicated  by  colitis  full  doses  of  salicylate  of  bismuth,  cyllin,  or 
guaiacol  should  be  prescribed.  The  selection  of  a  suitable  aperient 
is  always  a  matter  of  importance.  As  a  rule,  purgation  must  be 
avoided  and  reliance  placed  upon  small  doses  of  cascara  and 
euonyrnin,  combined,  if  necessary,  with  belladonna  and  rhubarb. 
In  other  cases  a  confection  of  cascara  and  maltine  taken  at  bed- time 
proves  efficient,  or  one  composed  of  guaiacum,  senna  and  ginger 
may  be  employed.  When  colitis  is  accompanied  by  constipation 
nothing  is  so  effectual  as  a  small  dose  of  castor  oil  each  morning 
before  breakfast ;  but  if  severe  neurasthenia  exists  all  purgatives 
may  have  to  be  omitted,  and  a  daily  evacuation  secured  by  an  enema 
of  soap  and  water.  Carlsbad  salts  and  other  salines  are  chiefly 
indicated  when  myasthenia  with  stagnation  of  food  exists,  as  their 
employment  in  this  condition  effects  a  kind  of  internal  lavage  and 
sweeps  the  fermenting  contents  of  the  stomach  into  the  intestine. 
In  other  respects  the  medicinal  treatment  of  gastroptosis  is 
conducted  upon  the  lines  laid  down  for  the  management  of  chronic 
gastritis  and  gastric  atony. 

W.    SOLTAU   FENWICK. 


323 


SURGICAL  TREATMENT  OF  GASTROPTOSIS. 

MANY  cases  of  gastroptosis  exist  without  symptoms,  and  therefore 
require  no  special  treatment,  but  when  symptoms  do  occur  it  will 


«/•-• -LIVER 


{/tTT/iCHMEHT  OF 

(GASTRO-HEMTIC 
\OMEHTUM  TO  LIVER 


'-LESSER    CURVATURE 
OF  STOMACH 


TURNED    Uf 


UTURES     TIED 
STOMACH 

LI/EK. 


FIG.  1.— EVE'S  OPERATION. 

Of  four  cases,  reported  by  Bier  and  twenty  by  Eve,  all  were 
said  to  have  done  well. 

usually  be  found  that  other  abdominal  organs  participate  in  the 
prolapse. 

When  the  stomach  is  both  dilated  and  prolapsed  and  shows  sign 

21  —  2 


324        Surgical  Treatment  of  Gastroptosis. 

of  stasis  and  catarrh,  but  without  actual  stenosis  of  the  pylorus, 
gastric  lavage  may  be  of  service. 

After  failure  of  general  treatment  the  operation  of  gastropexy 
may  be   called  for.     It  may   be   carried   out   effectually  either  by 


FIG.  2. — BEYEA'S  OPERATION  FOB  GASTROPTOSIS. 
Of  eight  reported  cases,  seven  were  apparently  cured  and  one  relieved. 

Be}rea's  method  of  shortening  the  gastro-hepatic  onientum,  or  by 
Bier's  or  Eve's  method  of  suturing  the  lesser  curvature  of  the 
stomach  to  the  free  border  of  the  liver.  These  methods  are  shown 
in  Figs.  1  and  2. 

A.  W.  MAYO  ROBSON. 


325 


HAEMORRHAGE    FROM    THE    STOMACH. 

H&SMATEMB8I8  occurs  in  many  diseases  of  the  stomach,  of  which 
the  following  are  the  most  important :  (1)  Acute  simple  ulcer ; 
(2)  chronic  simple  ulcer ;  (3)  cancer  ;  (4)  cirrhosis  of  the  liver. 
The  milder  forms  which  ensue  from  acute  gastritis,  malignant 
fevers,  peritonitis,  purpura,  scurvy,  haemophilia,  diseases  of  the 
spleen,  renal  inflammations  and  severe  antennas  do  not  require 
local  treatment. 

(1)  Acute  Gastric  Ulcer. — In  this  disease  the  walls  of  the  ulcer 
are  not  indurated  nor  are  the  blood-vessels  thickened,  so  that  the 
natural  cure  of  haemorrhage  by  contraction  of  the  ulcerated  vessel 
and  the  formation  of  a  protective  thrombus  almost  invariably 
occurs,  and  death  is  extremely  rare.  Only  about  |  of  the 
total  quantity  of  blood  effused  into  the  stomach  is  vomited,  the 
remainder  being  evacuated  by  the  bowel.  However  slight  the 
haematemesis  may  appear,  the  existence  of  this  masked  haemor- 
rhage must  be  borne  in  mind  and  careful  treatment  adopted. 
Absolute  rest  in  bed  is  essential,  and  the  patient  should  lie  flat 
on  his  back  with  the  head  low,  and  no  attempt  should  be  made 
to  sit  up  or  to  get  out  of  bed  even  for  the  purpose  of  micturition. 
The  atmosphere  of  the  room  should  be  kept  at  a  temperature  of 
50°  to  60°  F.,  and  talking  to  friends  or  other  forms  of  excitement 
prohibited.  Physical  examination  should  also  be  strictly  limited, 
and  as  few  questions  asked  as  possible  concerning  the  history  of 
the  previous  illness.  Pressure  of  the  bed  clothes  upon  the  abdomen 
should  be  removed  by  means  of  a  cradle  or  other  contrivance.  The 
first  indication  is  to  give  the  stomach  complete  physiological  rest. 
This  is  of  the  utmost  importance,  since  the  secretion  of  gastric  juice 
not  only  excites  gastric  peristalsis  but  also  dissolves  the  protective 
thrombus.  It  is  usually  advised  that  small  quantities  of  ice  be 
sucked  at  intervals,  or  teaspoonful  doses  of  iced  water  swallowed 
if  thirst  is  excessive.  Inasmuch,  however,  as  water  is  a  powerful 
excitant  of  the  gastric  juice,  the  fluid  should  only  be  used  for  the  pur- 
pose of  cleansing  the  mouth  and  should  not  be  swallowed.  Nutrition 
is  maintained  by  the  careful  administration  of  nutrient  enemata. 
It  was  formerly  the  custom  to  limit  the  size  of  each  injection  to 
2  fluid  ounces  of  milk,  to  which  the  yolk  of  an  egg,  dextrose  or  pep- 
tones were  added  when  necessary,  and  to  repeat  the  enema  every 


326  Haemorrhage  from  the  Stomach. 

two  hours.  These  frequent  injections  are  not  only  a  source  of  extreme 
discomfort  to  the  patient  and  very  disturbing,  but  are  really  insuffi- 
cient to  maintain  the  strength  for  many  days,  and  there  can  be 
little  doubt  that  when  death  ensues  a  week  or  ten  days  after  a  single 
haemorrhage,  inanition  rather  than  loss  of  blood  is  the  immediate 
cause.  At  the  present  day  it  is  customary  to  administer  nutrient 
enemata  of  peptonised  milk,  commencing  with  10  fluid  ounces 
every  six  hours,  and  rapidly  increasing  the  amount  until  a  pint  is 
retained  and  absorbed.  The  necessary  apparatus  consists  of  a  soft 
rubber  catheter,  about  3  feet  of  rubber  tubing,  and  either  a  glass 
reservoir  capable  of  containing  a  pint  of  fluid,  a  Thermos  flask  used 
in  the  inverted  position,  or  a  simple  funnel.  The  patient  reclines 
upon  his  left  side  with  the  buttocks  elevated  on  a  pillow;  the 
catheter,  previously  warmed  and  oiled,  is  inserted  into  the  rectum 
for  about  6  inches,  and  the  warm  (70°  to  80°  F.)  peptonised  milk  is 
allowed  to  flow  slowly  into  the  bowel  from  the  reservoir,  which  is 
placed  not  higher  than  1  foot  above  the  patient's  body.  The 
main  object  to  be  kept  in  view  is  to  ensure  that  the  milk  flows 
sufficiently  slowly  into  the  bowel  not  to  excite  peristalsis,  and  con- 
sequently one  hour  should  be  occupied  in  the  administration  of  a 
pint  of  milk,  and  no  attempt  made  to  hurry  the  operation.  If 
these  precautions  are  taken,  and  the  rectum  is  washed  out  with  a 
solution  of  common  salt  (1  drachm  to  the  pint)  night  and  morning 
complete  absorption  of  the  milk  takes  place,  and  the  nutrition  may 
be  maintained  efficiently  several  weeks,  if  necessary.  There  are 
three  conditions  under  which  the  enemata  are  evacuated  instead  of 
being  absorbed.  In  the  first,  the  presence  of  decomposing  blood  in 
the  intestines  is  apt  to  excite  excessive  peristalsis,  and  in  such  cases 
it  is  advisable  to  administer  one  or  two  large  soap  and  water  enemata 
before  the  rectal  alimentation  is  begun.  Secondly,  loss  of  blood  in 
highly  nervous  individuals  induces  active  contractions  of  the  rectum 
and  thus  prevents  the  retention  of  the  milk,  so  that  it  may  be 
necessary  to  add  10  min.  [U.S.P.  6  rnin.]  of  tincture  of  opium  to 
the  first  two  or  three  injections.  Lastly,  decomposition  of  retained 
blood  sometimes  produces  much  flatus  during  the  course  of  the 
treatment,  which  proves  inimical  to  the  retention  of  the  feed. 
This  condition  may  be  allayed  by  the  addition  of  10  min. 
of  the  glycerine  of  carbolic  acid  to  each  injection.  Some 
writers  advocate  more  elaborate  enemata,  such  as  the  following : 
(1)  Peptonised  milk  or  beef-tea,  10  oz. ;  the  yolk  of  one  egg; 
peptone  powder,  2  drachms ;  bicarbonate  of  sodium,  5  gr. ;  every 
six  hours.  (2)  Peptonised  milk,  8  oz. ;  the  yolks  of  two  eggs  ; 
a  dessertspoonful  of  whisky  or  brandy ;  every  six  hours.  (3)  Ten 


Haemorrhage  from  the  Stomach.          327 

ounces  of  Leube's  pancreatic  milk  emulsion  or  of  Roberts'  pep- 
tonised  milk  gruel,  or  of  freshly  defibrinated  ox-blood  ;  every  six 
hours.  (N.B.  Leube's  emulsion  is  prepared  as  follows  :  Mix  6  oz.  of 
scraped  and  finely-chopped  raw  beef  with  2  oz.  of  minced  pig's 
pancreas,  and  rub  them  up  in  a  mortar  with  a  little  water  until  the 
whole  acquires  the  consistency  of  gruel.  The  syringe  must  have 
a  wide  nozzle.  To  prepare  Roberts'  peptonised  gruel,  mix  equal 
quantities  of  well-boiled  gruel  and  fresh  milk,  and  add  to  the 
enema  2  drachms  of  Benger's  liquor  pancreaticus  and  5  gr. 
of  bicarbonate  of  sodium.)  In  those  rare  cases  where  extreme 
irritability  of  the  rectum  exists,  subcutaneous  injections  may  be 
given  of  peptonised  milk,  olive  oil,  or  beef  essence.  Nutrient 
suppositories  are  valueless. 

The  dryness  of  the  mouth  which  accompanies  prolonged  rectal 
alimentation  is  apt  to  give  rise  to  suppurative  parotitis  from  an 
ascending  infection  of  Stenson's  duct.  It  is  always  advisable,  there- 
fore, to  make  the  patient  suck  a  rubber  teat  at  frequent  intervals 
during  the  day,  since  by  this  simple  procedure  the  secretion  of  saliva 
is  stimulated  and  the  mouth  maintained  in  a  moist  and  clean  state. 
Antiseptic  mouth  washes  or  gargles  may  also  be  employed.  It  is 
usually  necessary  to  continue  rectal  feeding  for  at  least  one  week 
after  the  haemorrhage  has  ceased.  A  gradual  increase  in  the 
rapidity  of  the  pulse  with  a  diminution  of  tension  is  an  invariable 
indication  of  insufficient  nourishment. 

The  haemorrhage  from  an  acute  ulcer  ceases  spontaneously,  and 
it  is  rarely  necessary  to  administer  any  drugs  with  the  view  of 
controlling  the  bleeding.  Should  the  patient,  however,  exhibit 
extreme  nervousness  despite  the  assurance  that  recovery  will 
occur,  ^  to  ^  gr.  of  morphine  may  be  injected  subcutaneously, 
and  repeated  after  a  few  hours  if  necessary.  No  aperients 
should  be  administered  by  the  mouth  for  a  month.  A  steady 
diminution  of  the  pulse  rate  indicates  a  cessation  of  the  haemorrhage, 
and  four  weeks  are  usually  required  for  the  cicatrisation  of  the 
ulcer,  during  which  time  a  liquid  diet  should  be  maintained. 

(2)  Chronic  Simple  Ulcer. — In  this  variety  of  the  complaint  the 
process  of  healing  is  prevented  by  the  adhesion  of  the  base  of  the 
sore  to  an  organ  in  its  vicinity,  the  induration  of  its  edges  which 
prevent  contraction,  the  frequent  location  of  the  disease  close  to 
the  pyloric  or  cardiac  orifices,  which  are  never  at  rest,  and  the 
existence  of  a  hyperacid  gastric  juice  which  irritates  and  erodes 
healthy  granulations.  Haemorrhage  in  these  cases  is  usually  pro- 
longed, and  always  exhibits  a  tendency  to  recurrence,  owing  to  the 
fact  that  the  eroded  blood-vessel  is  firmly  embedded  in  fibrous 


328  Haemorrhage  from  the  Stomach. 

tissue  and  incapable  of  that  degree  of  contraction  and  retraction 
which  are  necessary  to  spontaneous  closure.  The  cessation  of 
bleeding,  therefore,  depends  upon  the  formation  of  a  clot  in  the 
aperture  and  its  subsequent  organisation.  The  premature  adminis- 
tration of  food  or  water,  by  stimulating  gastric  secretion,  almost 
invariably  leads  to  the  digestion  of  this  protective  thrombus,  while 
excitement  or  sudden  movements  of  the  body  accelerate  the  action 
of  the  heart  and  cause  the  .plug,  which  had  formed  in  the  orifice  of 
the  artery,  to  be  blown  out  like  a  cork,  with  consequent  renewal  of 
the  haemorrhage.  A  sudden  rise  of  the  pulse-rate  is  a  sure  sign 
of  this  untoward  accident.  The  general  measures  to  be  adopted  are 
similar  to  those  employed  in  haemorrhage  from  an  acute  ulcer. 
Absolute  rest  upon  the  back  for  a  week  or  ten  days  is  essential,  and 
no  talking,  attention  to  business  or  other  forms  of  excitement  are 
to  be  permitted.  The  nutrition  is  maintained  entirely  by  large 
nutrient  enemata  of  peptonised  milk,  and  the  mouth  kept  moist  by 
the  frequent  sucking  of  a  rubber  teat.  The  bowel  is  washed  out 
each  night  and  morning  with  normal  saline  solution.  As  a  rule 
rectal  alimentation  is  continued  for  a  week  or  ten  days,  after  which 
time  tablespoonful  doses  of  iced  whey  are  allowed  every  half  hour 
and  subsequently  changed  to  peptonised  milk.  The  object  of  pre- 
digesting  the  milk  is  to  stimulate  the  gastric  secretion  as  little  as 
possible.  Two  nutrient  enemata  in  each  twenty-four  hours  may 
be  continued  with  advantage  for  several  weeks. 

It  is  the  custom  to  apply  an  ice  bag  to  the  region  of  the  stomach 
for  a  few  days  after  an  attack  of  haematemesis,  and  if  the  bag 
is  suspended  from  a  cradle  in  such  a  manner  as  to  exert  only  slight 
pressure  upon  the  epigastrium,  it  is  probable  that  the  cold  applica- 
tion does  actually  diminish  the  peristaltic  movements  of  the  organ 
and  thus  favour  the  formation  of  a  firm  clot.  A  piece  of  lint  should 
be  interposed  between  the  bag  and  the  skin  to  prevent  the  dripping 
of  moisture  upon  the  body.  Palpation  of  the  abdomen  must,  of 
course,  be  avoided. 

It  is  a  good  plan  to  commence  medicinal  treatment  by  the  sub- 
cutaneous injection  of  J  gr.  of  morphine,  which  can  be  repeated, 
if  necessary,  three  hours  later.  Should  the  haemorrhage  be 
severe  and  the  rapidity  of  the  pulse  suggest  continued  leakage, 
ergotin  is  usually  administered  beneath  the  skin,  in  a  dosage  varying 
from  2  to  5  gr.,  which  may  be  repeated  in  three  hours  if  considered 
advisable.  In  cases  of  profuse  recurrent  haematemesis  many  autho- 
rities speak  favourably  of  turpentine,  given  in  the  form  of  an 
emulsion  (a  dessertspoonful  or  more  beaten  up  with  the  white 
of  one  egg)  or  in  capsules.  If  the  haemorrhage  persists  another 


Haemorrhage  from  the  Stomach.  329 

30  min.  may  be  given  after  the  lapse  of  two  hours.  Adrenalin 
chloride  (1  in  1,000)  is  sometimes  of  value,  when  given  in  doses  of 
30  min.  three  or  four  times  a  day,  but  the  presence  of  loose  clot 
over  the  ulcer,  from  beneath  which  the  blood  oozes,  often  prevents 
the  drug  from  coming  into  contact  with  the  bleeding  vessel.  Thirty 
minims  of  the  solution  of  perchloride  of  iron  [U.S. P.  8  min. 
solution  of  ferric  chloride]  combined  with  one  drachm  of  glycerine, 
and  given  every  hour,  has  been  recommended,  but  it  is  apt  to 
excite  vomiting.  In  obstinate  cases  a  trial  should  always  be  made 
of  the  gallic  acid  and  opium  pill  (acid  gallic  or  tannic,  2J  gr.,  ext. 
opii.  £  gr.),  two  of  which  are  given  every  three  hours. 

In  cases  of  exceptional  severity,  several  adjuncts  to  the  medicinal 
treatment  may  be  tried.  It  is  a  good  plan  to  apply  ligatures  round 
the  upper  parts  of  the  arms  and  thighs  sufficiently  tight  to  prevent 
the  iiow  of  blood  through  the  veins  but  not  to  interfere  with  the 
arterial  circulation.  In  this  manner  a  considerable  amount  of 
blood  becomes  stagnant  in  the  extremities,  and  the  slight  diminu- 
tion of  pressure  in  the  gastric  vessels  which  ensues  from  it  favours 
coagulation  at  the  bleeding  point.  High  rectal  injections  of  water 
at  a  temperature  of  112°  to  120°  F.  are  also  stated  to  be  of  value. 
In  a  few  desperate  cases  lavage  with  ice-cold  water  has  been  followed 
by  a  cessation  of  the  bleeding.  The  question  of  surgical  interference 
should  always  be  considered. 

Failure  of  the  heart  from  excessive  loss  of  blood  must  be  combated 
by  the  administration  of  ammonia,  ether,  strychnine,  or  camphor. 
Injections  of  warm  saline  fluid,  whether  subcutaneous  or  intra- 
venous, must  be  given  with  caution,  as  a  sudden  rise  of  blood  pressure 
often  excites  further  haemorrhage,  but  the  continuous  rectal  injection 
is  free  from  this  disadvantage  and  should  always  be  employed  in 
severe  cases.  It  is  probable  that  the  modernised  plan  of  direct 
blood-transfusion  will  some  day  prove  of  the  greatest  advantage. 

(3)  Cancer. — It  is  only  in  rare  instances  that  sloughing  of  the 
growth  gives  rise  to  an  excessive  and  dangerous  haemorrhage,  and 
in  such  the  measures  indicated  in  hsematemesis  from  chronic  ulcer 
must  be  adopted.      The  repeated  vomiting  of  small  quantities   of 
altered  blood,  which  is  so  characteristic  of  an  ulcerated  carcinoma 
or  an  oozing  medullary  growth,  require  that  the  patient  be  kept  in 
bed  and  fed  exclusively  on  peptonised  milk.     Lavage  should  never 
be  performed,  as  the  tube  often  injures  the  soft  vascular  growth. 
A  gallic  acid  and  opium  pill  given  three  times  a  day,  or  the  capsules 
of  turpentine,  usually  prevent  excessive  loss  of  blood. 

(4)  Hepatic  Cirrhosis. — In  this  disease  the  gastric  haemorrhage 
usually  proceeds  from  the  rupture  of  a  varicose  vein  at  the  cardiac 


330  Haemorrhage  from  the  Stomach. 

orifice ;  it  is,  therefore,  often  difficult  to  stop  and  very  apt  to  recur. 
As  a  rule,  2  gr.  of  calomel,  followed  after  a  few  hours  by  a  full  dose 
of  salts,  is  the  most  effectual  treatment,  by  the  relief  it  affords  to 
the  portal  engorgement,  and  may  be  repeated  each  day  for  a  week, 
if  necessary.  Otherwise  the  measures  previously  related  should  be 
adopted  in  this  and  other  forms  of  venous  haemorrhage  from  the 
stomach. 

W.    SOLTAU   FENWICK. 


SURGICAL  TREATMENT  OF  H^EMATEMESIS. 

THE  complication  of  haemorrhage  occurs  in  a  greater  or  less 
degree  in  from  50  to  80  per  cent,  of  all  cases  of  gastric  ulcer,  and 
according  to  various  authors  is  fatal  in  from  3  to  11  per  cent. 

From  the  point  of  view  of  treatment  it  seems  convenient  to 
classify  the  cases  under  two  divisions  : 

(1)  The  acute,  always  alarming,  and  sometimes,  though  rarely, 
fatal  attacks  that  occur  without  any  warning  and  without  any  pre- 
monitory symptoms  pointing  to  ulcer  ;  attacks  that,  when  occurring 
in  young  anaemic  women,  usually  cease   spontaneously  or   under 
treatment  and  do  not  tend  to  recur. 

(2)  The  attacks  associated  with  or  preceded  by  definite  symptoms 
of  ulcer,  which  may  be  (a)  Acute,  ending  rapidly  in  death ;  (b)  acute, 
temporarily  subsiding  and  recurring  in  a  few  hours  or  a  few  days, 
or  after  longer   periods ;  and  (c)  the  chronic  haemorrhages,  often 
slight  in  amount  but  frequently  recurring  and  leading  to  serious 
anaemia. 

From  the  fact  that  medical  and  general  treatment  is  successful  in 
arresting  acute  haematemesis  in  from  93  to  97  per  cent,  of  all  cases, 
and  that  it  is  difficult  in  the  present  state  of  our  knowledge  to  say 
at  first  that  the  bleeding  is  not  occurring  from  capillaries  or  small 
arterioles,  it  necessarily  follows  that  medical  treatment  should 
always  have  a  fair  trial  in  every  case  of  acute  haematemesis.  The 
very  fact  of  medical  treatment  being  so  often  successful  in  cases  of 
apparently  alarming  haematemesis  goes  to  show  that  capillary 
oozing  or  bleeding  from  arterioles,  as  in  the  first  division,  accounts 
for  many  cases  of  gastric  haemorrhage.  But  while  thoroughly 
believing  this,  we  must  also  not  close  our  eyes  to  the  experience 
we  have  in  general  surgery  of  bleeding  from  medium-sized  arteries, 
such  as  the  radial  or  ulnar,  which  we  know  would  rapidly  bleed  a 
patient  to  death  if  only  perforated  on  one  side  and  surrounded  by 
warm  compresses,  a  condition  that  practically  applies  in  all  cases 
of  haematemesis  where  the  larger  vessels  are  eroded.  If,  therefore, 
medical  treatment  and  rest  properly  carried  out  are  not  successful 
in  arresting  the  bleeding,  or  if  after  being  arrested  it  recurs,  we 
should  be  suspicious  that  a  large  vessel  is  perforated,  and  if  a 
surgeon  has  not  been  previously  asked  to  see  the  case,  I  would  say 
emphatically  tbat  a  surgical  consultation  ought  to  be  held  with  a 


332      Surgical  Treatment  of  Haematemesis. 

view  to  considering  the  question  of  operation  and  arrest  of  bleeding 
by  direct  treatment,  if  the  patient  is  in  a  fit  condition  to  bear  it. 

Where  there  have  been  distinct  signs  of  gastric  ulcer,  preceding 
the  haemorrhage,  and  where  a  sudden  haematemisis  has  occurred  with 
great  loss  of  blood,  accompanied  by  an  attack  of  syncope,  a  large 
vessel  will  usually  be  found  to  be  the  source  of  the  bleeding.  In  such 
haemorrhages  not  speedily  yielding  to  medical  and  general  means, 
or  recurring,  surgical  treatment  will  probably  be  advisable,  though 
there  can  be  no  absolute  rule  formulated  that  will  apply  to  every 
case,  and  each  must  be  considered  on  its  merits.  The  present 
condition  of  the  patient,  the  previous  history,  the  surroundings,  the 
possibility  of  skilled  surgery  and  of  good  nursing,  and  other  circum- 
stances, will  all  help  in  the  decision. 

Although  both  surgical  and  medical  treatment  in  cases  of 
fulminating  haemorrhage  have  so  far  yielded  disappointing  results, 
in  the  acute  cases  not  immediately  fatal,  where  repeated  bleedings 
occur  and  the  interval  between  the  first  seizure  and  death  varies  from 
a  few  days  to  two  or  three  weeks,  medical  treatment  will  have  been 
fully  tried  and  failed,  and  there  can  be  no  question  as  to  the  advis- 
ability of  surgical  procedures  being  adopted. 

At  present,  with  the  exception  of  Dieulafoy,  who  advocates  opera- 
tion during  the  first  bleeding  if  as  much  as  ^  litre  of  blood  is  lost, 
all  other  surgeons  who  have  written  on  the  subject  agree  that 
general  means  ought  to  be  relied  on  during  and  after  a  first  attack, 
as  in  from  93  to  97  per  cent,  of  cases  such  treatment  succeeds,  and 
until  our  means  of  diagnosis  as  to  the  size  of  vessels  injured  is 
rendered  more  reliable  we  must  advise  assent  to  this  rule  ;  but  after 
a  second  bleeding  I  have  no  hesitation  in  advising  surgical  treat- 
ment as  soon  as  the  condition  of  the  patient  will  permit  operation 
to  be  done,  for  experience  tells  us  that  further  haemorrhages  are 
almost  certain  to  occur  unless  preventive  measures  be  adopted. 

The  surgical  treatment  of  haematemesis  may  be  direct  or 
indirect. 

By  the  direct  method  is  meant :  (a)  Excision  of  the  ulcer  or  of 
the  ulcer-bearing  area  ;  (b)  arrest  of  haemorrhage  by  ligature  of  the 
bleeding  vessels,  by  cauterisation  of  the  ulcer,  or  by  ligature  of  the 
mucous  membrane  en  masse.  By  the  indirect  method  gastro- 
enterostomy  is  meant. 

Any  operation  for  haematemesis  must  as  a  rule  be  at  first 
exploratory,  and  when  the  condition  of  the  stomach  is  made  out  the 
question  of  direct  or  indirect  treatment  can  be  decided  on. 

In  all  the  early  cases  of  operation  for  haemorrhage  from  the 
stomach  the  direct  method  was  adopted,  as  it  had  not  then  been  realised 


Surgical  Treatment  of  Haematemesis.      333 

that  by  securing  physiological  and  physical  rest  to  the  stomach  hy  a 
well-executed  gastro-enterostomy  not  only  could  bleeding  as  a  rule 
be  arrested,  but  the  condition  of  ulceration  giving  rise  to  it  could  be 
cured. 

An  extensive  experience,  and  the  consideration  of  a  large  number 
of  cases  operated  on  by  others  whose  work  I  have  had  the  oppor- 
tunity of  seeing  and  studying,  has  convinced  me  that  the  operation 
of  gastro-enterostomy  is  usually  an  efficient  means  of  treating 
haemorrhage  from  the  stomach,  and  it  is  only  under  exceptional 
circumstances  that  I  should  now  think  it  worth  while  to  open  the 
stomach  and  treat  the  ulcer  directly ;  but  even  should'!  deem  direct 
treatment  of  the  bleeding-point  necessary,  I  should  also  think  it 
equally  desirable  to  perform  a  gastro-jejunostomy  in  order  to  secure 
rest  to  the  stomach  and  to  the  ulcer,  so  as  at  the  same  time  to  stop 
the  bleeding  and  cure  the  condition  giving  rise  to  it. 

Gastro-jejunostomy  possesses  the  advantages  that  it  is  applicable 
to  both  acute  and  chronic  haemorrhage,  that  it  avoids  the  necessity 
of  a  prolonged  search  through  a  gastrotomy  opening,  that  it  is 
quickly  performed,  and  not  least,  that  it  involves  little  shock  and 
has  a  very  small  mortality. 

To  put  the  matter  succinctly  I  would  say  : 

(1)  In  a  case  of  acute  haematemesis  from  ulcer  or  erosion,  when 
the  onset  of  bleeding  is  sudden  and  the  previous  history  of  ulcer  is 
absent,  medical  and  general  means  should  be  carried  out  thoroughly 
and  persistently  until  the  ulcer  has  healed. 

(2)  In  case  of  recurrence  of  bleeding,  or  if  the  bleeding  persists 
despite  treatment,  surgical  measures  are  called  for. 

(3)  In  case  of  bleeding  from  a  chronic  ulcer,  whether  the  bleeding 
be  slight  or  severe,  surgical  treatment  is  demanded,  not  only  for 
the  arrest  of  haemorrhage,  but  also  for  the  curative  treatment  of  the 
ulcer  itself. 

(4)  As  the  risk  of  operation  during  the  quiescent  period  is  less  than 
if  undertaken  while  the  bleeding  is  continuing,  it  is  desirable,  if 
possible,  to  secure  arrest  of  the  haemorrhage  even  in  chronic  ulcer 
before  undertaking  operation  ;  but  if  the  haemorrhage  is  persisting, 
the  surgeon  is  not  justified  in  waiting  until  the  patient  is  reduced 
to  such  a  condition  that  it  is  too  late  to  operate. 

A.  W.  MAYO-ROBSON. 


334 


HOUR-GLASS  STOMACH. 

HOUR-GLASS  STOMACH  owes  its  origin  to  definite  organic  disease — 
chronic  gastric  ulcer,  cancer,  or  perigastritis,  but  the  greater  number 
of  cases  are  caused  by  the  cicatricial  contraction  due  to  ulcer. 
Doubtless  very  rarely  the  condition  may  be  congenital,  just  as 
congenital  narrowing  may  be  found  at  the  pylorus,  in  the  intestine, 
or  in  the  rectum.  As  yet,  however,  I  have  not  met  with  a  single 
instance  in  which  I  could  say  that  the  case  was  one  of  congenital 
hour-glass  contraction. 

For  chronic  gastric  ulcer  to  be  allowed  to  pursue  its  course  until 
this  extreme  deformity,  hour-glass  stomach,  occurs  can  only  be 
described  as  a  disgrace  to  modern  medicine,  for  the  disease 
giving  rise  to  the  conditions  has  definite  signs  and  symptoms, 
and  is  one  attended  by  considerable  suffering.  In  nearly  all  my 
cases  the  patients  had  been  ill  for  years,  some  of  them  for  ten, 
twelve,  or  sixteen  years,  whereas  by  a  timely  operation  they  might 
have  been  cured  before  the  development  of  the  deformity. 

Surgical  treatment  is  alone  of  service  in  this  disease,  and  the 
conditions  to  be  aimed  at  are  to  overcome  the  obstruction  and  to 
secure  physiological  rest  for  the  healing  of  the  ulcer,  which  is  by 
far  the  most  frequent  cause  of  this  deformity. 

The  operations  available  are :  (1)  Gastroplasty,  (2)  gastro- 
enterostomy,  (3)  gastrolysis,  (4)  gastro-gastrostomy,  (5)  excision  of 
the  ulcerated  area  or  partial  gastrectorny,  (6)  divulsion  of  the 
stricture,  and  (7)  jejunostomy. 

As  the  disease  is  usually  associated  with  active  ulceration  in 
the  centre  of  the  stomach,  no  operation  will  be  likely  to  be 
permanently  effective  that  does  not  provide  for  efficient  drainage  of 
both  pouches,  in  order  to  secure  healing  of  the  ulcers ;  hence  a 
double  operation  is  often  necessary,  and  a  gastro-enterostomy  into 
one  or  both  pouches  is  generally  advisable. 

Of  seven  cases  in  which  I  performed  posterior  gastro-enterostomy 
for  hour-glass  contraction,  all  recovered,  and  five  are  well  at  the 
present  time,  three  to  six  years  later ;  one  died  of  cancer  of  the 
sigmoid  flexure  of  the  colon  four  years  and  one  of  cancer  of  the 
stomach  a  year  after  operation. 

Of  ten  cases  in  which  I  performed  simple  gastroplasty  all  the 
patients  recovered,  and  six  are  known  to  be  in  good  health  at  the 


Hour-Glass  Stomach. 


335 


present  time,  from  three  to  six  years  later  ;  one  was  well  a  year  after, 
but  cannot  be  traced ;  one  required  gastro-enterostomy  two  years 
later  for  ulcer  of  the  pylorus ;  one  was  well  for  four  years,  had 
recurrence  of  ulceration  and  died  of  haematemesis  ;  and  one  writes 


FIG.  1. — Partial  gastrectomy  for  hour-glass  stomach. 

to  say  that  after  five  years  she  has  had  some  gastric  pain  but  has 
not  needed  medical  attendance. 

Since  gastroplasty  has  been  followed  by  25  per  cent,  and 
gastro-gastrostomy  by  30  per  cent,  of  relapses,  while  gastro- 
enterostomy  alone  has  given  much  better  results,  and  the  com- 


FIG.  2. — Partial  gastrectomy  for  hour-glass  stomach. 

binatiou  of  either  of  the  two  former  operations  along  with  gastro- 
enterostomy  has  been  uniformly  successful,  it  seems  quite  clear  that, 
whatever  procedure  is  adopted  for  making  a  communication  between 
the  two  stomach  cavities,  a  gastro-enterostomy  ought  to  form  part 
of  the  operation,  in  order  that  the  ulceration  giving  rise  to  the 
disease  may  be  cured. 


336  Perigastritis. 

The  operation  of  partial  gastrectomy  for  hour-glass  stomach  is 
virtually  the  same  as  that  described  under  partial  gastrectomy  for 
cancer  of  the  stomach,  except  that  the  clamps  are  applied  well 
beyond  the  growth  at  the  centre  of  the  stomach.  Both  ends  are 
closed  in  the  same  way  after  excision  of  the  growth  and  a  posterior 
gastro-enterostomy  is  performed ;  or  if  preferred,  the  proximal  and 
distal  parts  of  the  stomach  may  be  united  by  a  double  row  of 
sutures,  the  first  embracing  the  whole  of  the  coats  and  the  second 

simply  the  serous  coats. 

A.  W.  MAYO-ROBSON. 


PERIGASTRITIS. 

PERIGASTRITIS  leading  to  disabling  adhesions  is  so  commonly 
associated  with  ulcer  that  I  must  mention  it  among  the  principal 
complications. 

When  the  adhesions  tie  up  the  pylorus  so  as  to  produce  a  kink, 
the  normal  peristalsis  of  the  stomach  may  be  interfered  with,  leading 
to  dilatation  -and  stasis  so  extreme  that  stenosis  of  the  pylorus  may 
be  suspected.  If  slight,  the  adhesions  may  be  separated  and  the 
right  free  border  of  the  omentum  may  be  interposed  between  the 
pylorus  and  its  abnormal  attachments  so  as  to  prevent  close 
adhesions  re-forming ;  but  if  the  adhesions  are  extensive,  a  gastro- 
enterostomy  will  be  found  to  be  the  more  satisfactory  operation 
and  to  give  excellent  results.  If  adhesions  form  on  the  anterior 
wall  of  the  stomach,  fixing  it  to  the  abdominal  parietes,  normal 
peristalsis  will  be  interfered  with  and  the  patient's  sufferings  after 
meals  or  on  exertion  may  be  considerable;  the  condition  may  give 
rise  to  irregular  dilatation  or  to  hour-glass  deformity  and  to  stasis 
of  the  stomach  contents. 

The  adhesions  must  be  detached,  but  are  apt  to  re-form  if  at  all 
extensive,  unless  the  raw  surfaces  can  be  covered  by  sliding  the 
omentum  or  grafting  the  peritoneum  over  them. 

Simple  gastrolysis,  or  detaching  adhesions,  is  practically  un- 
attended by  risk,  and  in  many  cases  I  have  seen  excellent  results 
by  this  simple  operation,  but  in  several  cases  relief  has  been 
followed  by  relapse,  necessitating  a  short-circuiting  operation. 
Posterior  gastro-enterostomy  should,  under  such  circumstances,  be 
performed  where  feasible,  but  in  case  of  adhesions  being  very 
extensive,  and  involving  the  posterior  wall  of  the  stomach,  an 
anterior  Roux's  operation  will  probably  be  found  to  be  the  best 
procedure  to  adopt. 

A.  W.  MAYO-ROBSON. 


337 


HYPERTROPHIC   STENOSIS  OF  THE  PYLORUS. 

HYPERTROPHY  or  hyperplasia  of  the  pylorus,  mainly  of  the 
circular  muscle  fibres,  can  exist  without  symptoms.  Gradual  con- 
traction of  the  muscle  produces  pyloric  obstruction  and  secondary 
dilatation  of  the  stomach.  In  deciding  on  the  best  mode  of 
treatment,  pyloric  spasm  must  be  differentiated  from  pyloric 
hypertrophy.  The  two  conditions  may  co-exist,  the  spasm  bein^r 
grafted  on  the  hypertrophy  and  increasing  the  obstruction  due  to 
the  gradual  contraction  of  the  circular  muscle  fibres  or  even  pro- 
ducing acute  symptoms,  or  either  may  occur  independently. 
Another  view  is  that  the  hypertrophy  is  secondary  to  spasm  and 
that  all  cases  can  be  cured  by  treatment  directed  to  the  relief  of 
spasm.  Anti-spasmodic  drugs  are,  however,  useless.  Almost  all 
infants  with  conclusive  evidence  of  pyloric  hypertrophy  have 
succumbed  when  treated  by  medical  remedies  only.  A  mild  degree 
of  hyperplasia  may  produce  no  definite  symptoms  unless  a  further 
factor,  generally  spasm  or  gastric  catarrh,  completes  the  obstruc- 
tion. Not  only  is  accurate  diagnosis  essential,  but  it  is  also 
necessary  to  estimate  the  relative  degree  of  hyperplasia  and  of  the 
secondary  causes  of  obstruction. 

Patients  suffering  from  these  conditions  are  almost  invari- 
ably infants  under  three  months  of  age.  The  symptoms  usually 
begin  in  the  third  week  of  life,  sometimes  earlier.  Cases  of  marked 
hypertrophy  in  childhood,  and  at  all  ages,  support  the  view  that 
the  hypertrophic  stenosis  of  later  life  is  due  to  the  persistence 
of  a  mild  degree  of  the  infantile  condition  and  that  operative 
treatment  of  the  affection  in  infants  is  not  always  essential. 

Pyloric  Spasm  gives  rise  to  repeated  and  severe  vomiting. 
The  meals  are  usually  returned  at  once,  but  sometimes  more  than 
one  is  kept  down  for  a  time.  The  spasm  may  begin  shortly  after 
birth  or  not  for  some  weeks  or  months,  or  may  occur  at  any  age. 
In  infants  it  is  generally  started  by  erroneous  feeding,  and  possibly 
depends  on  a  local  erosion  or  hyperaesthesia  of  the  pyloric  mucosa. 
There  is  no  reliable  evidence  that  it  is  due  to  hyperacidity.  It 
induces  constipation  and  emaciation.  Slight  dilatation  of  the 
stomach  and  a  little  gastric  peristalsis  may  be  present.  In  fatal 
cases  no  pyloric  obstruction  or  hypertrophy  is  found  after  death. 

A  simple  diet  of  breast  milk,  ass's  milk,  whey,  albumin  water,  or 

S.T.  — VOL.  II.  22 


338      Hypertrophic  Stenosis  of  the  Pylorus. 

Allenbury  No.  1  food,  in  small  quantities  every  two  hours,  is  suffi- 
cient to  cure  most  patients.  In  addition  cocaine  (y^  gr.)  in  water 
(1  drachm)  should  be  given  hourly.  Other  remedies  are  tr.  opii  (|  to  £ 
min.)  every  hour  or  two ;  and  drachm  doses,  every  2  to  4  hours,  of 
bismuth  carb.  1  drachm,  pulv.  acacise  1  drachm,  glycerine 
2  drachms,  aquam  ad  2  oz.  Such  doses  are  suitable  at  six  months 
of  age.  A  boy,  seven  months  old,  recovered  after  being  fed  on  raw 
meat  juice  every  fifteen  minutes  for  two  days,  in  addition  to  the 
cocaine. 

Should  there  be  no  improvement  the  next  step  is  lavage  of  the 
stomach  once  or  twice  daily  with  a  weak  alkaline  solution  (sod. 
bicarb.  1  drachm,  water,  I  pint). 

Infantile  Hypertrophic  Stenosis  gives  rise  to  the  symptoms  of 
pyloric  obstruction  and  definite  signs  of  hypertrophy,  viz.,  marked 
peristalsis  of  the  stomach,  gastric  dilatation,  and  a  pyloric  tumour 
the  size  of  a  filbert  or  the  last  joint  of  the  little  finger.  Vomiting 
is  characteristic.  After  two  or  three  feeds  have  been  taken  the 
whole  lot  is  ejected  violently  without  any  of  the  usual  signs  of 
nausea.  The  child  may  take  food  greedily  immediately  afterwards. 
In  mild  cases  nothing  may  be  found  save  an  indefinite  tumour  in 
the  pyloric  region,  and  vomiting  may  be  trivial  or  absent.  The 
child,  however,  progressively  wastes.  In  marked  cases  the  stools 
are  devoid  of  faecal  material,  like  meconium  in  consistence,  and 
like  darkish  red-brown  or  green  paint.  They  are  composed  of 
cholesterin,  mucus  and  epithelial  debris.  An  absolutely  positive 
diagnosis  is  impossible  in  the  early  stages  before  obstruction 
has  existed  long  enough  to  cause  marked  peristalsis  and  gastric- 
dilatation. 

At  first,  and  in  all  doubtful  cases,  the  condition  should  be  treated 
as  one  of  simple  pyloric  spasm.  The  stomach  must  be  washed  out 
once  or  twice  a  day,  and  the  amount  of  food  retained  and  the 
amount  of  faecal  matter  in  the  stools  noted.  Lavage  washes  away 
irritating  products  of  the  decomposition  of  food  long  retained  in 
the  stomach.  It  may  prove  curative  in  those  cases  of  mild  hyper- 
plasia  in  which  the  obstruction  is  due  to  secondary  spasm  or  gastric 
catarrh.  It  has  the  further  advantage  of  reducing  over-distension 
of  the  stomach,  provided  that  it  is  done  twice  daily  and  only  small 
feeds  are  given  in  the  intervening  periods.  In  this  way  it  may 
prevent  vomiting.  By  reducing  the  dilatation  the  muscular  power 
of  the  stomach  is  increased  and  may  then  prove  sufficient  to  drive 
.a  suitable  food  through  the  pylorus,  if  it  is  not  excessively  con- 
stricted. Probably  a  dilated  stomach  increases  the  obstruction  by 
dragging  on  the  pylorus  and  causing  a  certain  amount  of  kinking. 


Hypertrophic  Stenosis  of  the  Pylorus.      339 

Lavage  undoubtedly  assists  in  the  cure  of  gastric  catarrh  and  of 
acid  dyspepsia,  either  of  which  may  be  present.  It  is  difficult  to 
believe  that  it  can  have  the  least  effect  on  the  hypertrophied 
pylorus.  By  preventing  vomiting  it  may  lead  to  an  unduly  favour- 
able view  of  the  progress  of  the  case. 

Drug  treatment  is  similar  to  that  recommended  for  pyloric 
spasm.  Treatment  by  diet,  drugs  and  lavage,  may  be  continued 
for  days  or  weeks  if  the  child  does  not  lose  ground  and  there  is 
faBcal  matter  in  the  stools.  It  is  foolish  to  persevere  with  it  until 
the  child  is  so  emaciated  that  the  chance  of  recovery  from  the 
shock  of  operation  is  infinitesimal  ;  although  it  has  been  asserted 
that  after  a  stage  of  progressive  emaciation  the  almost  moribund 
child  suddenly  turns  the  corner,  because,  forsooth,  the  spasm  then 
relaxes.  My  experience  is  totally  opposed  to  such  a  termination. 
With  one  doubtful  exception,  cases  treated  on  these  lines  have 
proved  fatal.  Even  when  the  food  passed  through  the  pylorus  in 
moderate  quantities  and  vomiting  was  slight  or  absent,  the  infants 
became  marasmic  and  died. 

It  is  not  uncommon  for  parents  to  decline  operative  treatment  in 
the  early  stages,  when  good  results  can  be  obtained,  and  to  demand 
it  in  late  stages  when  the  outlook  is  almost  hopeless.  Under 
medical  treatment  a  child  may  progress  favourably  for  days  or 
weeks,  perhaps  longer,  and  then  comes  a  time  when  the  vomiting 
gets  severe  and  emaciation  is  rapid.  Kecovery  after  an  operation 
done  as  a  forlorn  hope  is  extremely  rare ;  indeed,  the  prognosis  of 
operative  treatment,  omitting  the  risks  incidental  to  the  operation, 
depends  on  the  degree  of  marasmus.  The  greater  the  emaciation 
and  gastric  dilatation,  the  smaller  is  the  chance  of  recovery.  Even 
if  recovery  is  possible  under  medical  treatment,  it  is  certain  that, 
except  in  mild  hyperplasia,  the  prolonged  illness  far  exceeds  in  risk 
the  dangers  of  operation  before  marasmus  has  developed. 

Surgical  Measures.  —  The  choice  lies  between  pyloroplasty, 
Loreta's  stretching  operation  and  posterior  gastro-enterostomy.  A 
skilled  anesthetist  is  necessary.  The  operation  must  be  done  quickly 
and  every  measure  taken  to  minimise  shock.  Pyloroplasty  is  in  my 
opinion  the  most  scientific  method,  for  afterwards  the  contrac- 
tion of  the  pyloric  muscle  will  enlarge  rather  than  constrict  the 
lumen,  and  there  is  no  fear  of  recurrence.  Out  of  twelve  cases  treated 
by  this  method  nine  recovered,  two  dying  subsequently  from  enteritis. 

Loreta's  stretching  operation  is  analogous  to  the  forcible  rupture 
of  a  urethral  stricture,  a  surgical  proceeding  now  discountenanced. 
It  involves  gastrotomy  and  rupture  of  some  or  all  of  the  circular 
muscular  fibres.  The  peritoneal  coat  is  liable  to  be  ruptured  as 

22-2 


34°      Hypertrophic  Stenosis  of  the  Pylorus. 

well,  and  must  be  sewn  up  or  fatal  peritonitis  may  ensue.  It  takes 
just  as  long  as  pyloroplasty,  but  has  proved  perfectly  successful  in 
many  cases.  Occasionally  it  has  been  followed  by  relapse,  through 
subsequent  contracture  of  imperfectly  ruptured  muscle  fibres,  and 
a  further  operation  has  been  needed. 

Some  surgeons  prefer  posterior  gastro-enterostomy  on  the 
grounds  tbat  it  is  a  simpler,  easier  and  more  rapid  operation,  and 
satisfactory  as  regards  the  nutrition  of  the  patient.  Many  success- 
ful cases  are  on  record.  Its  effect  on  the  state  of  the  pylorus  is 
interesting  as  an  argument  against  the  hypothesis  that  the  hyper- 
trophy is  due  to  spasm.  Morse  reported  a  case  treated  by  this 
method.  The  child  died  at  eight  months  of  age,  more  than  six 
months  after  operation,  and  the  pylorus  was  found  to  be  in  the 
same  state  as  at  the  time  of  operation. 

After-treatment. — Except  for  the  wound  the  treatment  after 
operation  should  be  entrusted  to  the  physician,  not  to  the  surgeon,  for 
it  is  the  treatment  of  the  gastric  condition  and  the  marasmus. 
Immediately  after  operation,  a  rectal  feed  of  peptonised  milk  and 
water  (aa  1  oz.),  and  brandy  (10  to  20  min.)  should  be  given.  This 
must  be  repeated  every  four  hours  for  two  days,  every  six  hours  for 
two  days,  and  every  twelve  hours  for  two  days,  a  rectal  wash  being 
given  once  daily.  Recurrence  of  the  vomiting  may  necessitate  a 
temporary  return  to  rectal  feeding.  In  one  case  even  better  results 
were  obtained  by  means  of  regular  saline  injections  instead  of 
peptonised  milk.  The  brandy  can  generally  be  omitted  in  twenty- 
four  hours.  For  the  first  twelve  hours  a  teaspoonful  of  plain  hot 
water  by  mouth  every  fifteen  minutes  should  be  given  if  the  child  is 
awake.  After  that  whey  in  similar  quantities  should  be  substituted. 
Then  in  two  days  whey,  2  drachms  every  fifteen  minutes  ;  next  day 
\  oz.  every  half  hour ;  on  the  fourth  day,  1  oz.  hourly  and  then 
2  oz.  every  two  hours.  Next  the  quality  of  the  food  should  be 
improved  by  the  addition  of  cream  (\  to  1  drachm)  to  each  feed. 
Such  a  diet,  increased  in  quantity  if  necessary,  can  be  continued 
for  some  weeks,  or  it  may  be  replaced  slowly  by  peptonised  milk 
and  water,  and  then  by  ordinary  milk  and  water.  The  main  in- 
dication for  increasing  the  whey  by  mouth  in  the  early  stages  is  the 
passage  of  food  through  the  pylorus,  faecal  matter  being  usually 
found  in  the  stools  on  the  third  day.  Vomiting  often  persists  for 
two  to  six  days,  and  altered  blood  may  be  brought  up  a  few  hours 
after  operation.  It  is  of  the  utmost  importance  not  to  overfeed 
these  infants  in  the  early  stages  of  convalescence.  They  are  very 
liable  to  enteritis,  for  the  intestinal  mucosa  appears  to  undergo 
nutritional  changes,  from  disuse  in  marasmic  infants,  and  the 


Hypertrophic  Stenosis  of  the  Pylorus.      341 

operation  allows  food  to  pass  rapidly  from  the  stomach  into  the 
intestines.  Evil  results  are  most  liable  to  occur  in  those  infants  in 
whom  operation  has  been  long  delayed. 

In  older  children  and  adults  treatment  is  carried  out  on  similar 
lines.  If  daily  lavage  is  insufficient  to  maintain  health  and  reduce 
the  gastric  dilatation,  operative  treatment  will  be  required. 

EDMUND    CAUTLEY. 


SURGICAL  TREATMENT  OF  HYPERTROPHIC 
PYLORIC  STENOSIS. 

FROM  being  one  of  the  curiosities  of  medicine,  having  little  more 
than  pathological  interest,  congenital  hypertrophic  pyloric  stenosis 
has  become  a  recognised  clinical  entity.  From  the  number  of  cases 
recorded,  it  is  evidently  far  from  uncommon,  and  it  is  extremely 
probable  that  many  of  the  children  dying  from  "  marasmus," 
vomiting,  or  intestinal  obstruction  have  really  been  its  victims. 
According  to  Mormiee,  80  per  cent,  of  cases  die  unless  treated 
surgically. 

In  the  earlier  stages  of  the  disease,  before  the  vomiting  has  become 
incessant,  much  good  may  be  done  by  careful  washing  of  the 
stomach  and  feeding  in  small  quantities  through  an  indiarubber 
catheter. 

In  feeding  it  is  better  to  pass  an  indiarubber  catheter  and  gently 
to  wash  out  the  stomach  with  a  little  sterile  salt  solution  before 
introducing  the  food.  The  best  food  is  diluted  and  sweetened  cow's 
milk.  It  should  be  given  in  small  quantities  of  2  drachms  or  slightly 
more,  and  be  gradually  increased  as  experience  may  sanction.  The 
catheter  may  be  passed  through  the  nose,  and  the  sucking  action, 
which  is  the  starting  of  the  peristaltic  wave,  thereby  avoided.  If  all 
goes  well  for  eight  or  ten  days,  an  attempt  may  be  made  to  feed  the 
child  by  the  mouth,  either  by  a  teat  or  with  the  spoon.  If  the 
food  is  quietly  retained,  the  nasal  feeding  may  be  gradually  aban- 
doned. 

Despite  the  fact  that  recovery  from  this  condition  under  medical 
treatment,  on  the  plan  just  described,  is  possible,  there  will  doubt- 
less remain  .a  proportion  of  cases  that  can  only  be  dealt  with 
satisfactorily  by  surgical  measures. 

The  operations  which  have  been  performed  are  Loreta's  operation 
(dilatation  of  the  pylorus),  pyloroplasty,  gastro-enterostomy,  and 
pylorectomy.  The  last  is  obviously  unsuited  to  the  tender  age  and 
the  prostrate  condition  of  the  infant,  and,  as  equally  effective 
methods  of  overcoming  the  mechanical  obstruction  exist,  it  is  not 
worthy  of  further  thought. 

Loreta's  operation  consists  in  opening  the  stomach  by  a  small 
incision  near  the  pylorus,  and  through  this  incision  introducing  a 
small  pair  of  forceps  through  the  stenosed  pyloric  orifice.  The 


Hypertrophic  Pyloric  Stenosis.  343 

blades  of  the  forceps  are  then  gently  separated  and  the  tissues 
around  them  stretched  as  widely  as  is  possible  without  rupturing 
the  serous  coat. 

Mr.  Burghard  prefers  this  operation  on  account  of  its  ease,  the 
rapidity  with  which  it  can  be  performed  and  the  absence  of  shock. 
He  employs  Hegar's  dilators.  In  one  case  a  rupture  of  the  peri- 
toneal coat  was  produced.  The  disadvantage  of  the  operation  would 
appear  to  be  the  likelihood  of  a  recurrence  of  symptoms  after  the 
paralysis  of  the  pyloric  sphincter  has  passed  away.  Experience  has 
shown  that  when  the  sphincter  ani,  for  example,  is  stretched,  to 
its  utmost  limit,  a  fair  degree  of  control  is  established  by  the  third 
or  fourth  day.  But  it  must  be  admitted  that  in  all  the  patients  who 
have  recovered  from  the  pyloric  operation  the  after-results  seem  to 
have  been  most  satisfactory. 

Pyloroplasty  has  been  practised,  and  especially  advocated,  by 
Mr.  Clinton  Dent.  He  believes  that  pyloroplasty  is  preferable  to 
dilatation,  for  the  following  reasons  : 

(1)  It  can  be  done  at  least  as  quickly. 

(2)  It  is  a  more  definite  proceeding  and  allows  more  range,  as 
the  length  of  incision  can  be  graduated  according  to  the  condition 
found. 

(3)  The  lumen  of  the  tube  can  be  examined,  and,  if  thought 
desirable,   the    longitudinal    fold   of    mucous    membrane    can   be 
removed. 

(4)  The  exact  amount  of  injury  done  to  the  "parts  is  known. 
Gastro-enterostomy ,  which  was  first  performed  in  congenital  pyloric 

stenosis  by  W.  Abel,  consists  of  an  anastomosis  between  the  stomach 
and  the  jejunum  which  may  be  made  upon  the  anterior  or  the 
posterior  surface,  though  posterior  gastro-enterostomy  is  the 
operation  most  frequently  selected.  Its  disadvantages  are  said  to 
be  the  greater  length  of  time  required  for  its  performance  and  the 
greater  exposure  of  viscera.  Neither  of  these  objections,  however, 
is  sound.  A  considerable  experience  of  the  operation  entitles  one 
to  say  that  no  more  than  half  an  hour  need  be  expended  in  the 
operation,  whilst  in  desperate  cases  twenty  minutes  will  be 
adequate.  During  the  operation  there  need  be  no  exposure  of  the 
viscera  except  those  parts  of  the  stomach  and  jejunum  which  are 
to  be  united.  The  soiling  of  the  peritoneum  is  certainly  less  in 
gastro-enterostomy  than  in  either  pyloroplasty  or  in  Loreta's 
operation,  and  there  is  no  blood  lost  from  cut  vessels  of  the 
stomach.  It  is,  however,  necessary  in  the  early  stages  of  the 
operation  of  gastro-enterostomy  to  handle  the  stomach  and  to 
prepare  it  for  the  application  of  the  clamp,  if  clamps  are  employed, 


344  Hypertrophic  Pyloric  Stenosis. 

whereas  in  pyloroplasty  the  stomach  need  hardly  be  touched  and 
the  intestines  are  not  seen. 

Congenital  Atresia  of  the  Pylorus,  in  which  there  is  no  com- 
munication between  the  stomach  and  duodenum,  is  extremely  rare, 
and  has  hitherto  pursued  a  rapidly  fatal  course  in  all  recorded 
cases.  If  diagnosed  early,  it  should  prove  amenable  to  treatment 
in  the  shape  of  gastro-enterostomy. 

A.  W.  MAYO-ROBSON. 


345 


INFLAMMATIONS  OF  THE  STOMACH. 

ACUTE  GASTRITIS. 

General  Treatment. — The  prevention  of  acute  gastritis  in 
persons  who  are  predisposed  to  the  disorder  is  a  matter  of 
much  importance.  In  the  case  of  young  children  an  attack 
is  usually  precipitated  by  exposure  to  cold  or  fog  or  by  the 
ingestion  of  substances  which  are  either  in  a  state  of  incipient 
putrefaction,  or  are  unsuitable  to  the  peculiar  digestive  powers  of 
the  individual.  However  pure  the  milk  may  appear  to  be  it  is 
always  advisable  to  sterilise  it,  and  drinking  water  should  always 
be  boiled ;  while  if  the  latter  contains  an  excess  of  lime  salts, 
Salutaris,  Malvern  water  or  that  obtained  from  some  natural  spring 
should  be  substituted  for  the  local  supply.  One  of  the  reasons 
why  so  many  persons  suffer  from  acute  gastritis  or  "  biliousness  " 
when  they  reside  at  certain  seaside  places  is  that  the  drinking 
water  is  exceptionally  hard  or  chalky.  The  epidemic  forms  of  acute 
gastro-enteritis  are  almost  invariably  due  to  the  presence  of  patho- 
genic organisms  in  the  milk  or  water.  Excessive  indulgence  in 
food  and  overloading  the  stomach  with  sweets,  fruit  and  cakes  are 
apt  to  lead  to  gastrectasis  in  persons  who  have  already  suffered 
from  attacks  of  inflammation  of  the  stomach  and  thus  to  pre- 
dispose to  frequent  recurrences  of  the  complaint.  In  such  cases  it 
is  advisable  that  the  meals  should  be  taken  at  regular  intervals 
and  be  composed  of  substances  that  are  least  liable  to  undergo 
fermentation  in  the  stomach.  Care  must  always  be  taken  to 
protect  the  surface  of  the  body  from  rapid  changes  of  temperature, 
and  with  this  object  woollen  underclothing  and  warm  stockings 
should  be  worn  all  the  year  round,  with  a  flannel  or  chamois 
leather  belt  next  the  skin.  Cold  baths  should  be  prohibited  even 
in  summer.  The  fact  that  unusual  excitability  and  buoyancy  of 
spirits  often  precede  an  attack  of  gastritis  in  a  child,  constitutes  an 
indication  for  preventive  treatment  in  the  form  of  a  dose  of  calomel 
and  a  saline  purge  ;  while  in  those  cases  where  excitement  or 
fatigue  provoke  the  disorder  the  amount  of  outdoor  exercise  must 
be  restricted,  and  parties  or  other  forms  of  entertainment  be 
prohibited  for  a  few  years. 

Diet. — An  inflamed  organ  requires  physiological  rest,  and  an 
inflamed  stomach  is  the  best  illustration  of  this  elementary  law. 


346  Acute  Gastritis. 

Starvation  is  essential  to  the  rapid  cure  of  acute  gastritis,  and  no 
food  should  be  administered  by  the  mouth  for  twenty-four  hours 
or  even  longer.  In  the  case  of  an  adult  this  abstinence  produces 
no  ill-effects,  but  in  young  or  debilitated  children  deprivation  of 
nourishment  is  apt  to  increase  the  exhaustion  produced  by  retching 
and  vomiting,  and  it  may,  therefore,  sometimes  be  necessary  to 
administer  nutrient  enemata  composed  of  peptonised  milk  with  a 
few  drops  of  brandy.  When  thirst  is  excessive  small  pieces  of  ice 
may  be  sucked  at  intervals  or  the  patient  may  be  encouraged  to 
drink  large  quantities  of  hot  water  with  the  view  of  inducing 
vomiting,  and  thus  of  cleansing  the  stomach  from  its  mucous 
contents.  It  is  usually  held  that  cessation  of  sickness  and  return 
of  appetite  are  indications  for  the  administration  of  food,  but  it 
must  be  borne  in  mind  that  profound  exhaustion  is  itself  productive 
of  anorexia  as  well  as  of  nausea,  and  that  the  latter  symptom  will 
often  disappear  if  the  patient  is  encouraged  to  take  food.  As  a 
rule,  feeding  may  safely  be  commenced  within  forty-eight  hours  of 
the  commencement  of  an  attack,  but  should  emesis  occur  recourse 
must  be  had  to  rectal  alimentation.  In  such  cases  from  8  to  15  oz. 
of  peptonised  milk  are  slowly  introduced  into  the  bowel  every  six 
hours  by  means  of  a  rubber  catheter  and  funnel,  about  forty-five 
minutes  being  required  for  the  due  performance  of  the  operation. 
A  rectal  douche  of  normal  saline  solution  night  and  morning 
prevents  irritation  of  the  lower  bowel  and  promotes  retention  and 
absorption  of  the  milk  (see  p.  326).  As  soon  as  the  stomach  is  able 
to  retain  food,  iced  milk,  diluted  with  an  equal  quantity  of  lime- 
water,  may  be  allowed  in  tablespoonful  doses  every  hour  for  six 
hours,  after  which  time,  if  vomiting  has  not  recurred,  the  dose 
may  be  increased  to  6  oz.  or  more,  and  the  proportion  of  lime- 
water  gradually  diminished.  In  severe  cases  egg-albumin  water, 
followed  by  iced  whey,  should  be  substituted  for  milk.  As  soon  as 
the  nourishment  is  retained  with  comfort,  the  diet  may  be  increased 
by  the  addition  of  clear  soups,  bovril,  beef-tea,  Benger's  food, 
toast  and  milk,  lightly  boiled  or  poached  eggs  ;  and  subsequently 
by  fish,  chicken,  sweetbreads,  scraped  raw  meat,  lean  ham,  etc. 
Cooked  meats  and  green  vegetables  should  be  prohibited  for  at 
least  a  week,  and  the  meals  should  be  moderate  in  amount  and  be 
taken  at  regular  intervals. 

Medicinal  Treatment. — Acute  simple  gastritis  undergoes 
spontaneous  cure  by  the  operation  of  two  great  natural  factors, 
namely,  the  evacuation  of  the  irritant  contents  of  the  stomach  by 
vomiting  and  the  period  of  physiological  rest  that  is  imposed  upon 
the  organ  by  the  suppression  of  appetite.  The  medicinal  treatment 


Acute  Gastritis.  347 

of  the  disease  should  therefore  be  conducted  upon  these  lines.  In 
every  case  the  first  consideration  should  be  the  probable  amount 
of  noxious  material  still  retained  in  the  stomach,  as  shown  by 
the  vomit.  Should  emesis  not  yet  have  commenced,  or  if  the 
ejecta  contain  food,  the  obvious  indication  is  to  assist  the  stomach 
fco  rid  itself  of  its  irritant  contents.  With  this  object  20  gr. 
of  powdered  ipecacuanha  should  be  administered  at  once  and 
followed  in  a  few  minutes  by  a  tumblerful  of  hot  water,  while  in  the 
case  of  a  child  10  to  15  min.  [U.S.P.  13  to  20  min.  fluid 
extract]  of  the  liquid  extract  or  a  dessertspoonful  or  more  of 
the  wine  may  be  employed.  A  dose  of  emetine  or  a  hypodermic 
injection  of  apomorphine  finds  favour  with  many  practitioners, 
but  they  prove  unduly  depressant  to  some  individuals.  Substances 
like  mustard,  tartar  emetic,  sulphate  of  zinc  and  sulphate  of  copper, 
which  cause  vomiting  by  direct  irritation  of  the  gastric  mucosa, 
should  be  avoided,  as  they  tend  to  increase  the  existing  inflamma- 
tion. Even  after  all  decomposing  food  has  been  evacuated,  the 
inner  surface  of  the  organ  may  still  be  irritated  by  the  presence  of 
fermenting  mucus,  the  expulsion  of  which  is  always  a  matter  of 
difficulty  owing  to  its  thick,  tenacious  character.  Continental 
writers  consequently  advise  lavage  of  the  stomach  with  warm  water 
containing  a  small  proportion  of  bicarbonate  of  sodium  whenever 
emesis  recurs  at  short  intervals  and  the  ejecta  consist  of  mucus. 
Washing  out  the  viscus  in  this  manner  is  an  excellent  remedy,  and 
will  usually  subdue  the  nausea  and  retching  more  quickly  than 
any  other  form  of  treatment ;  but  unfortunately  many  people 
strenuously  object  to  the  passage  of  a  tube,  and  will  only  submit 
to  its  use  when  milder  measures  have  failed.  The  stomach  may 
also  be  cleansed  by  the  propulsion  of  its  contents  into  the  intes- 
tine, and  since  the  time  of  Hippocrates  brisk  purgation  has  always 
been  regarded  as  indispensable  in  acute  gastritis.  In  infants  and 
young  children  a  dose  of  castor  oil  or  the  administration  of  the 
castor  oil  mixture  every  three  hours  will  usually  promote  a  rapid 
cure  in  mild  cases  ;  but  if  vomiting  is  a  troublesome  feature, 
?}  gr.  of  calomel  given  every  two  hours  until  free  purgation  has 
been  produced,  will  be  found  more  efficacious.  At  a  later  period  of 
life  the  same  treatment  is  equally  successful,  although  preference 
should  be  given  to  salines  rather  than  to  castor  oil.  As  soon  as 
the  stomach  is  free  from  food,  from  2  to  4  gr.  of  calomel  or  a 
mercurial  pill  may  be  administered,  followed  after  three  hours  by 
a  dose  of  Carlsbad  salts,  sulphate  of  sodium  or  magnesium,  or 
phosphate  of  sodium.  If  emesis  is  excessive  £  gr.  of  calomel 
should  be  placed  upon  the  tongue  every  half  hour  and  the  saline 


348  Chronic  Gastritis. 

draught  deferred  for  six  hours.  It  rarely  happens  that  vomiting 
continues  after  the  bowels  have  been  thoroughly  evacuated ;  but 
should  nausea  or  retching  still  persist,  a  mixture  containing 
solution  of  bismuth,  bicarbonate  of  sodium  and  dilute  hydrocyanic 
acid,  with  or  without  morphine,  administered  in  an  effervescent  form, 
will  usually  cause  these  symptoms  to  subside.  A  hypodermic 
injection  of  morphine  is  seldom  required.  In  the  after-treatment 
of  the  case  it  may  be  necessary  to  repeat  the  mercurial  and  salines 
at  intervals  or  to  prescribe  a  mixture  of  bicarbonate  of  sodium 
and  rhubarb  to  be  taken  between  meals.  Tonics  invariably  disagree 
with  the  subjects  of  gastritis,  and  the  employment  of  these  drugs 
either  causes  a  recrudescence  of  the  former  symptoms  or  induces  a 
subacute  form  of  the  disease.  Alkaline  remedies,  on  the  other 
hand,  always  agree,  and  if  the  case  shows  a  tendency  to  relapse 
they  may  be  continued  with  advantage  for  several  weeks. 

ACUTE    TOXIC    GASTRITIS. 

This  variety  of  gastric  inflammation  is  usually  due  to  the  indi- 
gestion of  metallic  salts,  corrosive  acids  or  alkalies,  so  that  actual 
destruction  of  the  tissues  of  the  stomach  frequently  exists. 

Vomiting  rarely  removes  all  the  poison  from  the  organ,  and 
consequently,  whenever  it  is  possible,  steps  should  immediately 
be  taken  to  wash  out  the  viscus.  No  tube  should  ever  be  passed 
when  there  is  reason  to  suppose  that  mineral  acids,  caustic  alkalies, 
or  carbolic  acid  have  been  swallowed,  or  when  excessive  pain  or 
haemorrhage  indicate  that  considerable  damage  has  been  inflicted 
upon  the  oesophagus  or  stomach.  As  soon  as  the  stage  of  collapse 
has  passed  away,  the  case  should  be  treated  in  the  same  manner 
as  a  severe  example  of  simple  gastritis.  As  regards  the  consequences 
of  the  disease,  oesophageal  stricture  will  require  the  use  of  a 
Symonds'  tube  or  the  performance  of  gastrostomy  and  stenosis  of 
the  pylorus,  systematic  lavage  ;  while  general  atrophy  of  the 
stomach  must  be  treated  in  the  manner  already  described  (p.  293). 

CHRONIC    GASTRITIS. 

General  Treatment.  —  The  various  conditions  which  tend 
to  excite  or  to  perpetuate  inflammation  of  the  stomach  must 
be  carefully  avoided,  and  such  adverse  influences  as  exposure 
to  extremes  of  temperature,  insufficient  mastication  of  food,  abuse 
of  alcohol  or  tobacco,  or  constant  indulgence  in  rich  and  indigestible 
articles  of  food  must  be  guarded  against.  Special  attention  must 
also  be  paid  to  those  organs  of  the  body  whose  functional  derange- 
ment is  apt  to  excite  gastritis,  and  the  treatment  appropriate  to 


Chronic  Gastritis.  349 

diseases  of  the  lungs,  heart,  liver,  kidneys  or  of  the  blood  should 
be  adopted  as  occasion  requires.  In  all  cases  the  patient  should 
endeavour  to  lead  a  rational  existence  and  indulge  in  some  regular 
form  of  exercise  which  does  not  require  over-exertion  or  pro- 
duce undue  fatigue.  Walking,  golf  and  horse-riding  are  usually 
beneficial,  and  in  many  instances  a  cold  or  tepid  sponge  bath  on 
rising,  followed  by  a  calisthenic  exercise  for  ten  minutes,  is  a  useful 
adjunct  to  other  methods  of  treatment.  Lavage  is  indicated  in  all 
chronic  cases  where  there  is  either  an  excessive  secretion  of  mucus 
or  stagnation  of  food.  In  the  former  case  it  is  most  advantageously 
performed  in  the  early  morning.  The  secretion  is  extremely 
tenacious  and  difficult  to  evacuate,  and  it  is  often  necessary  to 
make  the  patient  at  first  sit  upright,  then  lie  on  his  back,  and 
finally  recline  on  his  left  side  so  as  to  ensure  a  complete  washing 
of  the  organ.  Gentle  massage  of  the  stomach  during  lavage  often 
aids  the  expulsion  of  mucus  ;  while  the  addition  of  bicarbonate  of 
sodium  to  the  water,  in  the  proportion  of  one  teaspoonful  to  the 
quart,  renders  the  slime  more  easy  of  removal.  When  lavage  is 
performed  on  account  of  the  fermentation  of  stagnant  food  it  may 
be  performed  either  before  breakfast  or  three  hours  after  a  light 
evening  meal.  The  residual  food  is  first  evacuated  and  the  organ 
is  subsequently  washed  out,  one  or  other  of  the  antiseptic  solutions 
being  employed,  if  necessary,  for  the  purpose  (p.  813).  If  vomiting 
is  a  feature  of  the  case,  lavage  should  be  performed  both  morning  and 
evening  for  the  first  ten  days.  After  the  expiration  of  three  weeks 
or  a  month  every  alternate  day  is  usually  sufficient,  and  if  the 
patient  continues  to  make  satisfactory  improvement,  it  is  afterwards 
gradually  discontinued.  In  the  majority  of  cases  the  good  effects 
of  the  washing  out  become  apparent  about  the  third  day  of  the 
treatment,  when  the  appetite  begins  to  return,  and  the  nausea, 
distension  and  other  symptoms  subside.  When  lavage  is  discon- 
tinued a  douche  may  often  be  employed  with  advantage,  since 
forcible  spraying  of  the  gastric  mucosa  stimulates  secretion  and  also 
increases  the  tone  of  the  muscular  coat.  For  this  purpose  a  soft 
tube  provided  with  numerous  small  holes  at  its  lower  end  should 
be  used,  and  the  fluid  injected  under  pressure  by  raising  the  funnel 
or  reservoir  above  the  patient's  head.  Einhorn  advocates  an 
ordinary  spray  apparatus,  to  the  hard  rubber  branch  of  which  a 
soft  stomach  tube  is  attached.  Within  the  latter  is  another  soft 
tube  of  small  calibre,  which  conveys  the  fluid  from  the  bottle  to 
the  vulcanite  nozzle.  By  this  means  the  entire  surface  of  the 
organ  may  be  subjected  to  a  fine  spray.  When  the  coats  of  the 
viscus  require  tone,  water  at  a  temperature  of  65°  F.  is  employed, 


350  Chronic  Gastritis. 

but  if  the  secretion  is  also  deficient,  the  addition  of  .chloride  of 
sodium  (90  gr.  to  the  pint)  is  found  to  increase  the  production  of 
hydrochloric  acid,  while  nitrate  of  silver  (1  in  1,000)  produces  a 
contrary  effect.  Chloroform  water  added  to  the  douche  exerts  a 
sedative  action,  and  a  douche  of  the  infusion  of  hops  or  quassia  is 
stated  to  stimulate  the  appetite.  In  all  cases  where  a  medicated 
solution  is  employed  the  fluid  should  not  remain  in  the  stomach 
for  more  than  one  minute,  and  the  organ  should  afterwards  be 
washed  out  with  warm  water.  No  food  should  be  present  when 
the  douche  is  given.  Electricity  is  only  of  value  in  long-standing 
cases  of  gastritis,  where  the  muscular  coat  is  markedly  atonic  and 
secondary  my  asthenia  has  produced  retention  of  food.  In  such 
regular  massage  of  the  stomach  combined  with  hydrotherapeutic 
measures  may  be  employed. 

Diet. — It  is  impossible  to  formulate  a  definite  scheme  of  diet 
applicable  to  all  cases,  since  the  powers  of  digestion  and  assimila- 
tion vary  considerably  at  different  stages  of  the  complaint  and  in 
different  individuals.  The  main  object  to  be  kept  in  view  is  to 
order  food  of  a  quality  and  in  such  quantity  as  not  to  overtax 
the  enfeebled  organ.  When  a  case  first  comes  under  treatment, 
and  especially  if  there  are  any  acute  manifestations  of  the  disease, 
rest  in  bed  for  ten  days  or  a  fortnight  and  the  administration 
of  some  bland  form  of  nourishment  afford  immediate  relief  to  the 
pain  and  vomiting,  check  emaciation  and  promote  restful  sleep. 
As  a  rule,  food  should  be  administered  every  three  hours,  and  the 
fluid  be  restricted  to  ^  pint  on  each  occasion.  If  milk  agrees, 
from  8  to  4  pints  may  be  given  in  the  twenty-four  hours, 
but  if  it  produces  discomfort  it  must  be  diluted  with  lime-water, 
sterilised  or  peptonised.  In  some  cases  the  sour  milk  prepared  in 
the  manner  recommended  by  Metchnikoff  is  an  excellent  adjunct  to 
the  usual  diet,  but  ten  days  usually  elapse  before  its  good  effects 
become  apparent.  Half  a  pint  of  the  sour  curds,  well  sprinkled 
with  sugar,  nmy  be  given  twice  a  day.  Eggs,  either  poached  or 
lightly  boiled,  clear  soups,  meat  essences  and  jellies,  junket,  custard, 
cocoa  made  from  the  nibs,  milk  puddings,  Benger's  food,  revalenta 
arabica,  Gerrard's  peptones,  with  toast,  rusks  and  butter  should 
constitute  the  remainder  of  the  dietary.  It  is  often  stated  that 
proteids  should  be  withheld  whenever  the  gastric  secretion  is  deficient, 
but  in  cases  of  chronic  gastritis  the  motor  power  of  the  stomach 
is  rarely  impaired  until  the  terminal  stage  of  the  disease,  and  any 
diminution  of  proteid  digestion  in  the  organ  is  amply  compensated 
by  an  increased  activity  of  the  biliary  and  pancreatic  secretions. 
Carbohydrates  may  be  allowed  in  moderation,  but  vegetables  that 


Chronic  Gastritis.  351 

contain  a  large  amount  of  cellulose  and  all  raw  fruits  must  be 
excluded.  Fats  are  valuable,  especially  when  the  general  nutrition 
is  much  reduced,  and  for  this  purpose  the  patient  should  be 
encouraged  to  take  cream,  butter  or  dripping  with  his  meals. 
After  the  lapse  of  a  fortnight  he  is  usually  able  to  leave  his  bed 
and  to  attempt  a  more  extended  dietary.  If  the  milk  and  other 
fluids  agree  they  may  be  continued  in  lesser  quantities,  and  the  sour 
milk  be  taken  once  or  twice  a  day.  The  most  digestible  articles  at 
this  period  of  the  disease  are  as  follows  :  Calf's  brains  and  thymus, 
boiled  cod,  whiting  and  plaice,  oysters,  scraped  raw  beef,  tripe, 
sweetbreads,  mashed  potato,  cauliflower,  asparagus,  toast,  rusks, 
oatmeal,  tapioca,  sago,  cornflour  and  rice,  to  which  may  be  added 
boiled  chicken,  partridge  or  pigeon,  well-stewed  beef,  boiled  ham, 
calf's  feet,  sardines,  spinach  and  stewed  apple.  If  the  case 
continues  to  progress  in  a  satisfactory  manner,  the  diet  is  further 
enlarged  at  the  end  of  another  month  by  the  inclusion  of  such 
articles  as  turkey,  game  of  various  kinds,  underdone  roast  mutton 
or  sirloin  of  beef,  lightly  grilled  chops  or  steaks,  and  plain  puddings. 
On  the  other  hand,  hard  or  coarse-fibred  meats,  pork,  veal, 
sausages,  lobster,  salmon,  mackerel,  carrots,  salads,  celery,  cabbage, 
cucumber,  pickles,  cheese,  new  bread,  uncooked  fruits  and  alcoholic 
drinks  should  be  prohibited  until  the  health  has  been  completely 
restored. 

Medicinal  Treatment. — Natural  mineral  waters  have  always 
been  held  in  high  repute  for  the  treatment  of  chronic  inflammation 
of  the  stomach,  and  much  relief  is  sometimes  obtained  by  a  few  weeks' 
residence  at  a  suitable  watering-place.  Before  advising  a  "  cure  " 
of  this  description,  care  should  be  taken  that  the  general  health  is 
sufficiently  good  to  withstand  the  exertion  and  excitement  of  a  long 
journey  and  the  somewhat  debilitating  effects  of  the  treatment.  In 
this  connection  it  is  well  to  bear  in  mind  that  chronic  gastritis  is 
often  merely  an  expression  of  serious  disease  of  some  vital  organ 
of  the  body,  and  that  to  submit  a  person  suffering  from  a  fatal 
affection  of  the  heart,  lungs,  stomach  or  kidneys  to  the  orthodox 
treatment  at  a  foreign  watering-place  merely  because  chronic 
gastritis  complicates  the  original  complaint,  is  wholly  unscientific 
and  frequently  ends  in  disaster. 

Alkaline  waters  are  chiefly  indicated  in  cases  of  secondary 
gastritis,  where  the  heart,  lungs  or  kidneys  are  seriously  affected 
and  much  irritability  of  the  stomach  exists.  Under  these  conditions 
the  warm  springs  of  Vichy  are  particularly  valuable,  or  if  a  milder 
form  of  treatment  is  required  the  waters  of  Neuenahr  may  be  pre- 
ferred. The  salt  waters  of  Kissingen,  Homburg  and  Wiesbaden 


352  Chronic  Gastritis. 

exert  a  marked  influence  upon  gastric  subacidity  and  are  chiefly 
indicated  during  convalescence  from  primary  chronic  gastritis  and 
in  that  variety  which  ensues  from  long-standing  myasthenia.  In 
England,  Harrogate  and  Llandrindod  possess  somewhat  similar 
waters  and  have  the  advantage  of  a  more  bracing  climate.  The 
springs  that  contain  sulphate  of  sodium  in  addition  to  the  chloride 
and  bicarbonate  are  chiefly  of  use  in  the  gastritis  which  arises  from 
diseases  of  the  liver,  gall-bladder  and  pancreas,  from  habitual 
over-indulgence  in  rich  living  or  the  abuse  of  alcohol.  The  best 
waters  of  this  kind  are  those  of  Carlsbad,  Marienbad,  Tarasp  and 
Brides-les-Bains.  In  all  cases  the  water  should  possess  a  medium 
temperature,  as  the  inflamed  stomach  is  intolerant  of  cold  or  unduly 
hot  fluids. 

The  indications  for  the  administration  of  drugs  are  threefold : 
(1)  To  allay  the  symptoms  of  gastric  irritation  and  inhibit  fermenta- 
tion ;  (2)  to  stimulate  the  appetite  ;  and  (3)  to  correct  constipation. 

(1)  The  abdominal  discomfort,  distension,  nausea  and  other 
symptoms  of  the  complaint  are  partly  due  to  diminished  secretion 
and  partly  to  direct  irritation  of  the  mucous  membrane  of  the 
stomach.  Both  these  conditions  tend  to  subside  under  daily 
lavage  and  careful  dieting,  but  they  rarely  disappear  completely 
without  the  use  of  drugs.  The  carbonate  of  bismuth  is  pre- 
eminently valuable  in  these  cases,  and  may  advantageously  be 
combined  with  bicarbonate  of  sodium  (15  gr.  of  each)  and  from 
8  to  12  min.  of  the  glycerine  of  carbolic  acid.  The  further 
addition  of  1  drachm  of  pure  glycerine  to  the  mixture  increases 
its  sedative  and  antiseptic  properties.  The  medicine  is  given 
between  meals,  and  should  nausea  be  troublesome,  five  drops  of 
dilute  hydrocyanic  acid  may  be  added  to  it.  In  less  severe  cases 
the  solution  of  bismuth  may  be  prescribed  in  similar  combination. 
Morphine  is  only  indicated  when  acute  gastritis,  accompanied 
by  excessive  vomiting,  complicates  the  chronic  complaint  and  is 
contra-indicated  when  albumin  is  present  in  the  urine.  In 
gastritis  of  alcoholic  origin  chloretone,  in  doses  of  15  gr.,  or 
1  drachm  of  the  elixir  in  an  alkaline  mixture,  is  often  of  much 
value.  Salicylate  of  sodium  and  salicylic  acid  are  much  inferior 
to  carbolic  acid.  A  drachm  of  the  solution  of  perchloride  of 
mercury  administered  three  times  a  day  after  meals  is  an  excellent 
remedy  when  the  gastritis  is  associated  with  alcoholic  cirrhosis 
of  the  liver.  If  acidity  is  the  chief  cause  of  complaint,  the  com- 
pound lozenges  of  bismuth,  or  capsules  containing  calcined  magnesia 
and  bicarbonate  of  sodium,  taken  an  hour  after  food,  are  of 
service. 


Chronic    Gastritis.  353 

(2)  Lavage  is  the  best  stimulant  to  the  appetite,  but  when  this 
procedure  cannot  be  carried  out  recourse  may  be  had  to  medicines. 
In  some  instances  a  cupful  of  beef-tea  or  hot  water  taken  a 
quarter  of  an  hour  before  a  meal  excites  a  certain  amount  of 
relish  for  food,  or  15  min.  of  dilute  hydrochloric  acid  diluted 
with  2  oz.  of  water,  between  meals,  has  a  good  effect.  Condurango 
has  long  enjoyed  a  reputation  as  a  stomachic,  and  a  teaspoonful 
of  the  wine,  or  30  min.  of  the  liquid  extract,  with  or  without 
hydrochloric  acid,  may  be  prescribed  before  each  meal.  Orexin 
is  too  irritating  to  be  borne  by  an  inflamed  stomach,  while 
nux  vomica,  iron,  quinine  and  the  various  so-called  gastric  elixirs, 
increase  the  inflammatory  trouble.  The  fact  that  a  deficiency 
of  the  mineral  acid  is  always  accompanied  by  a  diminution  of 
the  peptic  ferment  has  led  to  the  introduction  of  pepsin,  papain, 
papayotin  and  the  pancreatic  preparations,  as  artificial  aids  to 
digestion.  Personally,  I  have  never  observed  the  slightest  benefit 
to  ensue  from  their  use,  and  even  takadiastase,  which  theoretically 
should  be  of  value,  is  quite  useless. 

ALCOHOLIC   GASTRITIS. 

In  every  case  of  alcoholic  gastritis,  as  well  as  in  many  of  the 
secondary  forms  of  the  complaint,  the  administration  of  a  saline 
each  morning  before  breakfast  is  of  the  greatest  value.  As  a  rule, 
a  mixture  in  equal  proportions  of  the  dried  sulphate  and  phosphate 
of  sodium  answers  best,  but  artificial  Carlsbad  salts,  Kutnow's 
powder,  the  sulphate  and  carbonate  of  magnesia,  or  the  Rochelle 
salts,  may  be  prescribed.  Enough  should  be  taken  to  procure 
two  liquid  motions  each  morning,  and  after  a  few  weeks  the 
dose  may  gradually  be  diminished.  The  natural  aperient  waters 
are  of  less  value. 

PHLEGMONOUS   GASTRITIS. 

The  treatment  is  chiefly  symptomatic,  and  is  identical  with 
that  of  other  acute  inflammations  of  the  stomach.  No  food  is 
allowed  by  the  mouth,  and  the  nutrition  should  be  maintained 
entirely  by  large  rectal  injections  of  peptonised  milk.  Opium 
or  other  sedatives  are  usually  required  on  account  of  the  severe 
pain  which  exists,  preference  being  given  to  hypodermic  injections 
of  morphine.  Hot  applications  to  the  epigastrium  usually  afford 
relief.  In  every  instance  full  doses  of  the  polyvalent  antistrepto- 
coccus  serum  should  be  tried,  and  also  stock  preparations  of  anti- 
staphylococcus  vaccines. 

W.    SOLTAU    FENWICK. 
S.T.  — VOL.  II.  23 


354 


NERVOUS  DISEASES  OF  THE  STOMACH. 

GASTRIC  NEURASTHENIA  (NERVOUS  DYSPEPSIA). 

THE  measures  usually  recommended  for  general  neurasthenia  are 
also  indicated  in  cases  of  nervous  dyspepsia.  The  patient  should  be 
encouraged  to  pursue  a  definite  line  of  treatment,  and  be  constantly 
reassured  as  to  the  non-existence  of  organic  disease.  In  mild  cases 
he  should  be  directed  to  pursue  his  usual  vocation,  provided  it  is 
not  of  too  arduous  a  nature,  to  devote  adequate  time  to  his 
meals,  to  go  to  bed  at  a  reasonable  hour,  and  to  avoid  adventitious 
forms  of  excitement  and  unnecessary  fatigue.  Sexual  intercourse 
is  often  harmful,  and  should  be  always  restricted  as  far  as  possible. 
Change  of  air  seldom  fails  to  afford  relief  if  care  is  taken  to 
avoid  humid  and  enervating  localities.  In  most  instances  high 
altitudes  are  beneficial,  and  a  residence  in  Switzerland  or  Scotland 
during  the  summer  months  tends  to  improve  the  appetite  and 
to  remove  the  indigestion.  When  much  physical  enfeeblement 
exists  a  voyage  to  Australia  is  of  greater  value.  As  a  rule,  the 
southern  and  south-western  parts  of  England  do  more  harm  than 
good,  and  many  persons  who  endeavour  to  regain  their  health 
by  a  holiday  at  Bournemouth,  Torquay,  the  Isle  of  Wight,  or 
in  Devonshire,  return  home  in  a  worse  condition.  Of  the  inland 
health  resorts,  Malvern  and  Ilkley,  in  the  north,  and  Hindhead,  in 
the  south,  are  the  best,  and  there  is  seldom  any  objection  to 
the  east  coast  during  the  warmer  months  of  the  year.  In 
every  case  the  patient  must  be  impressed  with  the  fact  that 
a  complete  rest  is  the  main  object  of  his  enforced  absence 
from  home,  and  he  should  consequently  free  himself  entirely 
from  business  worries,  and  remain  away  for  at  least  two  months. 
Short  holidays  are  quite  useless  and  week-end  visits  only  promote 
exhaustion.  Owing  to  the  important  influence  of  environment,  the 
patient  should  be  surrounded  by  cheerful  associates,  and  all  news 
of  a  depressing  or  irritating  character  be  withheld  from  him  as 
far  as  possible. 

In  the  severe  form  of  the  disease,  accompanied  by  rapid 
emaciation,  it  is  advisable  to  confine  the  patient  entirely  to  bed  for 
a  month  or  six  weeks  and  to  try  the  effects  of  a  milk  diet 
combined  with  general  massage  and,  if  necessary,  electricity.  The 
prohibition  of  literature  and  the  visits  of  friends  are  usually 


Nervous  Diseases  of  the  Stomach.         355 

harmful  owing  to  the  inherent  tendency  to  melancholia,  and 
very  often  when  an  effort  is  made  to  procure  complete  isolation 
the  patient  throws  off  all  restraint  and  refuses  to  subject  himself 
to  further  treatment.  In  every  instance  the  condition  of  the 
generative  organs  requires  special  attention,  and  careful  enquiries 
should  be  made  concerning  masturbation,  spermatorrhoea,  and 
venereal  excesses,  with  the  view  of  removing  these  potent  causes 
of  nervous  exhaustion.  Electricity  is  often  of  value,  both  in 
relieving  the  dyspepsia  and  in  the  treatment  of  the  constipation. 
For  the  stomach,  a  constant  current  of  3  to  5  niilliamperes 
should  be  passed  through  the  epigastrium  for  twenty  minutes 
daily,  the  negative  electrode  being  applied  over  the  lower  dorsal 
region  and  the  positive  one  immediately  below  the  left  costal 
margin.  Einhorn  and  others  prefer  direct  electrisation  of  the 
organ  by  means  of  a  metallic  wire  inserted  into  an  ordinary 
stomach  tube,  but  the  procedure  is  unpleasant  to  the  patient 
and  tedious  of  application.  When  electricity  is  employed  for 
constipation,  one  pole  is  inserted  into  the  rectum,  and  the  other, 
consisting  of  a  large  metal  disc,  is  successively  applied  to  the 
surface  of  the  abdomen  at  different  points  along  the  course 
of  the  large  intestine.  The  interrupted  current  is  to  be  preferred 
to  the  constant  one,  and  each  application  should  last  for  half 
an  hour.  This  electrical  treatment  may  be  combined  with 
massage  of  the  colon,  but  the  latter  should  be  avoided  if 
symptoms  of  mucous  colitis  exist.  If  anorexia  is  a  serious 
symptom  it  may  be  necessary  to  resort  to  gavage  (forcible 
feeding). 

Diet. — The  fact  that  the  dyspeptic  symptoms  are  only  slightly 
influenced  by  the  nature  of  the  food  renders  it  inexpedient  to 
prescribe  a  fixed  dietary.  As  a  rule,  an  excess  of  innutritions 
liquids,  such  as  beef -tea,  broths,  tea  and  mineral  waters,  tends 
to  inflate  the  stomach  and  to  increase  the  sense  of  discomfort ; 
while  green  vegetables  and  fruits  almost  always  disagree,  and 
are  to  be  prohibited.  The  meals  should  be  moderate  in  quantity, 
composed  of  materials  that  are  easily  digested,  and  be  taken 
at  intervals  of  three  hours.  If  an  excessive  craving  for  food 
occurs  between  the  meals,  egg  and  milk,  hard-boiled  eggs,  or 
a  cup  of  milk  cocoa  may  be  allowed.  The  advisability  of  an 
excess  of  milk  must  depend  upon  the  state  of  the  gastric  secretion. 
In  the  mild  form  of'  the  complaint,  where  the  secretory  and 
motor  powers  of  the  stomach  are  usually  unaffected,  5  pints  of 
warm  milk  each  day  in  divided  doses,  either  with  or  without  lime- 
water,  form  an  excellent  substitute  for  other  forms  of  nourishment 

23—2 


356         Nervous  Diseases  of  the  Stomach. 

and  promote  the  formation  of  fat  and  muscle.  In  the  severe 
variety  of  the  complaint,  on  the  other  hand,  the  failure  of  the 
gastric  secretion  renders  raw  milk  very  liable  to  disagree,  and 
it  must  be  given  in  restricted  amount,  and  either  peptonised 
.or  well  diluted.  Sometimes  Horlick's  malted  milk  is  tolerated 
when  other  forms  produce  discomfort.  The  sour  milk  is  extremely 
variable  in  its  action,  but  should  always  be  given  a  trial.  In  every 
case  mastication  must  be  thoroughly  performed,  and  no  exercise 
should  be  permitted  for  one  hour  after  meals. 

Medicinal  Treatment. — The  choice  of  drugs  depends  upon  the 
state  of  the  gastric  secretion.  When  hyperacidity  accompanies  the 
nervous  disorder  an  alkaline  mixture  containing  bicarbonate  of 
sodium,  carbonate  of  bismuth  and  glycerine  should  be  given  after 
each  meal,  or  a  compound  bismuth  lozenge  sucked  at  intervals 
during  the  course  of  digestion.  As  a  rule,  however,  the  severe  form 
of  the  complaint  is  accompanied  by  a  marked  deficiency  of  gastric 
secretion,  and  it  is  in  such  cases  that  hydrochloric  acid  is  of  value. 
In  most  instances  it  is  sufficient  to  prescribe  fifteen  drops  of  the 
dilute  acid  after  each  meal,  but  sometimes  a  wineglassful  of  a 
2  or  3  per  1,000  solution  of  hydrochloric  acid  at  the  end  of  each 
repast  is  more  beneficial.  The  various  digestives,  such  as  papain, 
pepsin,  pancreatin  and  lactopeptin  are  rarely  of  any  decided  use, 
nor  does  the  administration  of  maltine  or  takadiastase  appear  to 
relieve  the  symptoms  of  flatulence  and  distension.  The  treatment 
of  the  constipation  is  always  a  matter  of  difficulty  owing  to  the 
severe  exhaustion  that  is  apt  to  follow  the  use  of  purgatives.  In 
the  first  instance  a  trial  should  be  made  of  a  tablespoonful  of 
glycerine  by  the  mouth  each  morning  before  breakfast,  or  of  a 
small  dose  of  mercury  and  chalk,  cascara  or  euonymin  combined 
with  rhubarb  and  hyocyamus  every  evening.  Saline  aperients  and 
the  natural  aperient  waters  should  be  avoided,  as  their  administra- 
tion always  increases  the  symptoms  of  distress.  In  severe  cases 
reliance  must  be  placed  upon  enemata,  soap  and  water  or  warm 
water  containing  glycerine  or  castor  oil  being  used  for  the  purpose. 
Another  useful  method  is  to  inject  olive  oil  into  the  bowel  at 
atmospheric  pressure.  At  first  ^  pint  is  given  each  alternate 
morning,  but  as  the  patient  improves  the  injection  need  only  be 
employed  every  third  or  fourth  day,  and  the  amount  of  oil  may 
be  gradually  diminished.  In  all  cases  the  general  health  must 
receive  attention.  If  hysteria  exists,  a  course  of  bromides  combined 
with  valerian  often  affords  relief.  Anaemia  usually  requires  the 
exhibition  of  some  bland  preparation  of  iron,  with  which  arsenic 
and  nux  vomica  may  be  combined  if  necessary.  Zambelleti's 


Nervous  Diseases  of  the  Stomach.         357 

injections  of  soluble  arsenic  and  iron  are  of  great  value  in  some 
cases.  In  young  persons  cod-liver  oil  and  the  compound  syrup  of 
the  hypophosphites  constitute  an  admirable  tonic. 

NERVOUS    ERUCTATION. 

In  this  disorder  there  is  apparently  a  constant  eructation  of 
gas  from  the  stomach  accompanied  by  much  noise.  In  almost 
every  instance,  however,  it  may  be  shown  that  the  condition 
is  due  to  the  involuntary  swallowing  of  air  that  passes  up  the 
oesophagus  at  intervals  in  the  form  of  bubbles  which  burst  in 
the  mouth  and  excite  a  noisy  vibration  of  the  soft  palate.  The 
complaint,  when  well  established,  is  '  exceedingly  difficult  to  cure. 
The  most  effective  treatment  in  recent  cases  consists  of  the  passage 
of  a  full-sized  tube  into  the  stomach  and  its  maintenance  in 
position  for  twenty  minutes  on  each  occasion.  In  obstinate  cases 
it  may  be  necessary  to  administer  a  constant  electrical  current  by 
means  of  a  wire  passed  down  the  tube  and  to  apply  repeatedly 
small  blisters  to  the  epigastrium.  When  the  complaint  develops  in 
adults  without  obvious  cause,  its  violence  may  be  allayed  by  the 
insertion  of  a  gag  into  the  mouth,  so  as  to  keep  the  teeth  apart,  or 
of  an  instrument  to  depress  the  tongue,  but  these  expedients  are  only 
of  temporary  value.  Young  women  almost  invariably  require  a 
course  of  arsenic  and  iron,  with  perhaps  the  addition  of  bromides. 

HABITUAL    REGURGITATION. 

This  differs  from  rumination  in  being  an  acquired  and  not  an 
hereditary  complaint,  while  the  mouthfuls  of  food  are  usually 
ejected  from  the  mouth  with  disgust  rather  than  swallowed.  In 
every  case  the  patient  should  be  made  to  eat  slowly,  to  masticate 
thoroughly  and  to  avoid  any  form  of  pressure  upon  the  abdomen. 
Voluntary  efforts  to  suppress  the  regurgitation  are  attended  by  a 
certain  degree  of  success  and  should  be  encouraged  as  much  as 
possible.  Sometimes  the  swallowing  of  small  pieces  of  ice  reduces 
the  frequency  of  the  regurgitation  Electricity  should  be  tried  both 
internally  and  externally,  and  strychnine  may  be  prescribed.  A 
milk  diet  and  massage  often  reduce  the  severity  of  the  symptom, 
but  when  the  patient  returns  to  his  ordinary  mode  of  life  it  usually 
recurs. 

CARDIOSPASM. 

The  treatment  is  primarily  prophylactic.  If  the  inner  surface  of 
the  oesophagus  is  unduly  irritable  and  the  spasm  occurs  after  eating 
or  drinking,  mastication  must  be  thoroughly  performed  and  only 


358         Nervous  Diseases  of  the  Stomach. 

foods  and  fluids  of  medium  temperature  should  be  taken.  In  most 
instances  a  full-sized  oesophageal  tube  passed  night  and  morning 
and  maintained  in  position  for  ten  minutes  affords  considerable 
relief,  the  procedure  being  gradually  discontinued  as  improvement 
sets  in.  If  the  spasm  is  accompanied  by  pain,  it  is  probable  that 
secondary  erosions  of  the  mucous  membrane  exist  in  the  neighbour- 
hood of  the  cardia. 

In  such  cases  a  milk  or  pultaceous  diet  should  be  prescribed  for 
a  few  weeks,  while  in  severe  instances  recourse  should  be  had  to 
rectal  alimentation.  Internal  electrisation  is  always  worthy  of 
trial. 

W,   SOLTAU   FENWICK. 


359 


PARASITES  AND   CONCRETIONS   OF  STOMACH. 

IN  addition  to  various  worms,  the  stomach  is  occasionally  infested 
with  the  larvae  of  several  varieties  of  insects  and  even  by  living 
beetles.  In  most  cases  the  insects'  eggs  gain  an  entrance  to  the 
organ  by  the  ingestion  of  impure  water,  contaminated  milk,  high 
meats,  game,  mouldy  biscuits  or  decaying  vegetable  matter,  or  the 
minute  larvae  are  swallowed  alive  in  raspberries  and  other  fruits. 
Accidental  parasitism  would  probably  be  prevented  if  sufficient 
care  were  taken  to  preclude  the  access  of  flies  to  meat  and  other 
articles  of  food  during  the  summer  months,  and  to  avoid  uncooked 
vegetables,  musty  cakes  and  unboiled  water.  Muslin  safes  are 
alone  of  any  value  in  protecting  meat  from  blow-flies.  In  mild 
cases  of  internal  myiasis  a  sharp  purge  is  sufficient  to  rid  the  body 
of  the  larvae  and  eggs,  while  in  chronic  cases  the  administration 
of  thymol,  santonin,  or  other  anthelmintics  is  often  successful. 
Beetles  are,  however,  notoriously  difficult  to  kill,  and  large  doses  of 
turpentine  are  usually  required  to  free  a  patient  from  these  pests. 
Slugs,  leeches,  frogs,  lizards  and  other  living  creatures  are  often, 
though  erroneously,  supposed,  to  exist  in  the  human  stomach  for 
a  long  period,  and  it  is  comforting  to  be  able  to  assure  the  sufferers 
from  such  unusual  intruders  that  a  few  draughts  of  strong  salt  and 
water  will  never  fail  to  kill  them. 

Hair-balls,  bezoars  and  gastroliths  are  very  rarely  met  with,  the 
former  being  the  least  uncommon  and  practically  confined  to 
women.  When  a  history  of  hair-swallowing  suggests  the  cause  of 
the  intractable  dyspepsia,  but  no  abdominal  tumour  exists,  the 
cure  of  the  habit  combined  with  a  daily  saline  purge  will  gradually 
cause  the  elimination  of  the  material,  but  when  sufficient  hair  has 
accumulated  to  create  a  palpable  tumour,  surgical  interference  is 
always  necessary. 

W.   SOLTA.U   FENWICK. 


36° 


SECRETORY  DISORDERS  OF  THE  STOMACH. 

THIS  class  comprises  three  complaints.  In  the  first,  or  hyper- 
acidity, an  excess  of  free  hydrochloric  acid  is  secreted  as  the  result 
of  ingestion  of  food  ;  in  the  second,  hypersecretion,  gastric  juice, 
which  usually  contains  an  excess  of  the  free  mineral  acid,  is  secreted 
continuously,  both  when  the  organ  contains  food  and  when  it  is 
empty ;  while  in  the  third  variety,  or  achylia,  the  gastric  secretion 
is  almost  completely  suppressed. 

HYPERACIDITY. 

General  Treatment. — The  first  indication  is  to  avoid  every- 
thing which  tends  to  over-excite  the  glandular  activity  of  the 
stomach.  If  the  hyperacidity  arises  from  mental  exertion, 
emotional  excitement  or  physical  overstrain,  these  conditions  must 
be  obviated  as  far  as  possible.  During  an  acute  access  of  the 
malady  complete  rest  should  be  enforced,  and  the  patient  should 
remain  in  bed  or  upon  a  sofa  for  a  few  days.  Climate  always 
exercises  an  important  influence  upon  the  severity  of  the  symptoms, 
and  in  many  cases  exposure  to  cold  or  damp  will  invariably  provoke 
an  attack.  Residence  in  an  enervating  atmosphere  increases  the 
disorder,  and  hence  all  low-lying  districts  as  well  as  those  situated 
upon  the  south  coast  and  in  the  south-western  parts  of  England 
are  unsuitable  for  persons  affected  with  chronic  hyperacidity.  As 
a  rule  inland  health  resorts  are  preferable  to  those  situated  on 
the  coast,  especially  Hindhead,  Malvern,  Ilkley,  the  north  of 
Scotland  and  the  elevated  parts  of  Sussex  and  Bucks.  In  all 
cases  the  patient  should  be  advised  to  wear  warm  underclothing, 
with  a  woollen  or  chamois-leather  belt  next  the  skin,  and  should 
be  warned  against  the  use  of  cold  baths  in  winter  or  prolonged 
immersion  in  the  sea. 

Everything  which  tends  to  increase  the  production  of  hydro- 
chloric acid  is  to  be  avoided,  and  if  the  teeth  are  in  bad  condition 
they  should  receive  immediate  attention.  Nuts,  fruits,  salads  and 
other  substances  difficult  of  solution  by  the  gastric  juice  must  be 
prohibited,  as  well  as  such  stimulating  articles  as  salt,  pepper, 
mustard,  vinegar,  horseradish,  alcoholic  beverages  and  beer.  Tea 
always  increases  the  acidity,  and  in  most  instances  black  coffee  is 
inadmissible.  Moderate  smoking  need  not  be  prohibited,  but 


Hyperacidity.  361 

strong  tobacco  and  cigars  should  be  avoided,  and  inhalation  should 
not  be  practised.  The  spa  treatment  of  hyperacidity  is  often  dis- 
appointing, and  the  particular  watering-place  selected  should  depend 
upon  the  cause  of  the  gastric  complaint.  Hyperacidity  associated 
with  neurasthenia  or  gastroptosis  is  most  benefited  by  a  high  and 
bracing  locality,  and  consequently  a  prolonged  residence  in  Switzer- 
land is  often  of  the  greatest  value.  When  the  disorder  is  associated 
with  biliary  lithiasis,  gastric  ulcer,  pancreatitis  or  gout,  a  course  of 
treatment  at  Carlsbad  or  Marienbad,  Harrogate  or  Strathpeffer,  is 
sometimes  invaluable,  but  when  it  appears  as  a  sequela  of  disease 
of  the  nervous  system  the  warm  waters  of  Vichy  or  Neuenahr  are 
of  greater  value. 

Lavage  is  indicated  only  when  gastrectasis  complicates  the 
functional  complaint.  Some  writers  assert  that  internal  galvanisa- 
tion of  the  stomach  reduces  the  secretion  of  hydrochloric  acid  and 
is  capable  of  curing  the  complaint.  That  the  degree  of  acidity  does 
occasionally  diminish  under  this  method  of  treatment  cannot  be 
doubted,  but  I  have  never  met  with  a  case  where  a  genuine  cure 
had  been  effected  by  electricity.  Hot-air  baths  have  been  recom- 
mended as  a  means  of  controlling  the  secretion  of  acid,  and 
temporary  relief  is  often  experienced  after  copious  perspiration  has 
been  produced  in  this  manner. 

Diet. — The  chemistry  of  digestion  in  hyperacidity  demonstrates 
in  an  unmistakable  manner  that,  while  nitrogenous  foods  are 
rapidly  dissolved  and  passed  into  the  intestine,  starches  and  fats 
lie  stagnant  in  the  stomach  and  undergo  fermentation.  Pawlow 
has  shown  by  experiment  that  different  forms  of  proteid  food  excite 
varying  degrees  of  acidity,  the  most  potent  in  this  respect  being 
beef  and  mutton,  while  milk  not  only  induces  less  secretion  but  also 
fixes  the  greatest  proportion  of  free  hydrochloric  acid.  Clinical 
experience  also  teaches  that  starchy  substances  give  rise  to  more 
discomfort  than  proteids,  and  milk  to  less  than  meat.  In  every 
case,  therefore,  milk  should  constitute  the  staple  diet  during  an 
acute  attack  of  the  disorder,  care  being  taken  to  administer  it  in 
the  form  that  proves  most  agreeable  and  beneficial  to  the  patient. 
At  first  6  oz.  of  warm  milk  containing  a  tablespoonful  of  lime- 
water  should  be  given  every  two  hours,  and  after  a  few  days  the 
dose  may  be  increased  to  ^  pint  every  two  and  a  half  hours. 
Some  persons  prefer  the  milk  to  be  mixed  with  Vichy  or  soda  water, 
while  others  find  the  addition  of  15  gr.  of  citrate  of  sodium 
to  each  ^  pint  prevents  the  discomfort  that  ensues  from  its 
rapid  coagulation  in  the  stomach.  Peptonisation  is  of  course  super- 
fluous, and  milk  curdled  by  means  of  lactobacilline  never  agrees. 


362  Hyperacidity. 

When  the  stomach  is  exceptionally  irritable  it  may  be  necessary  to 
restrict  the  patient  entirely  to  whey.  Junket  and  koumiss  answer 
well  in  some  cases.  As  soon  as  the  acute  symptoms  have  subsided 
the  milk  may  be  thickened  with  fine  oatmeal,  sago  or  ground  rice, 
after  which  poached  and  boiled  eggs,  chicken-cream,  boiled  fish  rubbed 
through  a  sieve  and  cold  bacon  may  be  allowed.  Wheaten  bread 
and  toast  almost  always  produce  discomfort  and  should  be  replaced 
by  rusks  or  the  Brusson-Jeune  rolls.  Sole,  whiting,  plaice  and 
cod  usually  agree  better  than  the  oily  forms  of  fish,  and  should  be 
boiled,  finely  minced  and  served  with  plain  sauce.  Subsequently, 
poultry,  game  and  the  various  red  meats,  tongue,  sweetbreads, 
tripe  and  ham  may  be  tried,  with  a  small  quantity  of  boiled  or 
mashed  potato,  cauliflower,  seakale  or  asparagus.  On  the  other 
hand,  cabbage,  lettuce,  peas,  beans,  celery,  carrots  and  turnips 
never  agree,  and  no  fruits  should  be  allowed.  Although  starchy 
foods  appear  to  increase  the  secretion  of  hydrochloric  acid,  probably 
by  their  stagnation  in  the  stomach,  the  soluble  sugars  are  free  from 
this  defect,  and  according  to  some  authorities  a  considerable  amount 
of  dextrose  in  solution  may  be  given  each  day  without  disturbance 
of  the  digestion,  provided  that  the  motor  power  of  the  stomach  is 
intact.  A  moderate  amount  of  fat  may  be  included  in  the  dietary, 
especially  in  the  form  of  butter  or  cream,  but  fried  bacon  is  apt  to 
produce  acidity.  Olive  oil  is  sometimes  recommended  on  account 
of  its  inhibitive  influence  upon  gastric  secretion,  and  may  be  taken 
before  meals  or  mixed  with  the  food.  Salt  must  be  avoided  as  far 
as  possible. 

The  frequency  of  the  meals  should  vary  in  different  cases. 
If  the  appetite  is  normal  it  is  usually  advisable  only  to  allow 
three  full  meals  in  the  course  of  a  day,  so  as  to  afford  the  stomach 
definite  periods  of  rest ;  but  when  hunger  is  a  marked  feature  of 
the  case,  or  the  patient  finds  that  his  desire  for  food  is  easily 
satisfied,  it  is  better  to  administer  a  smaller  quantity  of  food  every 
three  hours. 

A  moderate  amount  of  fluid  may  be  taken  at  the  end  of 
a  meal,  as  it  helps  to  dilute  the  acid  secretion,  and  for  this 
purpose  warm  water,  or  water  containing  bicarbonate  of  potassium 
in  the  proportion  of  1  gr.  to  the  ounce,  is  particularly  valuable, 
or  one  of  the  natural  alkaline  waters,  such  as  those  of  Vichy,  Ems, 
Seltzer,  or  Contrex6ville,  either  alone  or  mixed  with  milk,  may  be 
prescribed.  Kefir  sometimes  agrees  well,  and  some  practitioners 
advise  cider,  but  as  a  rule  acid  fluids  tend  to  increase  the  pain  and 
discomfort.  Occasionally  a  glassful  of  fresh  lemonade  taken  at  night 
prevents  the  occurrence  of  acidity  in  the  early  hours  of  the  morning. 


Hyperacidity.  363 

Spirits  and  beers  always  augment  the  symptoms  of  indigestion,  but 
if  alcohol  is  considered  necessaiy,  a  light  white  wine  well  diluted 
with  water  is  probably  the  least  harmful. 

Medicinal  Treatment. — In  mild  cases  or  at  the  commencement 
of  an  attack  the  patient  should  be  directed  to  suck  two  or  three  com- 
pound bismuth  lozenges  after  meals  or  to  swallow  three  of  the  5-gr. 
tablets  of  bicarbonate  of  sodium.  As  a  rule,  however,  a  more 
active  form  of  treatment  is  required  in  which  the  exhibition  of 
alkalies  plays  an  important  part.  Most  authorities  prefer  the 
bicarbonate  of  sodium,  either  alone  or  in  combination  with  calcined 
magnesia  or  prepared  chalk,  to  neutralise  the  excess  of  acid  in  the 
stomach  ;  but  whichever  drug  is  used  it  should  be  given  in  full 
doses  about  two  hours  after  a  meal.  In  severe  cases  a  sedative  is 
always  required,  and  10  min.  of  the  solution  of  morphine  [U.S.P. 
gr.  ^  of  morphine  hydrochloride]  or  1  grain  of  the  phosphate  of 
codein  may  be  added  to  the  alkaline  mixture.  Belladonna  has 
been  recommended  on  account  of  its  supposed  influence  upon 
the  gastric  secretion,  but  neither  it  nor  atropine  really  diminish  the 
acidity  and  not  infrequently  produce  vomiting. 

When  the  pain  is  severe  and  only  partially  relieved  by  alkalies, 
it  is  safe  to  assume  that  the  symptom  is  due  in  great  part  to  a 
concomitant  hyperresthesia  of  the  gastric  mucosa  induced  by  long- 
continued  irritation  by  free  hydrochloric  acid,  and  under  these 
circumstances  the  salts  of  bismuth  are  invaluable.  As  a  rule,  the 
carbonate,  in  doses  of  15  or  20  gr.,  is  the  best  preparation, 
especially  when  combined  with  morphine  and  glycerine,  but  the 
solution  of  bismuth  prescribed  with  the  elixir  of  chloretone  finds 
favour  with  some  practitioners.  In  very  obstinate  cases  nitrate  of 
silver  has  been  recommended,  either  in  the  form  of  a  pill  or  as  a 
gastric  douche  (1  in  1,000),  but  I  have  never  seen  a  case  where 
permanent  benefit  was  derived  from  the  employment  of  this 
salt. 

The  constipation  which  invariably  accompanies  hyperacidity 
should  be  combated  in  the  first  instance  by  saline  aperients 
administered  in  the  early  morning.  Phosphate  of  sodium  (2 
drachms),  the  artificial  Carlsbad  salts  (2  to  4  drachms),  sulphate  of 
sodium  (2  drachms),  or  Eochelle  salt  (2  to  4  drachms),  should  be 
dissolved  in  a  tumblerful  of  hot  water  or  such  natural  aperient 
waters  as  those  of  Carlsbad,  Friedrichshall,  Hunyadi  Janos,  or 
Apenta  may  be  prescribed.  As  the  case  improves  the  quantity  of 
the  aperient  is  gradually  reduced,  and  finally  the  saline  is  omitted 
in  favour  of  an  occasional  dose  of  aloes  and  rhubarb,  mercury  and 
colocynth,  or  other  simple  aperient. 


364  Acute    Hypersecretion. 

HYPERSECRETION. 

The  Acute  Hypersecretion.— During  an  attack  the  patient 
must  be  confined  to  bed.  No  food  should  be  given  by  the  mouth, 
but  a  little  ice  may  be  sucked  if  the  thirst  is  severe,  or  the  mouth 
rinsed  out  from  time  to  time  with  hot  water.  If  vomiting 
persists  for  more  than  twenty-four  hours,  from  15  to  20  oz.  of 
warm  peptonised  milk  should  be  slowly  introduced  into  the  rectum 
through  a  tube  every  six  hours  and  the  bowel  washed  out  with 
normal  saline  solution  each  day.  In  this  manner  irritation  of 
the  stomach  by  the  ingestionof  food  is  avoided,  and  the  duration  of 
the  attack  is  much  curtailed.  Some  authorities,  however,  prefer  to 
administer  milk  diluted  with  Vichy  or  lime-water  or  white  of  egg 
during  the  whole  period. 

The  quickest  method  of  relieving  the  pain  and  sickness  is  to 
introduce  a  soft  tube  into  the  stomach,  and,  after  evacuating  the 
acid  contents  of  the  organ,  thoroughly  to  wash  it  out  with  a  weak 
solution  of  bicarbonate  of  sodium  (2  gr.  to  the  ounce).  The  use  of 
nitrate  of  silver  (1  in  1,000)  for  the  purposes  of  lavage  never  stops 
the  abnormal  secretion  and  does  more  harm  than  good.  As  a  rule, 
the  lavage  should  be  repeated  every  six  hours,  but  it  rarely  happens 
that  it  is  required  more  than  four  times.  If  the  tube  cannot  be 
employed,  the  patient  should  be  encouraged  to  drink  £  pint  of 
hot  water  at  intervals  and  to  induce  vomiting  by  inserting  his 
fingers  down  the  throat.  In  either  case  it  is  wise  to  administer  1 
drachm  of  carbonate  of  bismuth  suspended  in  4  oz.  of  water  at  the 
completion  of  lavage,  or  to  prescribe  an  alkaline  bismuth  mixture 
combined  with  morphine.  As  soon  as  vomiting  has  subsided,  milk 
diluted  with  lime-water,  whey,  or  albumin  water  may  be  allowed  in 
small  quantities  at  frequent  intervals,  and  after  a  short  time  a  more 
substantial  diet  can  be  given. 

In  the  meantime  it  is  always  advisable  to  administer  a  full 
dose  of  a  saline  aperient,  or  ^  gr.  of  calomel  every  hour  until 
the  bowels  have  been  thoroughly  evacuated.  When  the  latter 
has  been  accomplished  the  vomiting  hardly  ever  recurs.  Between 
the  attacks  an  effort  should  be  made  to  remove  the  cause 
of  the  complaint.  If  it  can  be  shown  by  the  incidence  of  the 
disease  that  mental  or  physical  overstrain  is  an  important  factor  in 
its  causation,  the  patient  must  be  advised  to  limit  his  labours  and 
to  take  moderate  exercise  in  the  fresh  air.  Excessive  smoking 
must  be  prohibited  ;  in  severe  cases  the  habit  should  be  abandoned. 
Alcohol  can  rarely  be  tolerated,  and  in  many  cases  an  attack  may 
be  traced  directly  to  indulgence  in  even  a  small  quantity  of  wine 
or  spirits.  It  is  highly  probable  that  acute  hypersecretion  is 


Chronic    Hypersecretion.  365 

merely  an  early  expression  of  the  chronic  complaint,  and  depends, 
like  it,  upon  an  organic  lesion  of  the  digestive  organs.  Sooner  or 
later,  therefore,  the  question  of  surgical  interference  will  have  to  be 
considered. 

Chronic  Hypersecretion.— Every  case  requires  to  be  treated 
upon  its  own  merits,  special  attention  being  paid  to  the  type  of  the 
disease,  the  degree  of  gastrectasis  and  the  presence  of  complica- 
tions. 

General  Treatment. — There  is  no  remedy  so  efficient  in  relieving 
the  attacks  of  pain  and  sickness  as  methodical  lavage,  while  in  those 
numerous  examples  of  the  complaint  where  the  perversion  of  secretion 
is  associated  with  stenosis  of  the  pylorus  the  performance  of  lavage  is 
essential  to  the  maintenance  of  nutrition.  In  every  case,  therefore, 
when  vomiting  occurs  at  night  or  food  is  found  in  the  viscus  in  the 
early  morning,  the  stomach  should  be  washed  out  once  a  day.  The 
time  at  which  the  operation  is  to  be  performed  must  be  determined 
by  the  peculiar  requirements  of  each  case.  Thus,  when  sleep  is 
disturbed  by  indigestion  or  vomiting,  it  is  most  conveniently  under- 
taken when  the  patient  retires  to  bed,  but  if  much  muscular 
insufficiency  exists  it  may  be  necessary  to  wash  out  the  organ 
again  before  breakfast.  As  a  rule,  warm  water  containing  about 
2  gr.  of  bicarbonate  of  sodium  to  the  ounce  is  the  rnqst  suitable 
medium  for  the  purpose,  but  some  writers  recommend  boric  acid  (10 
in  1,000)  or  other  antiseptics  (see  p.  313).  Reichmann  claims  that 
irrigation  of  the  stomach  with  a  weak  solution  of  nitrate  of  silver 
(1  in  1,000)  exerts  a  direct  inhibitive  influence  upon  the  secretion,  but 
this  plan  has  not  been  attended  by  much  success  at  the  hands 
of  other  observers  and  is  apt  to  produce  severe  pain.  It  is  a 
convenient  practice  to  administer  a  dose  of  a  saline  aperient  through 
the  tube  at  the  conclusion  of  the  morning  lavage. 

The  enlarged  and  dislocated  stomach  should  always  be  supported 
by  means  of  a  firm  abdominal  belt,  which  the  patient  can  readjust 
for  himself  night  and  morning.  When  duodenal  ulcer  or  gall- 
stones are  the  cause  of  the  secretory  disorder,  treatment  at  Carlsbad 
or  Marienbad  often  affords  considerable  relief,  but  should  the 
stomach  be  much  dilated  mineral  waters  in  large  quantities  must 
be  avoided.  Massage  should  never  be  recommended,  owing  to  the 
frequent  association  of  hypersecretion  with  an  open  ulcer  of  the 
stomach  or  duodenum  or  with  a  diseased  appendix,  while  rubbing 
of  the  stomach  itself  in  no  way  affects  the  excessive  secretion. 
Electricity  is  useless. 

Diet. — In  the  arrangement  of  a  suitable  dietary  the  principal 
indication  is  to  avoid  those  articles  of  food  which  stimulate  the 


366  Chronic    Hypersecretion. 

gastric  secretion  and  which  at  the  same  time  are  difficult  of  solution. 
This  class  includes  all  amylaceous  substances  that  have  not  pre- 
viously been  digested,  excess  of  fats,  and  cellulose.  Few  subjects 
of  chronic  hypersecretion,  whether  the  stomach  is  dilated  or 
not,  are  able  to  take  bread  and  starches  without  experiencing  an 
access  of  discomfort.  On  the  other  hand,  experience  teaches  that 
the  total  exclusion  of  starch  from  a  dietary  usually  increases  the 
tendency  to  emaciation  and  favours  constipation,  so  that  it 
becomes  necessary  to  devise  a  method  by  which  a  moderate 
amount  of  carbohydrates  may  be  given  each  day.  The  fact  that 
the  presence  of  gastric  juice  in  the  organ  at  once  inhibits  ptyalin 
digestion  and  favours  the  fermentation  of  sugar,  suggests  that  the 
viscus  should  be  emptied  of  its  acid  contents  before  starch  is  given, 
and  that  a  suitable  amount  of  diastase  should  be  added  to  the  meal 
to  aid  the  conversion  of  at  least  a  portion  of  the  amylacea  into 
sugar  before  the  accumulation  of  hydrochloric  acid  puts  a  stop  to 
the  process.  With  these  objects  in  view  it  is  customary  to  wash 
out  the  stomach  each  morning  with  a  weak  alkaline  fluid,  and 
immediately  afterward  to  give  a  meal  consisting  of  oatmeal,  a 
cereal  soup,  bread  and  milk,  milk  pudding,  or  some  special  form  of 
starchy  food  that  has  already  been  partially  digested.  Occasionally 
a  solution.of  dextrose  may  be  given  with  advantage,  or  a  full  dose 
of  maltine  or  takadiastase  administered  at  the  end  of  the  meal. 
Bread  almost  invariably  increases  the  distension  and  flatulence 
and  should  be  omitted  in  favour  of  thin  toast,  rusks,  starch-free 
biscuits  or  that  most  useful  and  palatable  preparation  which  has 
recently  been  introduced,  the  Brusson-Jeune  rolls.  Green  vege- 
tables never  agree,  but  well  cooked  asparagus,  seakale,  or  stewed 
celery  may  be  allowed  in  moderation.  All  varieties  of  fruit 
increase  the  gastric  acidity,  more  especially  strawberries,  goose- 
berries and  plums.  Apples,  baked  or  stewed  without  sugar,  and 
oranges  are  the  least  harmful.  The  patient  should  be  encouraged 
to  take  a  moderate  amount  of  butter  and  cream  with  his  meals,  but 
excess  must  be  avoided,  as  they  are  apt  to  produce  fat- vomiting  in 
the  later  stages  of  the  complaint.  Few  subjects  of  hypersecretion 
can  take  alcohol  without  discomfort,  and  very  often  an  attack  of 
gastric  intolerance  can  be  traced  to  indulgence  in  wine  or  spirits. 
Tea  always  disagrees,  and  in  many  instances  coffee  must  also  be 
prohibited,  but  cocoa  made  from  the  nibs  or  husks  and  diluted  with 
milk,  or  the  plasnion  and  peptonised  cocoas,  may  usually  be  taken 
with  benefit.  At  the  other  meals  one  of  the  natural  alkaline 
mineral  waters,  milk  and  soda  water  and  whey  are  the  most  suitable 
drinks.  Milk  is  invaluable,  since  it  rapidly  fixes  free  hydrochloric 


Chronic    Hypersecretion.  367 

acid  and  is  a  comparatively  slight  stimulant  to  secretion.  When 
raw  milk  disagrees  it  is  certain  that  the  stomach  contains  a 
large  quantity  of  stagnant  acid,  and  lavage  will  have  to  be 
performed  for  several  days  before  milk  can  be  tolerated.  As  a  rule, 
from  G  to  10  oz.  of  milk,  either  raw  or  mixed  with  lime-water,  may 
be  administered  every  two  hours.  In  other  cases  it  may  be 
necessary  to  employ  fresh  whey  or  Horlick's  malted  milk.  Of 
recent  years  curdled  milk  has  been  introduced  on  a  large  scale  into 
gastric  practice,  but  according  to  my  experience  it  never  agrees 
with  any  case  in  which  the  secretion  of  the  stomach  is  abnormally 
acid.  It  is  only  in  those  cases  of  "  appendicular  "  hyper-secretion, 
accompanied  by  gastric  sub-acidity,  that  the  use  of  sour  milk  is 
sometimes  attended  by  success.  Unless  the  complaint  depends 
upon  an  ulcer  of  the  stomach,  animal  food  may  also  be  allowed, 
especially  if  it  is  finely  minced  and  carefully  masticated.  Mutton, 
lamb,  veal,  ham,  cold  bacon,  poultry,  fresh  game,  sweetbreads, 
tripe,  calf's  head  and  feet,  or  sheep's  brains,  should  be  lightly 
cooked  and  taken  at  the  midday  meal,  while  at  other  times  fish, 
clear  soups,  meat  essences  and  jellies,  custard,  junket  and  eggs 
may  be  allowed.  When  a  craving  for  food  develops  soon  after  a 
meal,  it  may  usually  be  allayed  by  egg  and  milk  or  by  albumin 
water. 

MfdiciiKil  Treatment. — Drugs  are  administered  with  the  object  of 
allaying  pain  and  vomiting,  relieving  constipation  and  restricting  the 
secretion  of  gastric  juice.  Pain  usually  demands  the  use  of  an 
alkali  to  neutralise  the  excessive  acidity.  For  this  purpose  full 
doses  of  bicarbonate  of  sodium,  solution  of  potash,  carbonate  of 
magnesia,  or  of  ammonio-magnesium  phosphate,  are  given  two 
hours  after  a  meal  and  repeated  when  necessary.  When  much 
dilatation  of  the  stomach  exists  the  solution  of  potash  is  to  be 
preferred  to  the  bicarbonates.  Carbonate  of  bismuth  is  extremely 
valuable  as  an  antacid  and  gastric  sedative,  and  may  be  combined 
with  a  soluble  alkali  and  a  teaspoonful  of  glycerine.  If  flatulence 
is  also  a  troublesome  symptom  10  min.  of  the  glycerine  of  carbolic 
acid  may  be  added  to  the  mixture.  Sedatives  are  required  when 
pain  is  severe,  in  which  case  10  to  15  min.  of  the  solution  of 
morphine  [U.S. P.  gr.  y\j  to  gr.  ^  of  morphine  hydrochloride] 
may  be  added  to  the  prescription.  Belladonna  is  occasionally 
of  service,  but  is  apt  to  induce  dry  ness  of  the  mouth  and 
aggravate  the  thirst.  A  saline  administered  in  hot  water  before 
breakfast  each  morning  is  the  best  remedy  for  the  constipation,  as 
it  not  only  procures  a  free  action  of  the  bowels  but  also  sweeps  into 
the  intestine  the  gastric  juice  which  has  accumulated  during  the 


368  Achylia   Gastrica. 

night,  and  thus  performs  a  kind  of  internal  lavage.  As  a  rule,  a 
mixture  of  the  dried  sulphate  and  phosphate  of  sodium  in  equal 
parts  is  the  most  useful  saline,  but  the  artificial  Carlsbad  salts,  the 
carbonate  and  sulphate  of  magnesia  or  Kutnow's  powder  are  some- 
times preferred.  The  natural  aperient  waters  are  not  so  efficacious. 
In  very  chronic  cases  an  occasional  dose  of  calomel  or  blue  pill  at 
night  improves  the  appetite  and  removes  the  feelings  ascribed  to 
biliousness.  Hypersecretion  dependent  upon  latent  disease  of  the 
appendix  is  apt  to  be  accompanied  by  a  form  of  secondary  gastritis 
which  is  extremely  intolerant  of  all  medicines,  and  especially 
of  alkalies.  The  employment  of  opium,  belladonna,  atropine  and 
nitrate  of  silver,  with  the  object  of  directly  controlling  the  excessive 
secretion  of  the  stomach,  is  never  attended  by  any  permanent 
benefit,  owing  to  the  existence  of  an  organic  cause  of  the  complaint. 
Sooner  or  later  chronic  hypersecretion  has  to  be  submitted  to 
surgical  treatment.  For  the  treatment  of  the  various  complications 
of  the  disease  see  Haemorrhage  ;  Tetany  ;  Acute  H^persecretion 
or  Gastric  Intolerance  ;  Carcinoma,  and  Gastric  Dilatation. 

ACHYLIA    GASTRICA. 

Diminished  secretion  of  the  stomach  occurs  in  many  diseases 
of  that  viscus  and  especially  in  atrophy  of  the  mucous  membrane. 
The  term  "achylia,"  however,  is  limited  to  a  peculiar  nervous 
affection  of  the  stomach  in  which  the  production  of  hydrochloric 
acid  and  the  ferments  is  practically  absent. 

So  long  as  the  patient  suffers  no  ill-effects  from  the  absence  of 
gastric  digestion,  it  is  only  necessary  to  arrange  a  form  of  diet 
which  shall  not  unduly  distend  or  embarrass  the  organ  and  to 
assist  as  far  as  possible  the  compensatory  action  of  the  intestines. 
As  a  rule,  the  dietary  should  be  of  the  mixed  type  and  the  meals  be 
taken  every  three  hours.  Milk,  eggs,  fish,  sweetbreads,  tripe  and 
sheep's  brains  are  easily  digested  in  the  small  intestine,  while  such 
farinaceous  substances  as  rice,  sago,  tapioca,  macaroni  and  mashed 
potato  give  rise  to  no  difficulties  of  solution.  Well-cooked  spinach, 
turnips  and  cabbage  may  be  allowed  in  moderation,  but  salads, 
tomatoes,  raw  vegetables  and  fruits  are  apt  to  disagree.  If  the 
appetite  is  deficient  the  various  artificial  foods  that  have  undergone 
partial  digestion  may  be  given,  and  cod-liver  oil  and  maltine  are 
sometimes  useful.  Inflammatory  conditions  of  the  overtaxed 
intestines  must  be  carefully  treated,  and  the  patient  should  take 
special  precautions  against  cold.  Hydrochloric  acid  is  the  drug 
usually  employed,  and  may  be  given  in  doses  of  15  min.,  well 


Achylia  Gastrica.  369 

diluted,  after  each  meal,  or  as  a  draught  in  the  strength  of  1  in  1,000. 
Pepsin,  pepsencia,  lactopeptin,  or  the  peptenzyme  tablets,  may  also 
be  prescribed,  but  the  pancreatic  preparations,  which  from  a 
theoretical  point  of  view  appear  to  be  especially  indicated,  are 
rarely  of  any  value.  Metchnikoff's  sour  milk  is  always  deserving 
of  a  careful  trial.  When  motor  insufficiency  of  the  stomach 
develops,  lavage  with  warm  water  should  be  performed  each  day, 
and  massage  and  electricity  may  be  employed.  Mineral  waters 
must  be  avoided. 

W.   SOLTAU   FENWICK. 


S.T. — VOL.   II.  24 


370 


SYMPTOMATIC   TREATMENT   OF   DISORDERED 
DIGESTION   IN   THE    STOMACH. 

Acidity. — Regurgitations  of  an  acid  fluid  into  the  throat  or 
mouth,  known  by  the  name  of  pyrosis  or  heartburn,  accompany 
many  different  diseases  of  the  stomach.  In  the  vast  majority  of 
the  cases  the  symptom  depends  upon  an  excess  of  hydrochloric 
acid  in  the  gastric  secretion,  and  is  therefore  met  with  in  all 
varieties  of  hyperacidity  and  hypersecretion.  It  usually  develops 
between  one  and  three  hours  after  a  meal,  and  is  often  more 
severe  after  a  light  than  after  a  heavy  repast.  In  some  individuals 
it  is  accompanied  by  cardialgia,  palpitation,  dyspnea,  tachycardia, 
oppression  at  the  chest,  or  a  sense  of  impending  death.  Less 
frequently  the  regurgitations  arise  from  excessive  fermentation 
of  the  food,  the  acid  products  of  which  find  their  way  into  the 
oesophagus  or  pharynx  along  with  the  eructated  gases.  This 
phenomenon  is  consequently  met  with  in  many  forms  of  chronic 
gastritis,  especially  in  the  alcoholic  variety,  in  stenosis  of  the 
pylorus  due  to  conditions  which  are  not  accompanied  by  an 
excessive  gastric  secretion,  such  as  carcinoma  and  sarcoma,  peri- 
toneal bands,  adhesions  to  the  gall-bladder  or  abdominal  parietes, 
or  to  mechanical  displacements.  Finally,  pyrosis  is  often  com- 
plained of  in  nervous  affections  of  the  stomach  and  oesophagus, 
such  as  hyperaesthesia  and  neurasthenia  gastrica,  in  which  the 
secretion  of  the  organ  may  be  quite  normal,  but  the  increased 
sensibility  of  the  mucous  surfaces  that  accompanies  these  disorders 
renders  it  intolerant  of  even  the  normal  degree  of  acidity. 

Acidity  due  to  hyperacidity  requires  to  be  treated  in  the  manner 
recommended  for  the  cure  of  that  complaint  (p.  360).  Substances 
which  stagnate  in  the  stomach  and  excite  secretion  without  under- 
going digestion  must  be  avoided,  and  accordingly  green  vegetables, 
uncooked  fruits,  bread,  pastry,  cakes  and  sweets  must  be  prohibited, 
as  well  as  those  articles  which  unduly  stimulate  the  stomach,  such 
as  alcohol,  malt  liquors,  wines,  condiments,  salt  and  tea.  Milk 
diminishes  gastric  irritation  and  also  fixes  the  largest  percentage 
of  free  acid,  so  that  it  should  always  form  the  staple  diet  in  severe 
cases.  It  is  most  agreeable  when  taken  warm,  and  may  be  mixed 
with  a  moderate  proportion  of  lime-water  (a  tablespoonful  to 
\  pint),  Vichy  water,  or  citrate  of  sodium  (10  gr.  to  the  pint) 


Symptomatic  Treatment  of  Disordered  Digestion.  37 1 

if  it  seems  to  disagree.  As  the  symptom  subsides  the  quantity  of 
milk  may  be  diminished,  but  a  tumblerful  should  always  be  taken 
in  the  middle  of  the  morning  and  at  bedtime.  Any  kind  of  animal 
food  may  be  given  in  moderation,  but  those  which  possess  much 
grease  or  a  coarse  fibre,  like  veal  and  pork,  are  the  least  easily 
digested.  In  like  manner  oily  fish,  such  as  herring,  sardine, 
pilchard  and  salmon,  are  apt  to  create  acidity.  Eggs  may  always 
be  allowed,  but  the  amount  of  farinaceous  substances  taken  in  the 
form  of  milk  puddings  or  vegetables  must  be  restricted.  Fresh 
orange  or  lemon  juice  diluted  with  soda  water  sometimes  relieves 
the  symptom.  In  all  cases  a  saline  purge  administered  in 
\  pint  of  hot  water  each  morning  is  invaluable,  but  as  a  rule 
mercurials  should  be  avoided.  The  medicinal  treatment  of  the 
hyperacidity  comprises  the  exhibition  of  the  carbonate  or  solution 
of  bismuth,  combined  with  an  alkaline  bicarbonate,  prepared  chalk, 
calcined  magnesia,  carbonate  of  magnesia  or  the  solution  of  potash, 
according  to  the  necessities  of  the  case.  In  mild  instances  the 
compound  bismuth  lozenges,  or  the  tablets  of  soda  mint,  may  be 
sucked  at  intervals  between  the  meals.  The  cure  of  the  pyrosis 
must  depend  upon  its  cause. 

Acidity  due  to  excessive  gastric  fermentation  invariably  requires 
systematic  lavage  and  a  course  of  antiseptic  treatment.  In  most 
cases  the  stomach  should  be  washed  out  with  warm  water,  either 
alone  or  combined  with  an  antiseptic,  each  morning  for  a  month, 
after  which  it  is  gradually  discontinued;  but  if  sleep  is  much 
disturbed,  lavage  should  be  performed  at  night  as  well.  Vegetables, 
fruits,  sugars  and  amylaceous  substances  generally,  must  be  reduced 
to  a  minimum,  and  only  those  forms  of  animal  food  allowed  which 
are  comparatively  easy  of  digestion  (see  Dilatation).  An  alkaline 
mixture  containing  glycerine  and  carbolic  acid  administered  one 
hour  after  meals  seldom  fails  to  afford  relief,  and  a  saline  purge  in 
the  early  morning  is  usually  a  necessity. 

The  sensation  of  acidity  that  accompanies  nervous  affections  of 
the  stomach  must  be  treated  in  the  manner  appropriate  to  the 
primary  disease.  As  a  rule,  bromides  combined  with  a  sedative, 
such  as  hydrocyanic  acid,  morphine  or  nepenthe,  answer  best; 
but  occasionally  the  use  of  arsenic,  iron,  or  zinc  valerianate  is 
required.  Salines  and  all  drastic  purgatives  should  be  avoided, 
and  large  rectal  douches  should  be  employed  if  collapse  ensues 
after  an  evacuation.  Massage,  electricity  and  mountain  air  are 
required  in  severe  cases. 

Flatulence. — Inflation  of  the  stomach  by  gases,  small  quantities 
of  which  escape  at  intervals  through  the  cardiac  orifice,  is 

24—2 


372  Symptomatic  Treatment  of  Disordered  Digestion. 

usually  attributed  to  abnormal  fermentations  in  the  organ,  but 
this  conception  of  the  cause  of  the  symptom  is  not  always  correct. 
In  many  instances  much  of  the  eructated  gas  is  found  to  consist  of 
atmospheric  air  which  has  been  swallowed,  while  not  infrequently 
regurgitation  of  the  intestinal  fluids  increases  the  gaseous  contents 
of  the  stomach.  Starches  and  sugars  undergo  abnormal  fermenta- 
tion in  almost  every  disorder  of  the  gastric  functions,  whether  the 
mineral  acid  be  deficient  or  in  excess,  and  consequently  in  both 
hyperacidity  and  hypersecretion  flatulence  is  a  prominent  and 
troublesome  symptom.  The  treatment  of  the  condition  varies, 
therefore,  according  to  its  cause  and  the  state  of  the  gastric  juice. 
In  cases  of  excessive  acidity,  farinaceous  food  should  be  limited  as 
far  as  possible,  and  toast,  rusks,  or  Brusson-Jeune  rolls  substituted 
for  bread,  and  sugars  prohibited.  Animal  food  of  any  kind  may  be 
allowed,  and  the  fluids  need  not  be  restricted.  Flatulence  dependent 
upon  failure  of  the  motor  power  of  the  viscus,  which  is  usually 
associated  with  diminished  acidity,  also  requires  strict  limitation 
of  starches,  but  at  the  same  time  the  food  should  be  well  masticated 
so  as  to  favour  its  thorough  incorporation  with  the  saliva,  while 
only  the  most  easily  digestible  forms  of  meat  and  game  should 
be  allowed  and  the  quantity  of  fluid  reduced  to  a  minimum. 
Flatulence  due  to  chronic  subacidity  requires  to  be  treated  by  a 
dietary  similar  to  that  described  in  cases  of  chronic  gastritis, 
achylia,  and  atrophy  of  the  stomach. 

When  hyperacidity  exists  alkalies  are  usually  required,  and  in 
this  connection  it  is  to  be  observed  that  calcined  magnesia  and  the 
solution  of  potash  effect  neutralisation  without  the  production  of 
carbonic  acid  gas.  It  is  sometimes  advisable  to  combine  the  alkali 
with  spirits  of  cajuput  or  chloroform,  aromatic  spirit  of  ammonia, 
essence  of  peppermint,  or  tincture  of  ginger,  and,  if  much  irritability 
of  the  stomach  exists,  with  one  of  the  salts  of  bismuth.  A  saline 
draught  each  morning  is  of  great  service.  The  flatulence  of 
myasthenia  and  other  conditions,  accompanied  by  diminished 
gastric  acidity,  is  best  combated  by  dilute  hydrochloric  acid,  com- 
bined with  pepsin,  given  after  meals.  The  addition  of  a  teaspoonful 
of  glycerine,  with  carbolic  acid  or  other  suitable  antiseptic,  usually 
increases  the  value  of  the  medicine.  Takadiastase  is  also  some- 
times of  value.  Salines  in  this  disorder  tend  to  increase  the 
distension,  and  the  various  alkaline  mineral  waters  also  intensify 
the  symptoms.  A  dose  of  grey  powder,  mercurial  pill,  podophyllin, 
euonymin,  or  other  hepatic  stimulant,  two  or  three  times  a  week,  is 
always  advisable. 

Nausea. — A   feeling   of   sickness   at  intervals  usually  precedes 


SymptomaticTreatment  of  Disordered  Digestion.  373 

vomiting,  and  also  occurs  during  the  process  of  gastric  digestion  in 
several  nervous  disorders  of  the  stomach,  in  inflammatory  affections 
of  the  mucous  membrane,  in  carcinoma,  and  in  strictures  of  the 
pylorus.  Persistent  nausea  is  frequently  met  with  in  alcoholic 
and  other  forms  of  toxic  and  toxsemic  gastritis  and  in  gastroptosis. 
As  an  intermittent  symptom  it  usually  subsides  as  soon  as  vomiting 
has  occurred ;  but  the  persistent  forms  are  extremely  difficult  to 
treat.  The  administration  of  bromides,  combined  with  alkalies  and 
dilute  hydrocyanic  acid,  is  sometimes  of  service,  but  as  a  rule  nitro- 
hydrochloric  acid,  combined  with  nux  vomica  and  chloride  of 
ammonium,  is  of  more  value.  If  anaemia  is  a  conspicuous  feature 
of  the  case,  full  doses  of  ammonio-citrate  of  iron  often  remove  the 
symptom  within  a  few  days.  In  other  instances  injections  of 
soluble  arsenic  and  iron  are  more  valuable.  The  nausea  of  gastro- 
ptosis requires  the  use  of  a  firm  elastic  belt  to  support  the  dislocated 
organ,  while  in  carcinoma  of  the  body  of  the  stomach  10  gr- 
ot chloretone  or  10  min.  of  nepenthe  administered  before  food 
often  relieves  both  the  sense  of  sickness  and  the  abdominal  pain. 

Pain. — This  symptom  arises  from  so  many  different  causes 
that  concise  directions  as  to  its  treatment  are  almost  impossible. 
Genuine  pain  developing  within  half  an  hour  of  a  meal  usually 
indicates  some  form  of  gastric  ulcer,  and  requires  for  its  relief  a 
liquid  or  semi-solid  diet,  abstinence  from  green  vegetables,  fruit 
and  alcohol,  and  a  course  of  sedatives  combined  with  alkalies. 
When  pain  is  deferred  for  two  or  three  hours  it  is  usually  due  to 
hypersecretion  of  the  gastric  juice,  secondary  to  ulcer  of  the 
duodenum,  gall-stones,  or  disease  of  the  appendix,  and  must  be 
treated  by  a  milk  diet,  alkalies,  and  sedatives,  while  the  per- 
sistent pain  of  carcinoma  demands  the  administration  of  morphine. 
The  gastric  discomfort  that  ensues  from  gaseous  distension  of  the 
organ  must  be  treated  on  the  lines  laid  down  for  that  disorder. 

Vomiting. — This  symptom  usually  ensues  from  one  or  other 
of  the  following  conditions :  (1)  Stricture  of  the  cardiac  orifice 
from  cancer  or  simple  ulcer  (regurgitation) ;  (2)  inflammation  of 
the  stomach,  acute  and  chronic  ;  (3)  ulceration  of  the  stomach  or 
duodenum,  simple,  cancerous  or  syphilitic ;  (4)  irritation  of  the 
organ  by  hair-balls,  bezoars,  or  other  foreign  bodies ;  (5)  strictures 
of  the  pylorus  or  duodenum  from  carcinoma,  simple  ulcer,  pyloro- 
spasm  due  to  hyperacidity,  kinking,  adhesions,  or  from  central 
constriction  (hour-glass) ;  (6)  diseases  of  the  brain  and  spinal  cord, 
such  as  meningitis,  cerebral  tumour,  ataxia,  etc. ;  (7)  reflex  irrita- 
tion, from  peritonitis  and  other  serous  inflammations,  irritation  of 
the  gall-bladder,  kidneys,  ovaries,  uterus)tiand  intestinal  canal  in 


374  SymptomaticTreatment  of  Disordered  Digestion. 

children  ;  (8)  mechanical  causes,  such  as  violent  cough  in  pulmonary 
tuberculosis,  irritation  of  pharynx,  etc.  The  treatment  of  emesis 
must  depend  upon  its  cause.  Stenosis  of  the  outlet  requires  a  liquid 
diet,  systematic  lavage  and  gastric  sedatives,  combined  with  bismuth 
and  antiseptics.  The  rejection  of  food  that  ensues  from  inflamma- 
tions of  the  stomach  is  usually  relieved  by  rectal  alimentation  in 
the  acute  cases,  and  lavage,  with  whey  or  other  form  of  liquid 
food  in  the  more  chronic  conditions.  Cerebral  and  reflex  emesis 
requires  the  exhibition  of  sedatives,  while  ulceration  of  the  organ 
necessitates  the  special  treatment  for  that  complaint. 

Waterbrash. — This  term  is  confined  to  the  occasional  eructa- 
tion of  a  small  quantity  of  neutral  or  alkaline  fluid,  which  is  usually 
preceded  by  a  cramping  pain  in  the  epigastrium.  The  fluid  con- 
sists for  the  most  part  of  saliva  which  has  been  swallowed,  mixed 
with  a  neutral  secretion  of  the  stomach,  and  peptones.  It  is  a 
common  symptom  in  certain  cases  of  hyperacidity,  in  gastric 
neurasthenia,  and  in  the  mixed  gastric  neurosis  that  occurs  in 
women  about  the  climacteric.  The  most  effective  treatment  consists 
in  the  administration  of  bromides  and  a  sedative  in  an  alkaline 
mixture,  before  meals,  but  in  obstinate  cases  5  gr.  of  compound 
kino  powder  [U.S. P.  1^.  Pulveris  Kino,  gr.  4  ;  Pulveris  Opii,  gr.  5-  ; 
Pulveris  Cinnamomi,  gr.  1]  with  10  gr.  of  carbonate  of  bismuth  in 
the  form  of  a  cachet  answers  well.  When  a  strong  neurotic 
element  exists,  assafoetida,  valerian,  or  valerianate  of  zinc  are 
usually  prescribed  between  meals.  Counter-irritation  of  the  skin 
of  the  epigastrium  is  often  of  use. 

W.   SOLTAU   FENWICK. 


375 


ULCER  OF  THE  STOMACH  AND  DUODENUM. 

Prophylaxis. — So  many  simple  chronic  ulcers  of  the  stomach 
commence  in  the  acute  manner  that  the  utmost  care  should  be 
taken  to  promote  healing  of  the  disease  at  the  earliest  possible 
moment.  Excessive  caution  is  therefore  to  be  preferred  to  any 
suggestion  of  negligence,  and  if  doubt  exists  as  to  the  presence 
of  an  acute  erosion  or  an  open  ulcer  it  is  always  advisable  that  the 
patient  should  be  treated  as  if  he  were  the  subject  of  the  more 
serious  complaint.  Chlorotic  girls  are  especially  liable  to  develop 
the  chronic  form  of  the  disease  from  comparatively  slight  abrasions 
of  the  gastric  mucous  membrane,  since  anaemia  is  one  of  the  prin- 
cipal obstacles  to  the  repair  of  the  injured  tissue,  and  every  effort 
should  be  made  to  improve  the  state  of  the  blood  as  soon  as  the 
gastric  disease  is  recognised.  The  subjects  of  malaria  are  also  unduly 
prone  to  gastric  ulcer,  and  a  peculiar  and  obstinate  form  of  the 
disease  not  infrequently  develops  as  the  result  of  tertiary  syphilis. 
Continued  pressure  upon  the  epigastrium,  such  as  results  from 
the  use  of  ill-fitting  corsets  or  belts  or  from  occupations  in  which 
a  hard  substance  is  constantly  applied  to  the  abdomen,  may  prove 
the  exciting  cause  of  ulcer,  while  the  frequent  tasting  and  swallow- 
ing of  hot  foods  by  cooks  should  be  avoided  as  far  as  possible.  A 
severe  blow  upon  the  stomach  not  infrequently  induces  haemorrhage 
into  its  mucous  and  submucous  tissues,  followed  by  necrosis,  and 
under  these  conditions  precautionary  measures  in  the  form  of  rest 
and  diet  not  only  tend  to  limit  the  damage,  but  also  aid  the  pro- 
cesses of  repair. 

General  Treatment. — Rest  is  essential  to  the  cure  of  an  ulcer 
whether  this  is  situated  externally  or  in  the  stomach,  and  the  impor- 
tance of  this  curative  measure  cannot  be  too  strongly  insisted  upon. 
As  a  rule,  a  fortnight  in  bed  should  form  a  part  of  the  systematic 
treatment  of  the  disease,  while  in  cases  where  excessive  pain  or 
vomiting  suggest  acute  inflammation  of  the  ulcer  or  the  existence 
of  peritonitis  at  its  base,  the  period  of  complete  rest  should  be  pro- 
longed for  three  weeks  or  a  month.  Some  authorities  regard  the 
application  of  moist  heat  to  the  region  of  the  stomach  as  an  impor- 
tant procedure,  and  either  employ  frequent  fomentations  or  poultices 
to  the  epigastrium,  or  use  an  oval  tin  receptacle  for  hot  water  which 
is  fixed  in  position  by  a  belt.  In  chronic  cases  the  frequent 


376     Ulcer  of  the  Stomach  and  Duodenum. 

application  of  a  small  blister  over  the  site  of  maximum  tenderness 
certainly  produces  a  beneficial  effect  upon  the  symptoms,  which 
may  be  further  enhanced  by  dusting  the  raw  surface  daily  with 
\  gr.  of  acetate  of  morphine.  Occasionally  excessive  tender- 
ness of  the  epigastrium  rapidly  yields  to  cupping  or  after  the 
application  of  a  couple  of  leeches.  Lavage  is  only  employed  when 
the  ulcer  has  produced  stenosis  of  the  pylorus  or  when  concomitant 
hypersecretion  is  associated  with  pylorospasm.  Massage  should 
never  be  permitted,  owing  to  the  danger  of  perforation  and 
haemorrhage,  and  electricity  is  useless  and  usually  gives  rise  to 
pain. 

Diet. — Functional  rest  is  of  vital  importance  to  an  ulcerated 
stomach,  as  no  repair  can  take  place  unless  its  secretory  activity 
and  its  restless  peristalsis  are  kept  under  control ;  and  since  both 
secretion  and  motility  receive  their  greatest  stimulus  by  the  inges- 
tion  of  food,  the  selection  of  an  appropriate  dietary  is  a  matter  of 
the  greatest  moment.  Complete  rest  can  only  be  obtained  by  pro- 
hibiting food  by  the  mouth  and  maintaining  the  nutrition  by  means 
of  nutrient  enemata.  This  procedure  is  particularly  indicated  when 
severe  pain  is  experienced,  in  cases  where  vomiting  ensues  after 
meals  or  when  haemorrhage  has  occurred.  It  is  also  advisable  to 
feed  the  patient  entirely  by  the  bowel  during  the  period  of  physical 
rest  at  the  commencement  of  a  systematic  cure.  In  most  instances 
nutritive  enemata  solely  are  employed  for  eight  or  ten  days,  during 
which  time  the  patient  is  encouraged  to  wash  out  his  mouth  fre- 
quently with  an  antiseptic  solution  and  to  suck  a  rubber  teat  with 
the  view  of  stimulating  the  secretion  of  saliva.  If  there  is  much 
thirst  he  may  suck  a  little  ice  from  time  to  time  or  sip  hot  water. 
Opinions  concerning  the  relative  value  of  various  enemata  vary 
considerably,  but  there  can  be  no  doubt  that  the  administration  of 

15  oz.  to  a  pint  of  fluid  every  six  hours  is  infinitely  more  valuable 
than  the  old-fashioned  injection  of  2  oz.  every  three  hours.     The 
method  of  injection  has  already  been  discussed  (p.  326).     As  a  rule, 
simple  peptonised  milk  answers  every  purpose,  but  some  authorities 
recommend  peptonised  milk-gruel,  beef-tea  mixed  with  raw  eggs 
and  a  little  brandy,  or  milk  containing  pure  glucose,  powdered 
peptones    (somatose),    or    powdered   casein   (sanatogen,   plasnion, 
nutron).     The  latter  ingredients  should  not  be  used  in  a  concentra- 
tion greater  than  10  per  cent.     The  following  are  examples  of  such 
enemata :  (1)  Somatose,  300  gr. ;  glucose,  300  gr. ;  common  salt, 

16  gr. ;  water,  7  fluid  ounces.     (2)  The  yolks  of  two  eggs,  400  gr.  of 
pure  glucose,  8  gr.  of  salt,  and  10  fluid  ounces  of  peptonised  milk. 
To  supplement  rectal  feeding  the  subcutaneous  injection  of  pure 


Ulcer  of  the  Stomach  and  Duodenum.     377 

sterilised  olive  oil  has  been  recommended,  ^  oz.  of  which  is 
introduced  beneath  the  skin  night  and  morning.  A  sterilised 
solution  of  pure  glucose  has  also  been  used  in  a  similar  manner. 

At  the  termination  of  the  period  of  rectal  alimentation,  feeding 
by  the  mouth  is  commenced.  For  at  least  a  fortnight  milk  alone 
should  be  employed,  if  possible,  the  quantity  of  which  must  vary 
according  to  the  requirements  of  each  case.  The  value  of  milk  in 
cases  of  chronic  gastric  ulcer  is  of  a  threefold  kind  :  it  does  not  cause 
mechanical  irritation  of  the  sore,  it  induces  the  least  secretion  of 
gastric  juice  of  any  proteid  food,  and  it  fixes  a  large  proportion  of 
the  free  acid.  In  these  various  ways  it  serves  to  relieve  the  sym- 
ptoms of  pain  and  acidity  and  also  aids  the  repair  of  the  ulcer.  At 
first  from  2  to  4  oz.  may  be  given  every  two  hours,  and  subsequently 
3  to  4  pints  in  the  course  of  each  twenty-four  hours.  The 
majority  of  patients  prefer  the  milk  to  be  warmed  to  a  temperature 
of  70°  F.  Extremes  of  temperature  must  be  avoided.  If  milk 
produces  a  sensation  of  fulness,  or  if  it  be  followed  by  acidity,  it 
is  advisable  to  dilute  it  with  lime-water  or  barley-water  (a  table- 
spoonful  to  \  pint),  or  to  add  citrate  of  sodium  in  the  pro- 
portion of  2  gr.  to  the  ounce.  By  these  means  the  curd  is  rendered 
flocculent  and  more  easy  of  digestion.  Both  sterilised  and  boiled 
milk  are  more  readily  digested  than  raw  milk.  In  some  cases  it  is 
necessary  to  remove  a  portion  of  the  casein  before  it  can  be  tolerated, 
either  by  humanisation  or  by  the  process  of  Gartner  (fat-milk). 
Buttermilk  is  preferred  by  some  patients,  but  it  is  less  nourishing 
owing  to  its  inferior  percentage  of  fat  and  sugar.  Whey  is  chiefly 
of  value  when  vomiting  is  troublesome.  Koumiss  and  kefir  find 
many  advocates,  but  they  are  somewhat  difficult  to  obtain.  Sour 
milk  prepared  in  the  manner  recommended  by  Metchnikoff  rarely 
agrees,  owing  to  the  frequent  existence  of  hyperchlorhydria.  Con- 
densed milk  and  Horlick's  malted  milk  occasionally  agree  when 
every  other  variety  gives  rise  to  discomfort.  When  milk  cannot  be 
tolerated  in  any  form,  the  various  meat  essences  and  juices  must 
be  employed,  the  most  useful  of  which  are  freshly  expressed  meat- 
juice,  beef-tea,  concentrated  chicken,  veal  or  mutton  broth,  Liebig's 
beef  extract,  Valentine's  meat  juice,  Brand's  essence  of  meat,  the 
meat  solution  of  Leube  and  Kosenthal  or  Fleiner's  meat  jelly,  pre- 
pared by  boiling  chicken  or  beef  with  calf's  feet.  About  the  tenth 
day  it  is  often  possible  to  strengthen  the  diet  by  the  addition  of 
eggs  and  farinaceous  materials.  Wheaten  flour  boiled  with  milk 
is  usually  very  acceptable,  while  tapioca,  rice,  grated  biscuit,  toast, 
and  bread  and  milk  are  easily  digested.  Sanatogen,  somatose, 
nutrose,  plasmon,  and  such  semi-digested  foods  as  those  of  Nestle, 


378     Ulcer  of  the  Stomach  and  Duodenum. 

Savory  and  Moore,  or  Benger,  may  also  be  allowed.  At  the  begin- 
ning of  the  third  week  of  the  treatment,  the  diet  is  further  increased 
by  the  addition  of  boiled  calf's  brains,  boiled  thy m us,  boiled  and 
finely-minced  chicken  or  pigeon,  scraped  raw  beef,  boiled  calf's  feet 
and  oatmeal.  At  the  end  of  six  weeks  the  patient  is  permitted  to 
take  minced  broiled  beef,  raw  ham,  white  fish  which  has  been  passed 
through  a  sieve,  mashed  potato,  cauliflower  and  bread  that  has  been 
twice  baked,  while  after  the  expiration  of  three  months  the  dietary 
may  include  broiled  chicken,  pigeon,  venison,  underdone  roast  beef, 
sweetbreads,  tripe,  soups,  souffles,  etc.  Uncooked  vegetables,  fruits, 
pastry  and  alcoholic  liquors  must  be  prohibited  for  many  months. 
Lenhartz  has  suggested  a  concentrated  egg-albumin  diet  which 
has  received  considerable  support.  On  the  first  day  of  the  treat- 
ment the  patient  is  given  7  to  10  oz.  of  iced  milk  in  spoonful  doses 
and  three  or  four  beaten  eggs.  The  amount  of  milk  is  increased 
each  day  by  about  3  oz.  and  the  number  of  eggs  by  one,  so  that  at 
the  end  of  the  first  week  the  patient  receives  about  30  oz.  of  milk 
and  eight  eggs  each  day.  These  are  continued  in  the  same 
daily  amounts  for  another  week.  On  the  sixth  day  1  oz.  of  raw 
minced  meat  is  also  usually  allowed,  the  quantity  being  doubled  the 
following  day  and  subsequently  gradually  increased.  In  the  third 
week  of  the  treatment  a  mixed  diet  is  resumed. 

Medicinal  Treatment. — At  the  present  time  there  is  no  drug 
which  can  be  regarded  as  a  specific  for  ulcer  of  the  stomach  or  duo- 
denum. It  is  true  that  in  the  somewhat  rare  examples  of  syphilitic 
ulceration,  a  prolonged  course  of  iodides  and  mercury  not  only 
relieves  the  severe  pain  and  other  symptoms  but  also  appears  to  cure 
the  disease,  while  in  those  that  are  associated  with  chronic  malaria, 
injections  of  arseniate  of  sodium  sometimes  appear  to  produce  an 
equally  satisfactory  result ;  but  with  these  exceptions  the  treatment 
of  ulcer  of  the  stomach  or  duodenum  is  almost  entirely  sympto- 
matic. The  administration  of  horse  serum  by  the  mouth  in  doses 
of  25  cc.  each  day  has  recently  been  advocated  as  a  cure  of  the 
disease,  and  there  can  be  no  doubt  that  the  serum,  like  other 
albuminous  fluids,  does  in  some  measure  relieve  the  pain ;  but  in 
several  cases  that  have  come  under  my  notice,  in  which  the  disease 
was  reputed  to  have  been  cured  by  this  method,  no  indication  of 
healing  was  discovered  at  subsequent  operation.  It  is  usually 
held  that  repair  of  an  ulcer  is  aided  by  reduction  of  the  gastric  acidity 
and  the  protection  of  the  surface  of  the  sore.  The  hyperchlorhydria 
which  usually  accompanies  a  chronic  ulcer  may  be  allayed  by 
various  drugs  which  neutralise  an  excess  of  free  acid,  of  which 
the  most  reliable  are  the  alkaline  bicarbonates,  prepared  chalk, 


Ulcer  of  the  Stomach  and  Duodenum.     379 

the   salts   of   magnesia,  and    the   solution   of   potash.      The   best 
method,  however,  is  to  reduce  the  gastric  secretion  by  methodical 
depletion  of  the  portal  system  by  saline  purgatives.     In  suitable 
cases   a   course   of   waters  at  Carlsbad,  Neuenahr,  Marienbad,  or 
Vichy,  is  often  followed  by  excellent  results,  but  when  a  visit  to 
these  watering-places  cannot  be  undertaken  artificial  Carlsbad  salts 
of  the  following   composition   are   a  good  substitute  :  Chloride  of 
sodium,    1    part ;    bicarbonate   of   sodium,   2   parts ;     sulphate  of 
sodium,  5  parts.     A  mixture  of  equal  parts  of  phosphate  of  sodium 
and  the  dried  sulphate  of  sodium,  of  which  a  dessertspoonful  or 
more  dissolved  in  a  tumblerful  of  hot  water  is  taken  each  morning 
before  breakfast,  is  more  palatable  than  the  former  and  equally 
efficient.     The  saline  should  be  continued  for  six  weeks  at  least, 
one  or  two  liquid  evacuations  being  procured  each  day.     The  salts 
of  bismuth  have  long  enjoyed  a  great  reputation  for  the  treatment 
of  irritable  conditions  of  the  stomach,  and  in  cases  of  ulcer  they  are 
of   special  benefit,  since  the  deposition  of  the  salt  upon  the  raw 
surface  forms  a  protective  coating  and  not  only  allays  pain  but 
promotes  the  processes  of  repair.     Opinions  are  divided  as  to  the 
best  preparation  to  employ,  but  personally  I  am  greatly  in  favour 
of  the  carbonate  by  reason  of  its  antacid  properties  and  its  com- 
patibility   with    alkaline    bicarbonates.      When   it    is   desired   to 
protect  the  ulcer,  much  larger  doses  may  be  given  than  are  usually 
prescribed,  and  the  drug  should  be  administered  in  the  following 
manner.     After   the   stomach   has   been   thoroughly   cleansed  by 
lavage,  from  60  to  120  gr.  of  the  carbonate  or  subnitrate  of  bismuth 
are  suspended  in  6  oz.  of   warm   water   and  the  mixture  poured 
through   the   tube   and    washed    down  by   5   oz.   of  water.     The 
patient  reclines  upon  his  back  for  ten  minutes  after  the  completion 
of  the  operation  in  order  to  allow  the  salt  to  be  deposited  upon  the 
inner   surface   of   the   stomach,  and  the  excess   of  water  is  then 
siphoned  off.     This  treatment  is  repeated  every  morning  for  three 
weeks,  and  subsequently  each  alternate  day   for  another  month. 
When  the  passage  of  a  tube  is  not  considered  advisable,  the  patient 
may  be  instructed  to  drink  a  tumblerful  of  warm  water  containing 
2  drachms  or  more  of  the  bismuth  salt  in  suspension  each  morning 
before   breakfast.     These   large   doses   of   bismuth   rarely   induce 
constipation,  and  no  toxic  symptoms  ever  ensue.     Nitrate  of  silver 
is  an  old  remedy  for  gastric  ulcer,  which  is  much  lauded  by  some 
writers  and  condemned  by  others.     In  many  cases  it  undoubtedly 
relieves   the   pain,  but   its   effects   are    uncertain   and   cannot   be 
predicted.     It  is    most    advantageously    administered   in   solution, 
^   gr.    dissolved    in    1   oz.    of   distilled   water   being   given    three 


380     Ulcer  of  the  Stomach  and  Duodenum. 

times  a  day  before  meals,  with  the  patient  in  the  recumbent 
posture.  Subsequently  the  dose  is  gradually  increased  to  1  gr. 
Every  three  weeks  the  drug  is  omitted  for  a  week.  It  is  less 
useful  in  the  form  of  a  pill,  each  of  which  contains  i  gr. 
Argyria  is  stated  to  be  very  rarely  encountered.  Three  other 
remedies,  which  are  credited  with  direct  healing  powers,  require 
brief  mention.  Chloroform  given  in  doses  of  10  to  15  ruin.,  well 
diluted  with  water,  four  times  a  day,  has  been  recommended,  and 
the  decoction  of  condurango  bark  is  also  regarded  as  a  curative 
agent,  although  this  is  extremely  doubtful.  Lastly,  iodide  of 
potassium,  especially  when  combined  with  mercury,  is  very 
efficacious  in  that  intractable  and  painful  variety  of  ulcer  which 
develops  as  the  result  of  syphilis. 

Treatment  of  Symptoms  and  Complications. — (1)  Pain. — In 
most  instances  rest  in  bed,  combined  with  local  applications  to 
the  epigastrium  and  a  liquid  diet,  suffices  to  relieve  the  pain, 
but  if  this  symptom  persists  recourse  must  be  had  to  sedatives. 
Of  these  the  most  valuable  is  opium,  the  various  preparations 
of  which  have  always  been  held  in  high  repute.  The  drug  is 
often  given  in  the  form  of  the  tincture,  5  to  10  min.  [U.S.P.  3  to 
6  min.]  of  which  may  be  combined  with  an  alkaline  bismuth  mix- 
ture, but  some  practitioners  prefer  the  solid  extract  (i  gr.)  adminis- 
tered as  a  pill  three  times  a  day  after  food.  If  these  preparations 
produce  nausea  or  loss  of  appetite,  they  should  be  omitted  in  favour 
of  the  solution  of  morphia,  nepenthe,  or  codeine.  If  the  pain  is 
excessive,  hypodermic  injections  of  morphine  may  be  necessary. 
Among  the  other  preparations  of  opium  which  are  of  service  in  par- 
ticular cases  are  the  compound  ipecacuanha  and  kino  powders,  the 
astringent  properties  of  the  latter  being  sometimes  considered  of 
special  service.  Should  it  be  desirable  to  conceal  from  the  patient 
the  fact  that  he  is  taking  opium  the  compound  soap  pill  may  be 
prescribed.  Among  other  sedatives  that  are  sometimes  employed 
are  cannabis  indica,  belladonna,  cocain,  hyoscyamus,  bromide  of 
potassium,  chloric  ether  and  chloretone.  Whichever  drug  is 
employed  it  is  always  necessary  to  add  an  alkali  to  it  in  order  to 
neutralise  the  excessive  acidity  of  the  gastric  juice  which  is  such  an 
important  factor  in  the  production  of  pain. 

(2)  Vomiting. — This  symptom  usually  subsides  after  a  few 
days'  rest  in  bed  combined  with  a  liquid  diet  and  local  applications. 
Should  it  persist,  an  alkaline  mixture  containing  carbonate  of 
bismuth,  hydrocyanic  acid,  solution  of  morphine  and  1  drachm  of 
glycerine  may  be  given  two  or  three  times  a  day  before  food. 

(8)  Constipation. — The   bowels    are    usually   regulated    by    the 


Ulcer  of  the  Stomach  and  Duodenum.     381 

administration  of  Carlsbad  or  other  salines  previously  described. 
Drastic  purgatives  should  never  be  prescribed. 

(4)  Tetaini. — This  rare  complication  of  gastric  ulcer  is  exceed- 
ingly dangerous,  since  the  attacks  tend  to  recur  at  short  intervals 
and  usually  prove  fatal.  The  passage  of  a  tube,  palpation  of  the 
abdomen  and  even  the  use  of  a  catheter  is  apt  to  induce  a  seizure. 
Pending  the  performance  of  gastro-jejunostomy,  it  is  advisable  to 
prohibit  all  food  by  the  mouth  and  to  feed  the  patient  entirely  by 
the  bowel. 

The  treatment  of  the  other  complications  of  ulcer,  such  as 
haemorrhage,  perforation,  hypersecretion,  cancer,  has  either  already 
been  dealt  with  or  is  discussed  under  the  surgical  aspect  of  the 
disease. 

W.   SOLTAU   FENWICK. 


382 


THE  SURGICAL  TREATMENT  OF  ULCER  OF  THE 

STOMACH. 

FBOM  the  point  of  view  of  treatment,  ulcers  may  be  conveniently 
divided  into  two  classes,  acute  and  chronic. 

In  acute  ulcer  the  treatment  should  at  first  be  medical,  and  above 
all  things  it  should  be  thorough  ;  but  if  after  a  month  or  six  weeks 
in  bed  on  milk  diet,  followed  by  a  further  similar  period  of  from  two 
to  three  months  (in  which  only  soft  food,  chiefly  milk,  is  taken), 
the  patient  is  not  free  from  digestive  troubles,  or  if  after  a  period 
of  freedom  from  symptoms  relapse  occurs,  the  question  of  surgical 
treatment  should  be  seriously  considered. . 

In  chronic  or  relapsing  ulcer,  if  medical  treatment  has  not  had 
a  fair  trial,  a  rigid  course  of  diet  and  rest  as  in  acute  ulcer  should  be 
tried  ;  but  in  case  of  non-relief,  or  of  relapse  after  temporary  free- 
dom from  symptoms,  surgical  treatment  should  be  urged. 

Before  surgical  treatment  is  recommended  it  must  be  ascertained, 
as  far  as  possible,  that  the  symptoms  clearly  and  definitely  point 
to  ulcer,  and  to  this  end  a  chemical  as  well  as  a  clinical  investigation 
should  be  made,  since  operation  is,  as  a  rule,  contra-indicated  in 
purely  functional  cases,  and  when  carried  out  not  only  gives  no 
satisfaction,  but  tends  to  bring  discredit  on  operative  treatment. 

Gastric  ulcer  is  a  much  more  serious  disease  than  it  is  ordinarily 
thought  to  be,  and  the  profession  has  generally  considered  it  more 
amenable  to  medical  treatment  than  the  facts  warrant. 

The  accuracy  of  the  observations  of  Leube,  who  states  that  one- 
half  or  three-fourths  of  all  cases  of  ulcer  will  be  cured  by  four  or 
five  weeks  of  treatment,  but  if  not  cured  in  that  time  they  will  not 
be  cured  by  medical  treatment  alone,  has  been  more  than  borne  out 
by  the  careful  investigations  undertaken  by  Dr.  Bulstrode,  at  the 
instigation  of  Mr.  Mansell  Moullin,  in  500  cases  of  ulcer  occurring 
in  the  London  Hospital  from  1897  to  1902.  He  showed  that  18  per 
cent,  died  while  under  medical  treatment,  and  these  did  not  include 
any  of  those  patients  admitted  suffering  from  the  serious  complica- 
tions of  ulcer,  such  as  pyloric  stenosis,  hour-glass  contraction, 
gastric  dilatation,  etc. 

Of  the  82  per  cent,  discharged  as  cured,  Dr.  Bulstrode  calculated 
that  in  at  least  two-fifths  relapse  would  occur,  for  out  of  the  500 


Surgical  Treatment  of  Ulcer  of  the  Stomach.     383 

cases  no  less  than  211  had  suffered  and  been  under  treatment  for 
ulcer  from  one  to  four  or  more  times  previously. 

The  more  recent  observations  made  by  Mr.  Paterson  and  Dr. 
Rhodes  at  the  London  Temperance  Hospital  on  158  consecutive 
cases  under  the  care  of  Dr.  Soltau  Fenwick  and  Dr.  Parkinson  are 
still  more  striking,  showing  that  the  proportion  of  real  cures  in  cases 
of  gastric  ulcer,  even  after  prolonged  treatment  by  diet  and  rest  in 
hospital,  is  under  25  per  cent. 

Private  patients  amid  more  favourable  surroundings,  who  can 
rest  longer  and  are  more  willing  to  bear  restriction  of  diet  over  a 
lengthened  period,  suffer  less  from  relapses,  though  probably  not 
less  from  the  dangers  of  the  serious  complications,  haemorrhage  and 
perforation,  occurring  in  the  acute  ulcer. 

We  may  thus  on  ample  evidence  accept  the  fact  that  at  least  one- 
lihird  of  all  cases  of  ulcer  of  the  stomach  treated  medically  ultimately 
succumb  to  the  disease  or  to  one  of  its  many  complications,  and 
that  one-half  or  two-thirds  of  the  cases  that  recover  relapse.  How 
does  surgical  treatment  compare  with  this  ? 

As  surgeons  we  only  see  the  worst  cases  that  have  failed  to  yield 
to  medical  treatment,  or  cases  suffering  from  relapsing  or  chronic 
nicer ;  yet,  arguing  from  my  own  experience  alone  in  over  500 
operations  of  various  kinds,  such  as  pylorectomy,  excision  of  the 
ulcerated  area,  gastro-enterostomy,  ligature  of  bleeding  gastric 
vessels,  pyloroplasty,  gastrolysis,  etc.,  undertaken  for  ulcer  or  its 
complications  (excluding  peritonitis  after  perforation),  usually  in 
patients  at  the  time  very  seriously  ill,  the  total  mortality  has 
been  only  a  little  over  3  per  cent. ;  but  the  actual  risk  of  posterior 
gastro-enterostomy  in  my  private  practice,  the  most  frequent 
operation  in  this  class  of  cases,  has  only  been  1*7  per  cent.,  and  the 
patients  completely  relieved  have  been  over  90  per  cent. 

Surgical  treatment  may  be  direct  or  indirect.  By  direct 
treatment  excision  of  the  ulcer  or  of  the  ulcer-bearing  area  is 
referred  to ;  by  indirect  treatment  is  meant  gastro-enterostomy  or 
one  or  other  of  the  modifications  of  pyloroplasty,  operations  the 
aim  of  which  is  to  relieve  obstruction  and  to  secure  physiological 
rest  to  the  stomach. 

Excision  of  the  ulcer  has  been  practised  since  1881,  when 
Bydigier  excised  a  large  ulcer  from  the  posterior  wall  of  the 
stomach,  but  his  results  and  the  experience  of  other  surgeons 
appear  to  show  that  the  direct  operation  is  more  dangerous  than 
gastro-enterostomy.  Moreover,  gastric  ulcers  are  frequently 
multiple,  and  the  excision  of  one  ulcer  will  not  cure  the  remaining 
ones ;  hence,  as  might  be  expected  in  practice,  excision  of  ulcer  has 


384     Surgical  Treatment  of  Ulcer  of  the  Stomach. 

been  frequently  followed  by  relapse.      My  own  experience  shows 
that  the  dangers  with  modern  technique  need  not  deter  us  from 


FIG.  1. — Three  stages  of  the  operation  of  pyloroplasty. 

excision  if  it  is  the  better  operation  ;  but  as  excision  alone  has 
been  followed  by  relapse  in  20  per  cent,  of  cases,  it  is  advisable  at 
the  same  time  to  perform  posterior  gastro-enterostomy,  in  order  to 


Surgical  Treatment  of  Ulcer  of  the  Stomach.     385 

secure  physiological  rest  for  the  cure  of  any  other  ulcers  that  may 
he  present,  and  to  prevent  tension  on  the  sutured  area. 

The  operation  of  excising  the  ulcer-bearing  area  with  the  per- 
formance of  an  independent  gastro-enterostomy,  as  suggested  by 
Dr.  Rodman,  will  probably  in.  the  future  be  more  frequently  per- 
formed, for,  as  I  reported  in  my  Bradshaw  Lecture  at  the  Royal 
College  of  Surgeons,  no  less  than  59'3  per  cent,  of  cases  of  cancer  of 
the  stomach  on  which  I  had  operated  gave  a  history  of  chronic  ulcer. 

Dr.  Graham  states  that  a  pre-cancerous  history  of  ulcer  was 
obtained  in  36  per  cent,  of  cases  of  cancer  operated  on  in  the 
Rochester  clinic,  and  a  clear  evidence  of  cancer  development  on 
ulcer  in  30  per  cent,  of  the  last  forty  partial  gastrectomies.  This 
affords  the  most  potent  argument  for  the  radical  operation. 

The  indirect  operations  are  pyloroplasty  and  gastro-jejunostomy. 

Pyloroplasty,  invented  by  Heinecke  in  1886,  and  improved  by 
Mikulicz  in  1887,  although  excellent  in  principle  and  safe  and 
simple  in  practice,  has  been  followed  in  a  large  proportion  of  cases 
by  relapse.  Although  the  symptoms  may  be  relieved  for  months 
or  possibly  years,  the  tying  up  of  the  pylorus  by  adhesions  or  the 
subsequent  contraction  -of  the  cicatrix  has  ultimately  in  about  a 
quarter  of  all  the  cases  led  to  relapse  and  the  necessity  of  a 
further  operation.  I  have  personally  performed  twenty-eight 
pyloroplasties,  with  immediate  success  in  all  except  one  ;  that  died 
a  fortnight  later  from  perforation.  But  of  the  twenty- seven  that 
recovered  and  remained  well  for  various  periods,  in  only  sixteen 
have  the  results  been  perfect,  the  patients  being  well  from  four  to 
eleven  years  later ;  eight  have  required  a  subsequent  operation ; 
one  was  quite  well  for  nine  months,  relapsed  and  died  of  acute 
tetany  some  time  later ;  and  two  are  said  to  have  developed  cancer 
after  six  years  and  eighteen  months  respectively  of  good  health. 

Dr.  W.  J-  Mayo,  out  of  twenty-one  cases,  had  seven  that  required 
a  secondary  operation,  and  Mr.  Rutherford  Morison  had  four 
relapses  out  of  twenty-eight  cases. 

The  modification  of  pyloroplasty,  invented  by  Dr.  Finney  and 
improved  by  Dr.  Gould,  of  Boston,  which  gives  a  very  wide 
opening  from  the  stomach  into  the  duodenum,  is  a  severe  operation 
when  the  pylorus  and  duodenum  have  to  be  extensively  freed  from 
adhesions.  Out  of  fifty-eight  cases  operated  on  by  Drs.  W.  J.  and 
C.  Mayo  the  mortality  was  7  per  cent.,  and  of  112  cases  collected  by 
Dr.  Finney  it  was  9  per  cent. 

Dr.  Munro,  of  Boston,  says  that  the  operation  has  not  given  him 
good  results  and  he  has  abandoned  it,  and  Dr.  W.  J.  Mayo  thinks 
it  only  available  in  certain  selected  cases. 

S.T.-— VOL.  n.  25 


386     Surgical  Treatment  of  Ulcer  of  the  Stomach. 

Gastro-enterostomy,  first  performed  by  Wolfler,  at  the  sug- 
gestion of  Nicoladini  in  1881,  in  a  case  of  obstruction  of  the 
pylorus  due  to  cancer,  was  first  employed  for  the  treatment  of 
ulcer  by  Doyen  in  1893,  and  in  the  same  year  by  Talma,  who 
independently  came  to  the  conclusion  that  spasmodic  stenosis  of 
the  pylorus  was  the  chief  factor  in  maintaining  the  hyperacidity 
and  unrest  which  prevent  the  healing  of  gastric  ulcers. 

It  acts  by  affording  a  free  outlet  from  the  stomach,  thus  over- 
coming stasis,  relieving  hyperchlorhydria,  securing  rest,  and  pre- 
venting the  tension  induced  by  spasm  of  pylorus. 

The  after-results  of  the  operation  in  ulcer  of  the  stomach  and 
duodenum  are  usually  really  remarkable.  The  pain  vanishes,  food 
can  be  readily  taken  and  retained,  vomiting  ceases,  in  a  little  time 
the  anaemia  improves,  and  as  a  rule  the  patient  rapidly  puts  on 
weight. 

The  ill-effects  said  to  follow  the  operation  can  usually  be  avoided 
by  correct  technique.  I  well  remember  in  the  early  cases  of 
gastro-enterostomy  the  fear  that  was  entertained  of  regurgitant 
vomiting — the  so-called  vicious  circle — a  complication  that  I  have 
not  experienced  in  my  work  since  adopting  the  posterior  operation 
without  a  loop ;  neither  have  I  seen  a  case  of  closure  of  the 
anastomotic  opening  nor  any  of  the  forms  of  internal  hernia, 
either  through  a  loop  or  through  a  slit  in  the  niesocolon,  after  any 
of  my  operations.  Pneumonia  and  other  chest  complications  are 
seldom  seen  if  the  operating-room  is  properly  warmed  and  the 
patient  enveloped  in  a  gamgee  suit  at  operation,  and  placed  in  the 
semi-recumbent  position  subsequent  to  operation. 

Death  from  asthenia,  wrhich  at  one  time  was  to  be  feared  after 
stomach  operations,  when  starvation  for  some  days  was  adopted  in 
already  enfeebled  patients,  is  no  longer  a  danger  as  feeding  can  be 
begun  immediately. 

The  danger  of  primary  haemorrhage  is  avoided  by  continuous 
suture  embracing  the  margins  of  the  opening  between  the  two 
viscera,  though  it  is  not  always  possible  to  avoid  the  dangers  of 
secondary  haemorrhage  from  pre-existing  ulcers. 

The  only  complication  that  perhaps  is  unavoidable  is  somewhat 
rare — peptic  ulcer  of  the  jejunum,  which  arises  from  an  excessively 
acid  gastric  juice  passing  directly  into  the  jejunum.  I  think  the 
condition  may  be  avoided  by  making  the  opening  sufficiently  large 
so  that  there  can  be  no  possibility  of  stasis,  and  by  taking  pains 
to  carefully  diet  and  treat  the  patient  medically  for  some  time 
after  operation,  so  as  to  cure  the  hyperchlorhydria.  It  has  been 
clearly  proved  that  this  complication  occurs  more  frequently  after 


Surgical  Treatment  of  Ulcer  of  the  Stomach.     387 

the  anterior  operation,  where  there  has  been  a  long  jejunal  loop, 
but  whether  occurring  after  the  anterior  or  posterior  operation  it 
is  very  serious,  as  perforation  is  very  liable  to  occur. 

The  operation  is  performed  by  an  incision  about  4  inches  in 
length,  f  inch  to  the  right  of  the  mid-line  above  the  umbilicus. 
The  transverse  colon  and  the  great  omentum  are  brought  out  of 
the  wound,  exposing  the  under-surface  of  the  mesocolon  and  the 
commencement  of  the  jejunum.  A  slit  is  made  through  a  non- 
vascular  portion  of  the  mesocolon  close  to  the  duodeno-j-ejunal 
junction  ;  a  portion  of  stomach  is  dragged  through  the  opening 
and  seized  by  rubber-covered  clamps  applied  vertically.  The 
jejunum  close  to  its  junction  with  the  duodenum  is  then  seized 
and  the  stomach  and  jejunum  are  brought  into  apposition.  A 
suture  of  Pagenstecher's  thread  is  applied  to  unite  the  serous 
surface  of  the  stomach  and  jejunum  ^  inch  beyond  the  point 
at  which  it  is  intended  to  open  the  viscera. 

The  stomach  and  jejunum  are  then  opened  by  an  incision  of 
about  2  inches,  and  the  cut  margins  are  united  by  a  chromic  catgut 
suture,  beginning  at  the  left  and  carried  round  until  it  meets  the 
starting-point,  when  it  is  knotted  off.  This  suture  takes  up  all  the 
coats,  and  thus  acts  as  a  haemostatic  suture.  The  Pagenstecher's 
thread  is  then  picked  up  and  continued  round  so  as  to  approximate 
the  serous  surfaces  beyond  the  mucous  suture,  and  when  it  reaches 
the  starting-point  it  is  also  knotted  off.  The  clamps  are  then 
removed  and  two  or  three  sutures  are  applied  to  the  edge  of  the 
incision  in  the  mesocolon,  uniting  it  to  the  point  of  apposition  of 
the  stomach  and  jejunum,  thus  closing  the  slit  and  preventing 
hernia.  The  omentum  and  transverse  colon  are  then  brought 
down  in  front  of  the  small  intestines,  and  the  abdomen  is  closed  in 
the  usual  way.  After  the  operation  the  patient  is  propped  up  in 
bed  in  the  semi-recumbent  posture,  and  feeding  is  begun  as  soon  as 
the  patient  has  come  well  round  from  the  anaesthetic  and  feels  that 
he  can  take  water  or  albumen  water,  which  is  given  in  J-oz.  doses, 
at  first  hourly  or  every  half- hour,  and  within  a  few  hours  in  1-oz. 
doses.  On  the  second  day  chicken  broth  may  be  given  and  tea  or 
coffee,  and  on  the  third  day  milk,  jelly  and  junket,  after  which 
a  gradual  advance  is  made  to  pulpy  foods. 

This  is  the  ordinary  operation  of  gastro-enterostomy,  which  has 
been  modified  in  various  ways. 

In  certain  cases,  where  adhesions  are  so  extensive  as  to  prevent 
the  posterior  wall  of  the  stomach  being  reached,  or  where  growth 
has  invaded  the  posterior  wall,  it  may  be  desirable  to  perform  the 
anterior  operation,  in  which  case  the  jejunum  is  picked  up  and 

25-2 


388     Surgical  Treatment  of  Ulcer  of  the  Stomach. 

clamped  at  a  point  12  to  15  inches  from  the  duodeno-jejunal 
flexure.  This  clamped  loop  is  brought  round  the  colon  and  fixed 
horizontally  to  the  lowest  point  of  the  anterior  wall  of  the  stomach, 
in  a  way  similar  to  that  described  under  posterior  gastro-enterostomy. 
As  regurgitant  vomiting  was  found  at  times  to  follow  the  anterior 
operation  it  was  found  advantageous  to  short-circuit  the  long  loop 
or  to  perform  Koux's  operation,  which  consists  in  dividing  the 
jejunum  at  about  9  inches  from  the  duodeno-jejunal  flexure,  the 
distal  jejunal  opening  being  fixed  to  the  wall  of  the  stomach,  and 
the  proximal  opening  of  the  divided  loop  being  anastomosed  into 
the  jejunum  about  3  inches  below  the  stomach. 

A.   W.  MAYO-ROBSON. 


3*9 


PERFORATING  ULCER  OF  THE  STOMACH. 

THIS  complication,  which  is  estimated  by  various  authors  to  occur 
in  from  12  to  28  per  cent,  of  all  cases  of  gastric  ulcer,  is  fatal,  unless 
surgically  treated,  in  95  per  cent.  There  can,  therefore,  be  no  room 
for  any  difference  of  opinion  as  to  the  wisdom  of  operation  in  this 
serious  accident.  As  shown  by  the  statistics  drawn  from  a  very 
large  series  of  cases,  every  hour's  delay  adds  to  the  danger  ;  hence 
it  is  of  the  utmost  importance  that  an  early  diagnosis  and  imme- 
diate operation  should  be  insisted  on. 

In  cases  operated  on  within  twelve  hours  of  rupture  the  mortality 
has  been  25  to  28  per  cent.,  in  from  twelve  to  twenty-four  hours 
63  per  cent.,  in  from  twenty -four  to  thirty-six  hours  86  per  cent., 
and  after  thirty-six  hours  the  mortality  has  been  so  great  (95  to  100 
per  cent.)  that  purely  medical  treatment  would  seem  to  give  an 
equal  chance  of  recovery. 

The  results  of  operation  in  late  cases  will  probably  always  be 
unsatisfactory,  but  I  believe  that  the  cases  seen  within  twelve  hours 
of  rupture  should  give  much  better  results  than  those  yet  attained ; 
my  feeling  is  that  the  mortality  should  be  brought  down  to  from 
5  to  10  per  cent. 

Excision  of  the  ulcer  is  not  necessary  to  success,  since  folding 
in  of  the  edges  of  the  rupture,  the  careful  application  of  a  continuous 
serous  suture,  and,  if  possible,  the  use  of  an  omental  graft,  give 
good  results.  I  prefer  to  wash  out  the  abdomen  with  hot  normal 
saline  solution,  and  to  drain  above  the  pubes  with  the  patient  well 
propped  up  in  bed ;  but,  as  shown  by  a  series  of  cases  operated  on 
by  Mr.  Littlewood  in  which  lavage  was  not  adopted,  washing  out  is 
not  always  necessary  to  success. 

My  rule  is  that,  where  the  effusion  is  general,  lavage  should  be 
adopted,  but  where  it  is  local  a  mere  wiping  out  of  the  soiled  area 
only  is  necessary. 

The  important  point  is  the  actual  damage  to  the  peritoneum ; 
for,  if  it  has  not  lost  its  polish,  it  is  capable  of  absorbing  any 
amount  of  effusion ;  but  if  the  peritoneum  has  lost  its  polish  it 
must  be  assisted  by  artificial  drainage.  Seeing  that  in  one-third 
of  all  the  fatal  cases  other  ulcers  have  been  found,  that  in  20  per 
cent,  of  cases  of  ruptured  ulcer  the  perforations  are  multiple 
(Finney),  and  that  in  a  large  proportion  of  cases  recovering  from 
operation  the  patients  have  subsequently  had  other  gastric 
symptoms  or  even  a  second  perforation,  the  question  of  the 


390         Perforating  Ulcer  of  the  Stomach. 

desirability  of  gastro-enterostomy  at  the  time  of  operating  for  the 
perforation  is  well  worthy  of  consideration. 

Of  fifteen  cases  traced  by  Mr.  Crisp  English  four  suffered  subse- 
quently from  gastric  trouble ;  and  of  thirty-five  traced  by  Mr. 
Paterson,  one  died  from  perforation  within  two  years,  two  required 
subsequent  gastro-enterostomy,  nine  had  definite  symptoms  of 
gastric  ulcer,  and  five  had  gastric  symptoms.  In  Mr.  Moynihan's 
cases  seven  out  of  twenty-four  required  an  immediate  or  subsequent 
gastro-enterostomy. 

The  chief  argument  against  gastro-enterostomy  is  the  prolonga- 
tion of  the  time  of  operation  in  cases  already  very  seriously  ill  from 
the  perforation,  but  in  cases  not  too  ill  to  bear  it  the  following  argu- 
ments are  decidedly  in  its  favour  : 

(1)  Other  ulcers  present  at  the  time  of  perforation  will  probably 
be  cured  by  the  operation,  and  in  case  of  ulcer  at  the  pylorus  the 
effects  of  cicatricial  contraction  will  be  averted. 

(2)  If  a  second  ulcer  is  on  the  point  of  perforation,  such  perfora- 
tion will  probably  be  prevented,  as  tension  and  pressure  on  the 
stomach  wall  will  be  avoided. 

(3)  After  gastro-enterostomy  more  secure  healing  of  the  sutured 
ulcer  is  likely  to  occur,  and  there  will  be  less  likelihood  of  the  stitches 
giving  way. 

(4)  It    diminishes    the    risk    of    haematemesis    occurring   after 
operation. 

(5)  It  enables  saline  aperients  to  be  given  shortly  after  operation, 
and  so  secures  more  efficient  drainage  of  the  peritoneal  cavity. 

(6)  It  permits  earlier  feeding  than  would  otherwise  be  the  case 
had  no  gastro-enterostomy  been  done. 

On  all  these  accounts,  therefore,  it  is  important  that,  where  the 
patient's  condition  will  permit  of  it,  the  question  of  a  gastro- 
enterostomy  should  be  considered  at  the  same  time  that  the 
perforated  gastric  ulcer  is  closed. 

Preventive  Treatment. — Although  the  symptoms  of  ulcer  may 
be  latent  in  about  20  per  cent,  of  cases  and  only  slight  in  others,  yet 
in  fully  50  pei-  cent,  or  probably  more  there  are  serious  symptoms 
of  ulcer  which  should  lead  to  very  thorough  medical  treatment,  or 
that  failing,  to  curative  surgical  treatment,  before  the  onset  of 
perforation.  So  that,  besides  advocating  early  operation  in  case  of 
perforation,  I  think  we  ought  to  urge  quite  as  strongly  preventive 
treatment,  in  other  words,  the  curative  treatment  of  ulcer,  so  as  to 
avoid  the  serious  sequelae  of  perforation  and  haemorrhage. 

A.  W.  MAYO-ROBSON. 


SURGICAL  TREATMENT  OF  ULCER  OF  THE 
DUODENUM. 

IF  duodenal  ulcer  could  be  diagnosed  early  and  with  certainty, 
the  importance  of  a  thorough  course  of  treatment  by  diet  and  rest 
might  be  the  means  of  bringing  about  a  cure  of  the  condition.  But 
the  facts  that  the  symptoms  are  often  comparatively  slight  or  even 
absent  in  a  certain  proportion  of  cases  at  the  inception  of  the 
disease,  and  that  it  is  frequently  difficult  to  say  at  first  that  the  case 
is  not  one  of  simple  gastro-duodenal  catarrh,  result  in  the  trouble 
being  seldom  treated  seriously  until  the  symptoms  have  persisted 
off  and  on  for  a  long  time,  sometimes  for  many  years,  or  until  some 
more  severe  attack  or  one  of  the  serious  complications  leads  to  a 
diagnosis  being  made.  Then,  perhaps,  the  patient  will  submit  to 
restraint  in  diet  and  to  a  course  of  medical  treatment,  which  is,  as 
a  rule,  left  off  as  soon  as  he  is  relieved,  to  be  resumed  again  in  a 
half-hearted  manner  at  each  recurrence  of  symptoms,  until  the  time 
comes  that  the  disease  can  no  longer  be  dallied  with  ;  and  if  com- 
plications do  not  prove  it,  the  patient  grasps  the  fact  that  he  is 
seriously  ill  and  must  have  true  remedial  treatment.  I  have  seen 
so  many  cases  that  have  been  treated  medically  off  and  on  for 
years,  and  which  ultimately  had  to  submit  to  surgical  treatment 
either  for  the  disease  or  for  complications  resulting  from  it,  before 
obtaining  real  relief,  that  I  sometimes  wonder  whether  a  patient 
with  chronic  duodenal  ulcer  is  ever  cured  by  medical  treatment 
alone. 

Lapeyre  says  that  very  few  completely  cicatrised  ulcers  have  been 
observed,  but  Perry  and  Shaw  found  evidence  of  repair,  more  or 
less  complete,  in  50  per  cent,  of  cases  coming  to  autopsy,  and  in 
several  the  cicatrix  had  produced  stricture  of  the  duodenum. 

Fortunately  surgical  treatment  offers  not  only  a  means  of  relief, 
but  of  cure,  in  this  otherwise  troublesome  and  dangerous  disease. 

Surgical  treatment  may  be  either  direct  or  indirect.  By  direct 
treatment  I  mean  excision  of  the  ulcer  or  an  infolding  of  the 
duodenal  wall  at  the  site  of  the  disease.  By  indirect  treatment 
I  mean  a  gastro-enterostomy  with  or  without  occlusion  of  the 
pylorus. 

Except  in  some  of  my  very  early  cases  in  which  a  duodenal  ulcer 
was  associated  with  ulceration  and  thickening  of  the  pylorus,  and  in 


392    Surgical  Treatment  of  Ulcer  of  the  Duodenum. 

which  I  excised  the  ulcerated  area,  or  while  performing  pyloroplasty 
took  the  opportunity  of  excising  the  ulcer,  I  have  not  attempted  the 
direct  treatment  of  duodenal  ulcer  ;  moreover,  in  these  cases, 
though  temporary  relief  was  given,  subsequent  operative  treatment 
was  required,  so  that  my  experience  does  not  lead  me  to  favour  in 
any  way  the  direct  treatment  of  this  condition. 

My  results  after  the  indirect  method  have  been  so  satisfactory, 
whether  looked  at  from  the  immediate  or  ultimate  issues,  that  I  can 
see  no  need  to  consider  the  direct  operation  further,  especially  as 
there  seems  to  be  no  evidence  to  prove  that  carcinoma  develops 
in  the  healed  scars  of  duodenal  ulcers,  since  cancer  of  the 
duodenum  is  very  uncommon,  while  ulcer  is  by  no  means  rare. 

My  experience  leads  me  to  express  a  very  decided  opinion  that 
the  operation  of  posterior  gastro-enterostomy  is  the  treatment  for 
duodenal  ulcer.  It  acts  by  diverting  the  food  from  the  ulcerated 
region  and  so  relieving  the  ulcer  from  the  irritating  effects  of  the 
acid  stomach  contents  ;  the  ulcer  is  thus  enabled  to  heal  smoothly, 
and  in  addition  the  associated  conditions  of  hyperchlorhydria, 
spasm  of  the  pylorus,  and  dilatation  of  the  stomach  are  relieved. 

The  relief  is  immediate,  and  within  a  very  short  time  the  patient 
can,  as  a  rule,  take  his  food  without  pain  or  discomfort,  and  without 
the  subsequent  flatulency  and  other  distressing  symptoms  usually 
associated  with  duodenal  ulcer. 

Not  only  are  the  immediate  results  good,  but  the  ultimate  issue 
is  very  satisfactory,  as  I  know  by  the  communications  I  have  had 
subsequently  from  my  patients  or  from  the  medical  men  with  whom 
I  have  been  associated  in  their  cases.  But  my  information  of  the 
after-progress  of  some  of  these  cases  has  been  even  more  direct, 
for  in  quite  a  number  of  cases  the  operations  have  been  on 
medical  or  other  professional  men  whom  I  have  had  the  oppor- 
tunity of  seeing  subsequently  and  knowing  in  their  ordinary  social 
life. 

The  method  I  always  adopt  in  performing  gastro-jejunostomy  is 
the  posterior  operation,  in  which  the  stomach  is  united  to  the  jejunum 
as  near  to  the  duodeno-jejunal  flexure  as  can  be  conveniently 
managed  ;  clamps  are  always  used  ;  the  opening  is  made  sufficiently 
large  (about  2  inches),  the  margins  of  the  opening  are  united  by  two 
continuous  sutures,  an  outer  of  Pagenstecher's  thread  taking  up  the 
serous  coats  a  little  way  from  the  margin,  an  inner  of  chromic  catgut 
taking  up  the  whole  thickness  of  the  cut  walls  of  the  stomach  and 
intestine. 

If  the  duodenum  is  free  from  adhesions  and  can  be  easily  handled 
there  is  an  advantage  in  infolding  the  ulcerated  area  and  occluding 


Surgical  Treatment  of  Ulcer  of  the  Duodenum.    393 

the  pylorus.  Frequently  this  is  impracticable  on  account  of  adhe- 
sions and  from  the  position  of  the  ulcer,  and  in  such  cases  gastro- 
enterostomy  alone  may  be  relied  on. 

Subsequent  to  operation  the  patient  is  always  placed  in  bed  well 
propped  up,  in  fact  almost  in  the  sitting  posture,  a  position  which  I 
have  found  by  long  experience  is  not  only  the  most  comfortable  to 
the  patient,  but  is  one  that  avoids  chest  complications.  It  assists 
thoracic  breathing,  takes  off  pressure  from  the  heart,  assists  drain- 
age from  the  stomach  into  the  jejunum,  as  a  rule  prevents  vomiting 
subsequently  to  operation,  and  by  giving  the  patient  a  sense  of  well- 
being  it  hastens  convalescence,  and  enables  him  to  be  moved  on  to 
the  sofa  within  a  fortnight  of  operation. 

In  peritonitis  from  ruptured  duodenal  ulcer  this  position  serves 
another  purpose,  that  of  draining  septic  fluids  from  the  diaphrag- 
matic area  towards  the  pelvis,  where  they  can  be  more  easily  drained 
away,  or  if  not  removed,  can  be  more  safely  disposed  of  by  the 
efforts  of  nature. 

During  operation  the  patient  is  enveloped  in  a  cotton-wool  suit 
made  by  the  nurse  of  gamgee  tissue,  thus  preventing  chilling  of 
the  extremities  and  avoiding  shock  ;  this  suit  is  of  use  subsequently 
by  keeping  the  patient  warm  when  propped  up  in  a  position  in 
which  it  is  difficult  to  keep  him  covered  by  the  bedclothes. 

I  think  the  value  of  this  care  to  avoid  chill  during  operation  is 
shown  by  the  almost  total  absence  of  chest  complications  in  my 
cases  as  compared  with  their  frequency  in  many  of  the  Continental 
clinics,  in  some  of  which,  to  my  knowledge,  the  patient  suffers  much 
exposure  before  and  even  during  operation. 

The  administration  of  saline  fluid  per  rectum  subsequent  to  opera- 
tion in  large  quantities  is  of  great  service  in  relieving  thirst  and  in 
supplying  fluid  to  keep  the  blood-vessels  full  until  the  patient  can 
take  sufficient  fluid  and  food  by  the  mouth.  Feeding  by  the  mouth 
is  begun  as  soon  as  the  nauseating  effect  of  the  anaesthetic  has 
passed  off,  so  that  by  the  evening  of  the  day  of  operation  the  patient 
is  taking  1  oz.  of  albumen  water  or  other  bland  fluid  every  hour, 
and  on  the  day  following  2  oz.  at  hourly  intervals. 

The  administration  of  food  at  frequent  intervals  is  advisable  for 
some  time  after  operation  in  order  to  absorb  and  neutralise  the 
irritating  acid  of  the  gastric  juice. 

For  some  time  only  soft  food  is  allowed,  such  as  fish,  mashed 
potatoes  and  gravy,  jellies,  pounded  meats,  etc.,  and  between  each 
meal  I  usually  advise  that  some  milk  and  lime-water  should  be 
given  to  take  up  the  excess  of  acid;  this  saves  discomfort  and 
prevents  harm  should  any  of  the  stomach  contents  pass  through 


394    Surgical  Treatment  of  Ulcer  of  the  Duodenum 

the  pylorus.  If  the  pulse  is  feeble  during  or  after  operation,  sub- 
cutaneous injections  of  solution  of  strychnine  in  5-min.  [U.S.?. 
strychnine  hydrochloride  gr.  ^V]  doses  are  useful,  and  if  needful 
they  are  repeated  every  four  or  six  hours  for  a  time. 

I  have  thus  far  spoken  of  gastro-enterostomy  as  an  operation  for 
the  relief  and  cure  of  uncomplicated  duodenal  ulcer,  but  the  same 
operation  is  the  one  indicated  in  many  of  its  complications,  such  as 
haemorrhage,  obstruction  from  adhesions,  or  from  contraction  of  the 
lumen  due  to  cicatrisation  of  ulcer,  and  for  dilatation  of  the 
stomach  secondary  to  ulcer.  It  may  also  be  called  for  as  a  primary 
or  secondary  procedure  in  perforation  of  duodenal  ulcer,  and  as  a 
secondary  measure  in  abscess  or  in  extensive  adhesions  following 
on  perforation. 

A.   W.  MAYO-ROBSON. 


395 


PERFORATING  ULCER  OF  THE  DUODENUM. 

IT  is  universally  accepted  that  early  operation  is  as  desirable  in 
case  of  perforation  of  a  duodenal  as  of  a  gastric  ulcer,  and  that  time 
has  more  to  do  with  success  or  failure  than  has  any  other  element, 
if  ordinary  skill  is  used.  If  the  extravasation  occurs  through  a 
small  leak,  the  peritoneal  soiling  will  be  localised  to  the  right  side 
of  the  abdomen,  and,  as,  at  first,  effusion  is  only  slightly  septic,  a 
vertical  incision  through  the  right  rectus,  about  1  inch  to  the  right 
of  the  mid-line,  which  will  enable  the  right  kidney  pouch  to  be 
cleansed  and  the  opening  in  the  duodenum  to  be  sutured,  is  only 
necessary.  Drainage  in  such  a  favourable  case  is  not  abso- 
lutely necessary,  though  personally  I  think  it  is  safer  to  drain. 
Irrigation  of  the  peritoneal  cavity  under  these  circumstances  is 
undesirable,  and  excision  of  the  ulcer  is  not  called  for.  The  edges 
of  the  perforation  should  be  turned  inwards,  and  a  Lembert  con- 
tinuous suture,  or  several  interrupted  peritoneal  sutures,  or  a 
purse-string  suture  according  to  the  size  of  the  opening,  must  be 
applied,  and,  if  possible,  an  adjoining  piece  of  omentum  should  be 
stitched  lightly  over  the  line  of  suture. 

If  the  perforation  is  a  large  one  and  the  abdomen  has  been 
flooded  with  the  stomach  and  duodenal  contents,  the  incision  over 
the  right  rectus  will  still  be  called  for  to  remedy  the  rupture ;  but, 
in  addition,  a  small  incision  should  be  made  over  the  pubes  just 
large  enough  to  admit  a  tube  that  will  reach  to  the  bottom  of 
Douglas's  pouch  in  the  female,  and  to  the  bottom  of  the  pouch 
between  the  rectum  and  bladder  in  the  male. 

Now  comes  the  question  of  irrigation  with  hot  saline  fluid. 
Man}-  surgeons  do  not  advise  it,  and  say  that  they  get  better  results 
without  it.  Murphy  is  very  emphatic  on  this  point.  I  must  confess 
that  I  have  only  seen  good  to  result  from  saline  irrigation  if  applied 
judiciously  in  such  cases,  for,  with  the  patient  in  the  half-sitting 
posture,  all  the  fluid  gravitates  to  the  pelvis  and  escapes  through 
the  tube,  bringing  with  it  any  foreign  matter  that  has  entered  the 
peritoneum.  The  viscera  should  not  be  handled,  and  any  rough 
swabbing  or  wiping  out  of  the  abdomen  should  on  no  account  be 
done. 

If  the  patient  is  in  fair  condition  at  the  time  of  operation,  and 
the  peritoneum  has  not  lost  its  polish,  the  prognosis  is  good. 


396        Perforating  Ulcer  of  the  Duodenum. 

If  the  endotheliurn  of  the  peritoneal  sac  has  been  damaged,  and 
the  intestines  are  distended  from  paralysis  of  the  muscular  coat,  the 
duodenal  opening  should  be  rapidly  repaired,  irrigation  with  hot 
normal  saline  solution  be  thoroughly  but  quickly  performed,  and 
free  pelvic  drainage  adopted. 

In  exceptional  cases  seen  late,  after  distension  has  supervened,  it 
may  be  advisable  to  bring  out  a  loop  of  distended  small  gut  and 
incise  it  transversely  so  as  to  get  rid  of  flatus  and  fluid  faces  in 
order  to  relieve  the  distension,  afterwards  suturing  and  returning  it ; 
and  while  the  patient  is  under  the  anesthetic  the  stomach  tube 
should  be  passed  and  gastric  lavage  effected. 

The  patient  must  afterwards  be  well  propped  up  in  bed  so  as  to 
favour  drainage,  and  must  have  saline  fluid  administered  by  the 
rectum  in  large  quantity  after  the  manner  recommended  by  Murphy. 

Although  the  prognosis  in  such  a  late  case  is  not  good  it  is  not 
hopeless ;  the  danger  will  have  been  due  to  the  delay  and  to  the 
absorption  of  toxins,  and  if  the  patient  can  be  kept  going  for  a  time 
until  the  poison  is  washed  out  of  the  blood  he  may  recover. 

In  case  of  perforation  leading  to  localised  suppuration  it  is 
important  not  to  delay  operation  lest  the  abscess  burst  secondarily 
into  the  peritoneum,  or  if  extending  upwards  burst  into  the  pleura 
or  pericardium. 

In  such  cases  the  abscess  must  be  opened  and  drained,  but  it  is 
neither  necessary  nor  wise  to  look  for  the  perforation,  which  is  often 
very  small  and  may  give  no  further  trouble  ;  moreover,  to  search 
for  a  perforation  under  such  conditions  would  involve  danger  of 
separating  adhesions  and  spreading  infection. 

The  question  of  performing  gastro-enterostomy  in  perforated 
duodenal  ulcer  is  important,  and  not  always  easy  to  decide.  In 
some  cases,  when  the  patient  is  seen  shortly  after  perforation  and 
is  in  good  condition,  a  gastro-enterostomy  will  lead  to  a  more  rapid 
repair  of  the  ulcer,  and  may  not  seriously  add  to  the  shock ;  but  as 
a  rule  the  added  shock  of  an  extended  operation  is  not  advisable, 
and  I  prefer  to  do  the  gastro-enterostomy  as  a  subsequent  operation 
if  necessary.  In  abscess  following  on  perforation  I  think  this  course 
ought  always  to  be  followed,  and  in  my  experience  this  has  proved 
satisfactory. 

Dr.  W.  J.  Mayo  in  speaking  of  the  subject  says :  "  In  three  out  of 
ten  cases  of  acute  perforation  we  made  a  gastro-jejunostomy  at  the 
same  time,  but  generally  speaking  it  is  safer  to  do  this  as  a  second 
operation  if  necessary."  Out  of  the  ten  cases  four  died. 

During  the  past  two  or  three  years  a  considerable  number  of 
cases  of  operation  for  perforated  duodenal  ulcers  have  been  recorded 


Perforating  Ulcer  of  the  Duodenum.        397 

by  individual  surgeons,  but  owing  to  the  limited  number  of  cases 
coming  under  the  notice  of  any  one  surgeon  a  statistical  estimate  is 
almost  useless  unless  a  considerable  number  of  cases  from  various 
sources  can  be  collected  and  analysed  together. 

Out  of  155  operations  for  acute  perforating  duodenal  ulcer  (of  which 
fifty-two  recovered  and  103  died,  a  mortality  of  66  per  cent.),  sixty -one 
were  operated  on  within  twenty-four  hours  of  rupture,  with  thirty- 
eight  recoveries  and  twenty-three  deaths  (a  mortality  of  37'7  per 
cent.),  whereas  of  sixty-three  cases  operated  on  later  than  twenty-four 
hours  after  rupture  there  were  eleven  recoveries  and  fifty-two  deaths, 
(a  mortality  of  82'5  per  cent.).  Of  the  remaining  thirty-one  cases, 
in  which  the  time  of  operation  was  not  stated,  but  in  which  the 
time  of  operation  was  probably  over  twenty-four  hours  after 
rupture,  three  recovered  and  twenty-eight  died  (a  mortality  of  90*3 
per  cent.). 

One  point  is  clearly  brought  out  on  analysis,  and  this  is  the 
fact  that  the  earlier  operation  is  performed  after  rupture  the  better 
the  result. 

A.  W.  MAYO-ROBSON. 


398 


SEA-SICKNESS. 

A  LIGHT  diet  should  be  taken  before  embarking.  Fresh  air  is  a 
powerful  element  in  the  prevention  of  the  nausea  and  vomiting, 
and  the  voyager  should  remain  on  deck  if  possible,  the  temperature 
of  the  body  being  maintained  by  wrapping  in  shawls  and  the  use 
of  a  hot  bottle  applied  to  the  feet.  The  face  may  be  bathed  with 
eau-de-Cologne  and  water,  and  the  vapour  of  ammonia  or  smelling 
salts  inhaled  through  the  nose.  An  effervescent  mixture  contain- 
ing an  alkali,  valerian  and  chloroform  water  finds  favour  with 
many  people,  and  may  be  given  every  two  hours,  while  others 
prefer  the  solution  of  bismuth  and  hydrocyanic  acid.  In  bad  cases, 
ice  should  be  sucked  at  intervals  and  iced  champagne  be  given  when 
symptoms  of  collapse  develop.  If  such  patients  are  tolerant  of 
opium,  15  min.  of  the  solution  of  morphine  [U.S.P.  gr.  -j^  of 
morphine  hydrochloride]  or  a  hypodermic  injection  will  some- 
times stop  the  incessant  retching.  Among  other  remedies, 
hydrochlorate  of  cocaine,  antifebrin,  nitro-glycerine  and  chloral, 
have  been  advocated.  Of  recent  years  chloretone  has  been  used 
with  great  success  and  appears  to  control  sea-sickness  in  about 
80  per  cent,  of  all  cases.  Ten  grains  enclosed  in  gelatine  capsules 
are  taken  when  the  traveller  goes  on  board,  and  are  repeated  at  the 
end  of  two  hours.  Should  nausea  ensue  at  any  time,  another  dose 
may  be  given.  The  general  dietary  to  be  observed  should  include 
soups,  broths,  toast,  fish,  chicken,  and  milk  puddings,  but  alcoholic 
liquors,  cheese,  pickles,  oily  sauces  and  greasy  meats  must  be 
avoided.  A  saline  purge  each  morning,  with  an  occasional  dose  of 
grey  powder  or  mercurial  pill  at  night,  is  invaluable. 

W.   SOLTAU    FENWICK. 


399 


TETANY    OF    THE   STOMACH. 

To  make  a  distinction  between  the  severe  and  fatal  form  of 
gastric  tetany  and  the  tetanoid  spasms  associated  with  gastric 
dilatation  is  purely  arbitrary,  and  it  seems  more  rational  to  include 
all  cases  of  tetany  and  tetanoid  spasms  dependent  on  stomach 
diseases  under  the  term  of  "  gastric  tetany." 

Moreover,  to  conclude  that  gastric  tetany  is  almost  necessarily 
fatal,  as  is  insisted  on  in  certain  medical  works,  is  to  my  mind  a 
great  mistake,  as  an  extensive  experience  of  the  disease,  both  of 
the  mild  and  severe  varieties,  has  convinced  me  that  under  efficient 
surgical  treatment  hardly  any  case  is  hopeless. 

The  treatment  of  gastric  tetany  is  essentially  surgical,  as  I  had 
the  privilege  of  first  pointing  out  in  a  paper  in  the  Lancet  on 
November  26th,  1898,  when  several  cases  were  given  as  examples  of 
successful  surgical  treatment.  Since  that  time  my  experience  has 
increased,  and  out  of  a  large  number  of  cases  in  which  I  have  operated 
I  can  state  definitely  that  in  no  single  case  has  drainage  of  the  stomach 
by  gastro-enterostomy  failed  to  give  relief.  Moreover,  at  the  same 
time  that  relief  to  the  tetany  is  secured,  a  cure  of  the  disease  producing 
it  is  accomplished,  as  in  almost  all  cases  there  is  a  grave  mechanical 
obstacle  to  the  onward  passage  of  the  food.  It  is  this  obstacle  which 
causes  dilatation  and  hypertrophy,  to  be  later  followed  by  stasis  and 
fermentation  of  the  contents  of  the  stomach.  To  relieve  this 
obstruction  and  to  do  away  with  the  stagnation  of  the  stomach 
contents  surgical  measures  are  necessary.  In  simple  cases  gastro- 
enterostomy  will  be  the  method  of  choice,  in  malignant  cases  a 
partial  gastrectomy  or  gastro-enterostomy  as  circumstances  dictate. 
In  hour-glass  stomach,  gastro-gastrostorny,  combined  with  gastro- 
enterostomy  performed  in  the  distal  pouch,  will  as  a  rule  be  the 
suitable  operation. 

A.    W.    MAYO-ROBSON. 


400 


BENIGN  TUMOURS  OF  THE  STOMACH. 

THOUGH  simple  tumours  of  the  stomach — adenoma,  lymph- 
adenoma,  lipoma,  lipo-myoma,  myoma,  nbro-inyoma,  and  cysts — 
are  rare,  they  are  clinically  important,  in  that  they  may  simulate 
cancer  or  sarcoma,  and  may  produce  pyloric  stenosis  or  may  assume 
importance  from  their  volume,  which  is  at  times  considerable. 

The  first  stage  of  any  operation  for  the  treatment  of  a  simple 
tumour  inside  the  stomach  will  be  exploratory  gastrotomy.  If  the 
tumour  is  attached  by  a  pedicle  it  must  be  divided  and  the  base 
ligatured.  If  the  attachment  is  sessile  it  will  be  advisable  to 
excise  that  portion  of  the  stomach  wall.  The  incision  must  be 
well  beyond  the  growth,  and  the  healthy  edges  of  the  gap  must  be 
brought  together  in  such  a  way  as  to  avoid  leaving  a  stenosis. 

If  the  growth  is  at  the  pylorus  it  may  be  necessary  to  perform 
pylorectomy,  then  to  close  the  open  ends  of  the  stomach  and 
duodenum  respectively,  afterwards  completing  the  operation  by  the 
performance  of  gastro-enterostomy. 

Pedunculated  tumours  of  large  size — usually  myomas  or  fibro- 
myomas — may  hang  as  pendulous  masses  from  the  stomach  and 
may  be  removed  by  simple  ligature  of  the  pedicle  without  opening 
the  stomach  cavity. 

Cysts  of  various  sizes  both  simple  and  multilocular  have  been 
found  in  the  gastric  wall;  they  may  be  treated  by  tapping  or 
drainage,  or  by  excision,  according  to  their  size  or  situation. 

A.  W.  MAYO-ROBSON. 


VOLVULUS  OF  THE   STOMACH. 

VOLVULUS  of  the  stomach  is  a  rare  condition  that  can  only  occur 
when  there  is  gastroptosis. 

The  treatment  consists  in  immediate  laparotomy  with  untwisting 
of  the  volvulus,  and  in  order  to  prevent  a  recurrence  of  the 
condition  the  performance  of  Beyear's  or  Eve's  operation  (see 
p.  824). 

A.    W.    MAYO-ROBSON. 


401 


DISEASES    AND    AFFECTIONS    OF   THE 
INTESTINES. 

APPENDICITIS. 

INDICATIONS   FOR   OPERATION. 

THE  treatment  of  appendicitis  is  entirely  a  surgical  problem, 
and  in  the  great  majority  of  cases  operation  is  the  only  rational 
procedure.  In  this  article  the  general  principles  of  treatment  will 
be  discussed,  but  individual  cases  vary  so  considerably  that  each 
must  be  carefully  judged  on  its  merits. 

Personally  I  believe  that  every  case  of  appendicitis  should  be 
treated  by  operation,  unless  there  is  some  strong  reason  to  the 
contrary ;  that  acute  cases  should  be  operated  upon  as  soon  as 
possible  after  the  diagnosis  has  been  made,  unless  the  symptoms 
are  obviously  subsiding ;  and  that  the  appendix  should  be  removed 
in  all  cases  in  which  there  is  evidence  of  past  or  of  chronic 
inflammation,  unless  there  is  some  condition  in  the  patient's  general 
health  which  contra-indicates  operation.  An  unbiassed  study  of 
available  statistics  will  show  that  expectant  treatment  is  associated 
with  a  higher  mortality  than  the  policy  of  immediate  operation, 
and  that  the  mortality  of  appendicitis  is  a  mortality  <>j '  <l<-lay.  A.  study 
of  the  work  in  any  large  hospital  where  cases  of  appendicitis  in  all 
stages  are  constantly  being  admitted  will  certainly  lead  to  the  same 
conclusions.  Nearly  all  of  the  patients  who  die  of  this  disease  might 
have  been  saved  if  operation  had  been  performed  earlier,  and  a 
large  proportion  of  them  have  had  previous  attacks  and  could  have 
had  their  appendices  removed  in  the  quiescent  interval  without 
incurring  any  risk. 

Indications  for  treatment  must  be  based  as  far  as  possible  upon 
ascertainable  facts,  and  the  following  series  of  cases  collected  by 
my  late  house  surgeon,  Mr.  Gilbert  Humphry,  illustrates  certain 
points  in  the  frequency  and  mortality  of  the  various  forms  of 
appendicitis.  It  must  be  remembered  that  appendicitis  as  seen  in 
hospital  practice  is  a  more  severe  -  disease  than  that  met  with 
amongst  better-class  patients,  for,  in  hospital,  mild  cases  seldom 
come  under  notice,  and  a  large  proportion  of  those  admitted  have 
already  been  ill  for  several  days. 

S.T. — VOL.  ii.  26 


402 


Appendicitis. 


One  thousand  Consecutive  Cases  admitted  into  the  Surgical  Wards 
of  St.  George's  Hospital  bettveen  1905  and  1910. 


1905  (November  and  December) 

1906 

1907 

1908 

1909 

1910 


28  cases 
167  „ 
158  „ 
213  „ 
206  „ 
228 


1  death 
15  deaths 
14 


Total 


1,000 


70 


Analysis  of  Cases. 


Mortality. 

Per  cent. 

Acute  without  Abscess       .... 

272 

10 

3-6 

Acute  with  Abscess  :  Appendix  removed  . 

209 

18 

8-6 

Acute  with  Abscess  :  Appendix  not  removed 

80 

11 

13  7 

Acute  with  General  Peritonitis 

35 

24 

65-6 

Sub-acute  ....... 

86 

0 

— 

Chronic  and  Quiescent       .... 

246 

1 

•4 

No  operation      ...... 

72 

6 

8-3 

1,000 

70 

The  difference  between  the  mortality  in  cases  of  abscess  in  which 
the  appendix  was  removed,  and  in  those  in  which  the  appendix  was 
not  removed,  is  mainly  explained  by  the  fact  that  the  latter  class 
included  a  larger  proportion  of  serious  cases.  Of  the  cases  not 
submitted  to  operation,  the  non-fatal  ones  were  practically  all 
sub-acute  or  quiescent  cases,  in  which  operation  was  not  considered 
necessary  or  was  refused :  in  the  fatal  cases  the  patients  were  too 
ill  for  operation,  and  all  but  one  of  them  died  shortly  after 
admission. 

In  discussing  the  indications  for  operation  in  detail,  it  is  most 
convenient  to  divide  the  cases  into  the  groups  in  which  they  are 
met  with  clinically. 

(1)  Acute  Cases  seen  within  Twenty-four  Hours  of  the  Onset 
of  Symptoms. — There  is  no  shadow  of  doubt  that  the  ideal  time 
for  operation  is  during  the  first  twenty-four  hours  of  the  attack, 
and  when  the  condition  is  diagnosed  during  this  period  and 
operation  can  be  arranged,  the  appendix  should  be  removed  at 
once.  This  advice  applies  especially  to  patients  under  twenty 
years  of  age. 

The  reasons  for  urging  operation  at  this  stage  are  the 
following : 


Appendicitis.  403 

(//)  It  is  the  safest  course  for  the  patient.  This  is  obviously  the 
strongest  argument.  All  statistics  show  that  the  mortality  of 
operation^  ]»'rf< inin'iJ  on  the  first  daii  in  eery  *>tt<i!/,  mnl  considerably 
less  titan  of  those  performed  at  any  later  time  during  the  attack :  at 
this  stage  the  inflammatory  mischief  will  have  involved  the 
peritoneum  but  very  little,  and  complications  will  not  have  occurred. 
In  the  St.  George's  Hospital  series,  twenty-eight  patients  were 
operated  upon  on  the  first  day  of  the  attack,  and  twenty-seven  of 
these  recovered. 

Prognosis  is  impossible  in  appendicitis :  even  those  who  have 
had  extensive  experience  cannot  tell  by  the  clinical  symptoms  what 
the  condition  of  the  appendix  is,  or  whether  the  attack  is  likely  to 
be  a  mild  or  severe  one.  At  the  onset  of  symptoms  there  may 
already  be  perforation  or  gangrene :  cases  which  are  apparently 
mild  may  at  any  moment  suddenly  develop  signs  of  widespread 
infection. 

(b)  A  comparatively  small  incision  is  adequate,  and  drainage  is 
often  unnecessary,  so  that  the  abdominal  wall  is  not  weakened. 

(c)  The  shortest  convalescence  follows  this  procedure,  and  the 
patient  is  spared  the  pain  and  discomforts  of  the  days  of  waiting 
and  the  long  illness  which  so  often  follows  a  late  operation. 

(d)  The  need  for  a  subsequent   operation   for   removal   of   the 
appendix,  for  ventral  hernia,  or  for  adhesions  and  their  results,  is 
obviated. 

Some  writers  point  out  that  it  is  seldom  possible  to  operate  as 
early  as  this  ;  but  as  the  importance  of  early  operation  is  recognised 
by  the  profession  and  the  public,  it  will  become  a  practicable 
proceeding  in  an  increasing  number  of  cases.  Most  cases  of 
perforated  gastric  ulcer  are  operated  upon  within  twenty-four  hours 
of  perforation,  and  there  is  no  reason  why  it  should  not  be  possible 
to  treat  appendicitis  in  the  same  way.  The  practitioner  should  be 
prepared  to  have  a  case  of  appendicitis  operated  upon  within  a  few 
hours  at  any  time  when  such  a  case  arises  in  his  practice,  and  a 
surgeon  should  have  his  arrangements  so  planned  that  no  delay 
occurs  when  he  is  summoned  to  such  a  case. 

(2)  Acute  Cases  seen  after  the  First  Twenty-four  Hours  of 
the  Attack. — Each  case  calls  for  the  most  careful  judgment.  In 
the  great  majority  of  cases  immediate  operation  is  indicated,  and 
operation  should  not  be  postponed  without  very  definite  reasons. 
The  medical  attendant  should  ask  himself  "  irhat  reasons  are  there 
to  justify  delay !  "  realising  that  to  countenance  delay  is  to  assume 
a  great  responsibility,  and  that  this  course  frequently  leads  to 
difficulties,  and  is  responsible  for  most  fatal  results.  As  stated 

26-2 


404  Appendicitis. 

above,  the  mortality  of  appendicitis  is  a  mortality  of  delay,  and 
those  who  advocate  expectant  treatment  will  inevitably  meet  with 
cases  in  which  they  will  regret  it.  A  critical  study  of  published 
statistics  shows  indisputably  that  the  risk  of  acute  appendicitis 
increases  with  each  day  of  delay. 

The  morbidity  of  the  disease  must  also  be  considered  ;  late 
operations  involve  prolonged  illnesses,  grave  complications,  and 
unnecessary  weakening  of  the  abdominal  wall.  Moreover,  when 
large  abscesses  are  allowed  to  form,  it  may  be  expedient  to 
drain  the  abscess  without  removing  the  appendix,  so  that  the  patient 
is  faced  with  the  risk  of  further  trouble  from  the  appendix,  or  the 
inconvenience  of  a  second  operation. 

Any  one  of  the  following  symptoms  is  a  definite  indication  for  imme- 
diate operation  :  Pain  which  is  severe  or  of  increasing  severity,  or 
which  is  spreading ;  pain  on  micturition  or  defaeeation  ;  a  rigor ; 
persistent  vomiting ;  any  increase  in  the  pulse-rate;  a  fall  of  tempera- 
ture unaccompanied  by  a  corresponding  fall  in  the  pulse-rate  ; 
distension. 

If  the  symptoms  are  obviously  subsiding  when  the  surgeon  first 
sees  the  patient,  delay  is  usually  justifiable  ;  but  these  cases  must  be 
watched  most  carefully,  and  unless  the  improvement  is  continuous 
and  rapid,  operation  is  the  wisest  course.  The  cases  which  are 
most  likely  to  mislead  are  those  in  which  a  temporary  improve- 
ment occurs  after  the  first  two  or  three  days  of  the  attack,  and 
is  followed  by  a  secondary  rise  of  temperature  denoting  abscess 
formation. 

(3)  Cases  in  which  the  Symptoms  and  Signs  point  to  the 
Presence  of  Abscess. — In  all  of  these  cases  I  feel  strongly  that 
operation  should  be  performed  at  once,  and  this  opinion  accords 
with  the  general  principle  that  any  abscess  should  be  opened  as  soon 
as  it  is  diagnosed. 

Some  recommend  delay  in  order  that  the  abscess  cavity  may 
become  more  firmly  shut  off  by  adhesions,  or  may  become  adherent 
to  the  abdominal  wall,  and  so  the  risk  of  infecting  the  general  peri- 
toneal cavity  by  earlier  operation  may  be  avoided.  This  risk,  how- 
ever, is  a  very  small  one,  if  the  general  cavity  is  carefully  protected 
with  gauze  packing,  and  if  the  abscess  cavity  is  properly  opened 
and  drained.  The  risk  is  decidedly  smaller  than  that  of  leaving  pus 
inside  the  abdomen ;  moreover,  experience  shows  that  the  longer 
an  abscess  has  lasted  the  greater  are  the  difficulties  and  dangers  in 
the  management  of  the  case,  removal  of  the  appendix  becomes 
more  difficult  each  day,  and  it  may  become  the  wisest  course  to 
leave  it. 


Appendicitis.  405 

If  an  appendix  abscess  is  allowed  to  remain  unopened,  the 
following  risks  are  incurred  :  (a)  Rupture  of  the  abscess  into  the 
general  peritoneal  cavity ;  (b)  steady  enlargement  of  the  abscess 
towards  the  pelvis — a  process  which  may  occur  without  causing 
external  signs,  and  which  considerably  adds  to  the  seriousness  of 
the  case ;  (c)  rupture  into  the  bladder ;  (d)  infective  thrombosis 
of  the  mesenteric,  iliac,  or  portal  veins  ;  (e)  portal  pyaemia,  liver 
abscess,  septicaemia ;  (/)  sudden  exacerbation  of  symptoms  with 
Spread  of  the  peritonitis,  in  which  case  hurried  operation  becomes 
necessary  under  far  less  favourable  conditions. 

(4)  "  Fulminating  "  Cases. — These  cases  are  marked  by  sudden 
onset,  very  acute  symptoms,  severe  pain  and  quick  pulse ;  they  are 
quickly  fatal  unless  they  are  operated  upon  at  once.     Such  cases, 
therefore,    obviously   demand   operation    at    the    earliest   possible 
moment,  provided  that  the  patient's  condition  allows  it.      Special 
attention  should  be  directed  to  the  fact  that  the  temperature  is  often 
normal  or  subnormal  in  these  cases. 

(5)  Cases    with   Symptoms    of  General    Peritonitis.  —  For 
practical   purposes,  the  only  hope  for    these    cases  is   immediate 
operation.      It  is  true  that  cases   of  apparent  general  peritonitis 
have  recovered  under  expectant  treatment,  or  have  improved  to  the 
point  that  signs  have  localised,  and  a  later  local  operation  has  been 
successful  ;  such    cases    are    rare,    and    should  not  influence  the 
surgeon  to  postpone  operation. 

(6)  Desperate   Cases. — When  the  surgeon  first  sees  the  patient 
his  condition  may  appear  almost  hopeless.     This  unfortunate  state 
of  affairs  is  met  with  most  often    in   children,  and   in  those  who 
have  been  treated  with  morphia  and  purgatives.     Every  effort  should 
be  made  to  produce  some  improvement  in  the  general  condition, 
so  that  rapid  opening  of  the  abdomen  may  be  possible.     A  large 
rectal  injection  of  saline  and    brandy  should  be   given,    and   the 
body  temperature  should  be  raised  by  hot-water  bottles  and  warm 
blankets.     The  condition  of  the  pulse  should  be  carefully  watched, 
and  if  improvement  occurs,  an  incision  is  made,  preferably  under 
local  anaesthesia,  through  the  lower  part  of  the  right  rectus  muscle, 
and  free  drainage  is  instituted.     Under  this  treatment  cases  will 
occasionally  be  saved  which  are  otherwise  quite  hopeless. 

(7)  Acute  Cases  in  Children. — It    should,  be   an    invariable 
rule  to  operate  as  soon  as  the  diagnosis  has  been  made. 

Acute  appendicitis  in  children  is  a  very  severe  disease,  with  a 
high  mortality  ;  the  large  amount  of  lymphoid  tissue  in  a  child's 
appendix,  the  poor  development  of  the  ornentuin,  and  the  lower 
resistance  to  infection,  are  factors  which  account  for  this  high 


406  Appendicitis. 

mortality.  The  condition  is  often  unrecognised  during  the  first 
three  or  four  days  of  the  attack,  and  complications  such  as  sub- 
phrenic  abscess  and  empyema  are  much  more  frequent  than  in 
adults. 

Statistics  show  very  clearly  that  the  mortality  is  small  when  cases 
are  operated  upon  during  the  first  twenty-four  hours  of  the  attack, 
and  that  it  rises  rapidly  with  each  day  of  delay. 

Cases  of  Appendicitis  in  Children,  ten  years  of  age  and  under, 

at  St.  George's  Hospital,  1904  to  1910. 
Total  number  of  cases  .         .         .88 

Males 61 

Females 27 

Youngest  patient    .         .         .         .         .14  months 

Acute  cases 79 

Deaths    .......     15 

Mortality  in  acute  cases         .         .         .19  per  cent. 

Two  cases  were  not  operated  upon,  one  being  moribund  when 
admitted. 

(8)  Appendicitis  in  Elderly  Patients. — Appendicitis  in  elderly 
patients  is  usually  insidious  in  onset,  and  the  clinical  symptoms 
are  relatively  mild  :  the  rise  in  temperature  may  be  quite  moderate. 
As  a  result,  operative  treatment  is  often  considerably  delayed,  and 
the  mortality  of  these  cases  is  high.     In  the  St.  George's  Hospital 
series  there  were  twenty-six  patients  over  fifty  years  of  age ;  twenty- 
two  of  the  cases  were  acute  and  seven  died,  a  mortality  of  31 '8  per 
cent. 

Operation,  therefore,  should  be  performed  as  early  as  possible, 
before  the  occurrence  of  complications,  unless  there  is  some 
co-existing  disease  which  strongly  centra-indicates  operation. 

(9)  Appendicitis  and  Pregnancy. — Appendicitis  during  preg- 
nancy involves  great  risk  to  the  mother,  and  frequently  causes 
abortion.     As  Kelly  says :  "  The  danger  involves  two  lives  and  the 
entire  happiness  of  a  family." 

Acute  cases  demand  immediate  operation,  for  the  mortality  is 
high,  and  increases  with  each  day  of  delay.  Cases  in  which  an 
abscess  has  formed  are  especially  serious,  for  abortion  usually  occurs, 
and  the  contraction  of  the  uterus,  which  often  forms  part  of  the 
abscess  wall,  causes  widespread  diffusion  of  the  infective  material. 
On  the  other  hand,  prompt  operation  usually  saves  the  patient  and 
leaves  the  pregnancy  undisturbed.  The  risk  of  miscarriage  is  small, 
if  care  is  taken  that  the  necessary  manipulations  are  as  gentle  as 


Appendicitis.  407 

possible,  that  the  uterus  is  not  touched  or  dragged  upon,  and  that 
drainage  tubes  and  gauze  do  not  pass  down  to  its  neighbourhood. 

Sub-acute  cases  may  usually  be  treated  expectantly :  the  inflam- 
mation generally  subsides  without  influencing  the  course  of  the 
pregnancy.  In  most  cases  it  is  wiser  to  remove  the  appendix  soon 
after  the  subsidence  of  a  sub-acute  attack,  rather  than  to  incur  the 
risk  of  a  more  severe  attack  during  the  later  months  of  pregnancy. 
If  appendicectomy  is  decided  upon,  the  best  time  for  its  performance 
is  between  the  fourth  and  seventh  months,  preferably  in  the  latter 
part  of  the  fourth  month.  If  operation  is  carefully  carried  out,  the 
risk  of  miscarriage  is  slight. 

A  patient  who  has  had  appendicitis  and  who  is  likely  to  become 
pregnant  should  most  certainly  be  advised  to  have  her  appendix 
removed  whilst  it  is  still  quiescent,  owing  to  the  grave  risk  which 
she  will  run  if  an  attack  should  occur  during  pregnancy.  On  the 
other  hand,  if  she  is  already  pregnant  when  advice  is  asked,  opera- 
tion is  not,  as  a  rule,  to  be  recommended,  unless  there  are  definite 
signs  that  the  trouble  is  not  quite  quiescent.  Such  a  patient  must 
be  kept  under  careful  observation,  and  should  be  instructed  to  send 
for  her  medical  attendant  at  once  if  she  should  feel  pain  in  the  right 
side  of  the  abdomen  (s<v  also  Medical  Diseases  in  Pregnancy, 
Vol.  IV.). 

(10)  Sub-acute  Cases. — Very  great  caution  is  needed  in  these 
cases.     There  are  undoubtedly  many  cases  of  appendicitis  which, 
though  definite,  are  so  mild  that  immediate  operation  is  obviously 
not  called  for ;  cases  in  which  the  temperature  does  not  reach  100°, 
and  the  pulse-rate  does  not  exceed  90,  and  in  which  the  physical 
signs  are  slight  and  localised.     Most  of  these  cases  may  be  treated 
expectant^,  but  they  require  very  careful  watching ;   if  decided 
improvement  has  not  occurred  within  forty-eight  hours,  operation 
should  be  performed  at  once. 

As  a  corollary  to  this,  all  cases  in  which  the  temperature  exceeds 
100°,  or  in  which  the  pulse-rate  reaches  100,  should  be  regarded  as 
acute. 

(11)  The  Quiescent  Appendix. — Patients  who  have  had  one 
definite  attack   of   appendicitis  should   be  advised   to  have  their 
appendix  removed,  unless  there  is  some  centra-indication  in  the 
general  condition.     It  is  now  known  that  recurrent  attacks  occur 
in  the  majority  of  cases,  and  any  one  of  these  attacks  may  be  fatal ; 
moreover,  it  is  indisputable  that  a  large  proportion  of  patients  who 
die  of  appendicitis  have  had  previous  attacks,  and  would  have  lived 
if  their  appendices  had  been  removed  in  the  quiescent  stage. 

Operation  in  the  quiescent  stage  is  very  safe.     Many  surgeons 


408  Appendicitis. 

are  able  to  record  long  series  of  cases  without  a  fatality.  At  St. 
George's  Hospital  between  the  years  1900  and  1910  over  500  cases 
of  sub-acute,  quiescent  and  chronic  appendicitis  were  operated  upon, 
and  there  was  only  one  death,  the  mortality  thus  being  less  than 
'2  per  cent.  The  operation  itself  is,  as  a  rule,  quite  simple  ;  a  com- 
paratively small  incision  is  usually  sufficient,  little  inconvenience 
follows,  a  weak  scar  is  exceedingly  rare,  and  the  period  of  convales- 
cence is  short. 

Any  healthy  patient,  therefore,  who  has  had  one  definite  attack 
should  be  strongly  recommended  to  have  his  appendix  removed  in  the 
quiescent  stage,  and  this  applies  particularly  to  those  who  are  going 
abroad  and  to  others  who  may  be  far  removed  from  surgical  aid. 

Children  who  have  had  appendix  trouble  should  always  be 
operated  upon ;  the  great  majority  of  them  will  otherwise  get 
further  attacks,  and  these  attacks  are  twice  as  dangerous  as  those 
in  adults.  Boys  with  doubtful  appendices  should  never  be  allowed 
to  return  to  boarding  schools  without  operation,  for  circumstances 
at  school  are  such  that  appendicitis  is  easily  mistaken  for  ordinary 
"  stomach-ache,"  and  there  have  been  many  instances  in  which  fatal 
delay  has  occurred  before  operation.  In  elderly  subjects,  and  in 
those  with  serious  visceral  disease,  it  is  usually  wise  to  leave  the 
appendix  in  the  hope  that  it  will  remain  quiescent. 

Date  of  Operation  when  the  Attack  has  been  Severe. — As  a  rule  at 
least  three  weeks  should  elapse  before  operation.  If  operation  is 
performed  earlier  it  may  be  found  that  the  inflammatory  trouble 
has  not  fully  subsided,  that  there  is  still  a  small  pocket  of  pus 
which  will  complicate  the  operation  of  removal :  it  is  probable  that 
virulent  organisms  lurk  in  the  neighbourhood  of  the  appendix  for 
many  days  after  an  acute  attack.  When  practicable,  therefore,  the 
patient  should  take  a  holiday  before  having  the  operation.  In  the 
meantime  he  should  attend  to  the  regular  action  of  the  bowels,  and 
especially  avoid  anything  in  his  diet  which  might  excite  intestinal 
disturbance. 

Should  the  Appendix  be  removed  after  Recovery  from  the  Operation 
of  Incision  and  Drainage  of  an  Appendicular  Abscess?  —  Reliable 
statistics  are  needed  as  to  the  subsequent  history  of  cases  in  which 
an  appendicular  abscess  has  been  treated  without  removal  of  the 
appendix.  Those  which  we  possess  at  present  are  contradictory. 
It  is  estimated  by  some  authorities  that  85  to  90  per  cent,  of  the 
cases  under  discussion  heal  satisfactorily  and  have  no  further  trouble, 
and  that  only  10  to  15  per  cent,  suffer  from  further  symptoms,  such 
is  a  persistent  sinus,  fsecal  fistula,  and  recurrent  attacks  of  inflam- 
matory trouble  in  the  appendix.  Within  the  last  few  years,  how- 


Appendicitis.  409 

ever,  evidence  has  been  accumulating  to  show  that  recurrent  troubles 
and  even  fatal  attacks  are  more  common  than  was  formerly  supposed. 
G.  H.  Makins,  in  Burghard's  "  System  of  Operative  Surgery,"  states 
that  in  iifty-nine  cases  of  localised  suppuration  fifty-two  recovered, 
and  that  of  those  in  which  the  future  course  has  been  able  to  be 
followed,  twenty-three  (or  39*9  per  cent.)  are  known  to  have  suffered 
from  recurrences,  and  in  seventeen  of  these  the  recurrence  was 
accompanied  by  suppuration.  Personally,  I  believe  that  in  most 
cases  the  surgeon  should  advise  subsequent  removal  of  the  appendix. 
This,  of  course,  is  the  only  plan  which  will  guarantee  the  patient 
against  further  trouble,  and  the  operation  involves  but  trifling  risk. 
Amongst  the  cases  of  this  nature  operated  upon  at  St.  George's 
Hospital  there  has  been  no  fatality. 

Each  case,  however,  must  be  considered  on  its  merits,  and  in 
making  a  decision  the  following  points  should  be  borne  in  mind : 

(a)  Suppuration  about  an  appendix  does  not  lead  to  its  destruc- 
tion ;    further  attacks  may  occur  and  may  terminate  fatally.     In 
most  cases,  however,  these  recurrent  attacks  are  less  severe  than 
first  attacks.     The  presence  of  adhesions  makes  the  process  more 
localised,  and  the  inflammation  is  less  intense  owing  to  the  thicken- 
ing of  the  appendix  and  of  the  surrounding  peritoneum. 

(b)  The  longer  the  abscess  had  lasted  before  it  was  opened  the 
less  the  risk  of  subsequent  attacks. 

(c)  Further  trouble  is  more  likely  in  those  under  twenty  years 
of  age  than  in  those  over  forty.     In  children  the  appendix  should 
always  be  removed  subsequently. 

(d)  It  is  clear  that  if,   after  the  opening  of  an  abscess,  satis- 
factory healing  does  not  occur,  the  appendix  should  be  removed ; 
sinuses,  persistent  pain,  or  induration  are  indications  for  opera- 
tion. 

(e)  The  appendix  may  have  come  away  as  a  slough  after  the 
opening  of  an  abscess. 

These  secondary  operations  are  usually  simple  if  a  sufficient 
interval  is  allowed  to  elapse  after  the  primary  operation ;  in  most 
cases  the  best  time  for  their  performance  is  about  two  months  after 
the  healing  of  the  abscess.  Complete  removal  of  the  appendix 
rarely  presents  any  special  difficulty,  except  in  retro-caecal  cases, 
and  the  opportunity  may  be  used  to  repair  the  damaged  abdominal 
wall. 

(12)  Chronic  Appendicitis  and  Appendix  Dyspepsia. — 
Chronic  appendicitis  is  undoubtedly  a  common  disease,  and  often 
exists  without  any  clinical  evidence  of  the  occurrence  of  an 
acute  attack. 


4io  Appendicitis. 

The  term  "  appendix  dyspepsia "  has  been  applied  to  the 
symptoms  which  occur  in  certain  cases  of  chronic  appendicitis. 
These  cases  fall  into  two  groups  :  (1)  Cases  in  which  chronic 
appendicitis  actually  causes  dyspepsia;  some  authorities  also 
believe  that  chronic  lesions  of  the  appendix  may  even  act  as 
infective  foci  and  originate  ulcers  of  the  stomach  and  duodenum  ; 
(2)  cases  in  which  the  symptoms  of  chronic  appendicitis  have  been 
attributed  to  dyspepsia,  their  real  nature  being  overlooked. 

The  most  important  aspect  of  these  cases  is  their  diagnosis,  and 
the  possibility  of  chronic  appendicitis  must  always  be  remembered 
when  investigating  disturbances  of  the  digestive  functions. 

The  only  treatment  is  appendicectomy,  and  it  may  be  again 
pointed  out  that  the  operative  mortality  in  this  group  of  cases  is 
practically  nil. 

(13)  Removal  during  Laparotomy  for  Conditions  other  than 
Appendicitis. — When  the  abdomen  is  opened  for  some  condition 
other   than   appendicitis,  and    it   is   found  that  the   appendix   is 
adherent,  thickened  or  in  any  way  abnormal,  it  should  be  removed, 
unless  the  circumstances  of  the  original  operation  contra-indicate 
this  proceeding.      It  is  now  recognised  that  chronic  appendicitis 
may  simulate  many  other  abdominal  diseases,  and  the  differential 
diagnosis  is  a  matter  of  great  difficulty.     In  doubtful  cases,  there- 
fore, the  appendix  should  always  be  examined,  and  this  applies 
particularly  to  operations  for  affections  of  the  stomach,  duodenum, 
gall-bladder  and  pelvic  organs. 

When  a  median  sub-umbilical  incision  has  been  made,  it  is 
usually  possible  by  good  retraction  of  the  wound  to  remove  the 
appendix ;  but  if  there  is  difficulty  owing  to  adhesions  or  to  the 
retro-csecal  position  of  the  appendix,  a  second  incision  should  be 
made. 

It  is  generally  agreed  that  if  a  normal  appendix  is  exposed  during 
the  course  of  a  laparatomy  for  some  other  condition,  it  is  not 
justifiable  to  remove  it  unless  the  patient  has  previously  expressed 
a  strong  wish  for  its  removal. 

(14)  The  Appendix  in  a  Hernial  Sac. — Acute  appendicitis  may 
occur  in  a  hernial  sac,  and,  as  a  rule,  is  the  result  of  strangulation 
of  the  appendix,  the  part  above  the  constriction  being  quite  healthy. 
Careful  judgment  is  required  in  these  cases,  for  the  inflammation  is 
limited  to  the  hernial  sac,  and  when  an  abscess  has  formed  it  is 
usually  advisable  to  be  content  with  its  drainage,  leaving  removal  of 
the  appendix  for  a  later  date. 

Whenever  the  appendix  is  found  during  the  course  of  a  radical 
operation  for  hernia  it  should  be  removed,  for  it  is  rarely  normal. 


Appendicitis.  411 

(15)  The    Appendix    and    Tuberculous  Peritonitis. — Appen- 
dicectomy  is  not  advisable  in  these  cases  unless  the  symptoms  of 
appendicitis  are  very  definite.     The  disease   in    the   appendix   is 
usually  secondary  to  the  more  extensive  trouble,  and  not  much 
good  can  be  expected  from  its  removal.     If  operation  is  performed, 
especial   care   is   needed   in  the   separation   of  adhesions   and   in 
covering  the  stump,  for  otherwise  fistulas  are  apt  to  develop. 

(16)  Appendicitis    and    Typhoid    Fever. — The    diagnosis    of 
appendicitis    as    a    complication    of    enteric    fever    is    obviously 
difficult.      If    the   symptoms   are    sudden    and   acute,   it   will   be 
impossible   to     eliminate   perforation   of    an    enteric    ulcer,    and 
operation    will    be    performed   if   the    patient's   condition   allows 
it.     In    other    cases   it   is   best    to    treat    the    case    expectantly, 
and  if  an  abscess  forms  to  deal  with  it  by  simple  incision   and 
drainage. 

(17)  Malignant  Disease  of  the  Appendix. — This  affection  is  not 
recognisable  clinically,  and  therefore  the  question  of  its  treatment 
is  of  little  importance.     There  are  two  groups  of  cases  :  (a)  Those 
in  which  the  disease  is  discovered  when  the  appendix  is  examined 
macroscopically  and  microscopically,  after  an  operation  for  appendi- 
citis :  the  prognosis  in  these  cases  is  usually  excellent ;  (6)  those  in 
which  there  is  a  palpable  tumour  for  which  the  abdomen  is  opened, 
and  which  is  usually  too  advanced  for  radical  operation.     The  point 
of  practical  importance  is  that  all  appendices  should  be  carefully 
examined  after  removal ;  otherwise  the  existence  of  a  malignant 
growth  will  often  be  overlooked. 

REMOVAL    OF    THE    APPENDIX    IN    THE     QUIESCENT    STAGE. 

Surgeons  vary  considerably  as  to  the  exact  details  of  the 
operation  for  removal  of  the  appendix.  The  methods  described 
below  are  simple  and  efficient. 

The  Incision. — Of  the  many  incisions  devised  for  this  operation 
two  are  in  common  use,  and  their  position  is  shown  in  Figs.  1 
and  2. 

(1)  McBurney's  Muscle -splitting  or  Gridiron  Incision. — An  oblique 
incision  is  made  which  crosses  the  line  between  the  anterior  superior 
spine  and  the  umbilicus  at  a  point  1^  inches  internal  to  the 
spinous  process,  corresponding  as  accurately  as  possible  in  direction 
to  the  fibres  of  the  external  oblique  aponeurosis.  These  fibres  are 
now  exposed  and  are  separated  throughout  the  length  of  the 
incision  ;  the  underlying  fibres  of  the  internal  oblique  and  trans- 
versalis  muscles  are  next  separated  with  a  blunt  dissector  and  are 
well  retracted.  A  quadrilateral  opening  results,  the  floor  of  which  is 


412 


Appendicitis. 


formed  by  the  trans  versalis  fascia  and  the  peritoneum  ;  these  struc- 
tures are  picked  up  with  a  pair  of  dissecting  forceps  and  are 
carefully  incised.  There  is  no  bleeding  except  from  small  vessels 
in  the  skin,  and  no  muscle  nerves  are  divided. 

(2)  Battle's  Incision  through  the  Outer  Part  of  the  Rectus  Sheath, 
with  Temporary  Displacement  of  the  Rectus  Muscle. — A  slightly 
oblique  incision  is  made  over  the  outer  part  of  the  right  rectus 
muscle,  midway  between  the  anterior  superior  spine  and  the 
umbilicus.  The  anterior  layer  of  the  sheath  is  divided  and  the 
underlying  fibres  of  the  muscle  are  freed  from  the  outer  margin  of 


FIG.  1. — Appendicectomy  :  muscle-splitting  incision. 

the  sheath  and  are  displaced  inwards ;  the  posterior  sheath  and  the 
peritoneum  are  then  divided  obliquely  to  avoid  injury  to  the  dorsal 
nerves.  Care  must  also  be  taken  to  avoid  haemorrhage  from  the 
deep  epigastric  vessels  and  their  branches,  for  such  haemorrhage  is 
apt  to  cause  annoying  delay.  The  outer  margin  of  the  wound  is 
well  retracted,  and  good  access  to  the  right  iliac  fossa  is  obtained. 

The  Choice  of  Incision  depends  on  the  circumstances  of  the  case. 
When  the  patient  is  comparatively  thin  and  the  diagnosis  is  clear, 
the  muscle-splitting  incision  is  best ;  if  there  is  any  doubt  as  to  the 
diagnosis,  and  especially  if  the  pelvic  organs  require  careful  exami- 
nation, Battle's  incision  is  to  be  preferred.  The  operator  should 
accustom  himself  to  the  use  of  either  incision. 


Appendicitis. 


413 


The  Length  of  the  Incixioii  must  vary  with  the  thickness  of  the 
abdominal  wall  and  the  ease  with  which  the  appendix  can  be 
brought  to  the  surface.  In  simple  cases  in  which  the  abdominal 
wall  is  thin,  it  is  usually  possible  to  perform  the  operation  through 
an  incision  1^  to  1|  inches  long.  As  a  rule,  the  primary  incision 
should  be  1^  to  2  inches  long,  and  may  be  enlarged  subsequently  if 
necessary.  In  general,  the  shorter  the  incision  the  better ;  but 
shortness  of  the  incision  should  never  so  increase  the  difficulty  as 


Fi<;.  L>. — Appendicectomy  :  incision  through  sheath  of  rectus: muscle. 

to  cause  any  increased  risk  to  the  patient,  or  to  involve  possibility 
of  overlooking  disease  of  surrounding  structures. 

As  soon  as  the  peritoneal  cavity  has  been  opened,  a  finger  is 
inserted  and  the  parts  are  explored.  The  operator  then  decides 
whether  he  can  remove  the  appendix  through  the  opening  made,  or 
whether  special  difficulties,  such  as  dense  adhesions,  necessitate 
enlargement  of  the  wound. 

Isolation  of  the  Appendix. — The  appendix  may  be  quite  easily 
found,  unfettered  by  adhesions  and  sometimes  at  once  presenting 
through  the  peritoneal  opening ;  on  the  other  hand,  its  isolation 
may  involve  the  hardest  task  that  can  be  set  to  a  surgeon,  and  this 
is  especially  liable  to  occur  when  there  has  been  an  abscess 
around  it. 

Usually  there  is  no  difficulty  in  detecting  the  appendix  with  the 


414  Appendicitis. 

finger.  If,  however,  it  cannot  be  felt  and  brought  up  to  the  wound, 
it  is  usually  best  to  pull  up  the  caecum,  for  its  anterior  longitudinal 
band  will  lead  to  the  base  of  the  appendix.  When  there  is  trouble 
in  finding  it,  it  is  usually  lying  behind  the  caecum,  or  is  buried  in  a 
mass  of  adhesions  close  to  the  bowel.  Soft  adhesions  may  be 
gently  broken  down  with  the  finger  or  with  a  pad  of  gauze  ;  strong 
fibrous  adhesions  require  careful  division  and  ligature. 

When  the  appendix  has  been  isolated,  it  should  be  carefully 
inspected.  Even  if  it  appears  normal  on  its  outer  aspect,  it  should 
be  removed,  for  it  not  infrequently  happens  that  there  is  ulceration 
or  a  stricture  in  its  interior  which  presents  no  external  sign  ;  but 
before  removal,  a  thorough  examination  must  be  made  of  the 
surrounding  structures. 

Removal  of  the  Appendix. — The  appendix  and  the  adjacent 


1cm.  across  flat 
Dart  of  blade 


FlG.  3. — Crushing  clamp. 

portion  of  the  caecum  are  brought  out  of  the  wound ;  the  opening 
through  the  wound  and  the  edges  of  the  wound  itself  are  packed  off 
with  gauze,  to  avoid  any  accidental  contamination  during  the 
removal  of  the  appendix,  and  the  operation  now  becomes  extra- 
abdominal. 

The  meso-appendix  is  tied  off  as  a  whole,  or  in  sections  according 
to  its  arrangement,  especial  care  being  taken  to  secure  the  vessels 
in  the  angle  between  the  appendix  and  caecum. 

The  proximal  end  of  the  appendix  is  then  crushed  with  a  special 
crushing  clamp  (Fig.  3),  or  with  stout  artery  forceps  ;  the  clamp  is 
left  on  for  twenty  to  thirty  seconds,  and  is  then  removed.  The  thin 
transparent  segment  which  results  is  shown  in  Fig.  4 ;  a  fine  silk 
ligature  is  applied  to  its  proximal  portion.  The  appendix  is  then 
removed,  a  pair  of  forceps  having  been  placed  just  beyond  the  point 
of  section  to  prevent  any  leakage  from  its  interior.  The  application 
of  pure  carbolic  acid  to  the  stump  is  quite  unnecessary. 


Appendicitis. 


415 


A  purse-string  suture  is  then  inserted  into  the  caecum  around  the 
stump,  which  is  seized  by  the  assistant  with  a  pair  of  dissecting 
forceps  and  inverted  into  the  caecum,  whilst  the  purse-string  suture 
is  tightened  and  tied  ;  the  appearance  of  the  parts  at  this  stage  is 
shown  in  Fig.  5.  The  cut  surface  of  the  mesentery  is  covered  in 
with  a  fine  silk  suture,  and  any  other  surfaces  denuded  of  peritoneum 
are  similarly  covered. 

Some  surgeons  have  suggested  that  inversion  of  the  stump  into 


FIG.   4. — Appendicectoiny  : 


base  of    appendix    crushed ; 
applied. 


purse-string  suture 


the  caecum  is  unnecessary,  simple  ligature  being  sufficient.  Cases, 
however,  have  occurred  in  which  this  proceeding  has  been  followed 
by  untoward  results,  such  as  adhesions,  intestinal  obstruction,  and 
slipping  of  the  ligature,  and  there  can  be  no  doubt  that  inversion  of 
the  stump  is  an  additional  safeguard. 

The  structures  in  the  neighbourhood  of  the  appendix  should 
always  be  examined,  for  co-existing  diseases  are  easily  overlooked. 
One  or  more  fingers  should  be  passed  to  the  pelvis,  to  ascertain  the 
condition  of  the  right  tube  and  ovary  and  of  the  uterus ;  a  finger 
is  passed  along  the  ureter  up  to  the  right  kidney,  which  is  examined 


416 


Appendicitis. 


especially  as  regards  its  mobility,  and  the  gall-bladder  is  palpated  if 
possible  for  the  presence  of  gall-stones.  Adhesions  of  omentum  or 
intestine  are  searched  for  ;  the  peritoneum  and  mesenteric  glands 
are  examined  for  tuberculosis,  especially  in  children. 

Closure  of  the  Wound. — When  the  muscle-splitting  incision 
has  been  used,  the  wound  is  closed  as  follows  :  The  peritoneum  is 
sutured  with  fine  catgut;  the  muscular  fibres  of  the  internal  oblique 
and  transversalis  are  allowed  to  fall  together,  and  are  kept  in  apposi- 
tion by  two  or  three  interrupted  catgut  sutures ;  the  external 


FIG.  5. — Appendicectomy  :  inversion  of  stump. 

oblique  aponeurosis  is  sutured  with  chromicised  catgut  or  with  two 
interrupted  fine  silk  sutures ;  and  the  skin  edges  are  united  by  a 
sub-cuticular  stitch  of  catgut,  or  by  interrupted  silkworm-gut 
sufcures. 

For  the  rectus  sheath  incision,  Mr.  Battle  recommends  closure  in 
the  following  way  :  The  posterior  layer  of  the  sheath  and  the  peri- 
toneum are  sutured  with  a  continuous  suture  of  silk  (00)  or  fine 
sterilised  catgut  in  the  case  of  females;  whilst  in  the  male,  owing  to 
the  more  fixed  character  of  the  peritoneum,  it  is  frequently  necessary 
to  use  silk  or  catgut  of  a  larger  size  and  interrupted  sutures.  The 


Appendicitis.  417 

rectus  is  then  permitted  to  fall  back  into  its  usual  position  ;  the 
anterior  layer  of  the  sheath  is  closed  with  three  to  six  interrupted 
silk  sutures,  and  the  skin  edges  and  the  superficial  wound  are  then 
united. 

Special  Difficulties. — (1)  When  the  distal  portion  of  the 
appendix  is  situated  deeply  or  is  hidden  in  adhesions,  it  is  some- 
times best  to  deal  with  the  caecal  end  first ;  the  appendix  is 
amputated  from  the  caecum,  and  the  distal  half  is  then  followed 
up  and  isolated.  This  plan  is  especially  useful  when  the  appendix 
lies  behind  the  caecum  in  a  mass  of  adhesions. 

(2)  If  the  appendix  is  buried  in  very  dense,  firm  adhesions  and 
lies  close  to  the  bowel,  its  separation  in  the  ordinary  way  may 
involve  grave  risk  of  tearing  the  bowel,  and  the  plan  recommended 
by  Dr.  Howard  Kelly  should  then  be  adopted.    An  incision  is  made 
through  the  peritoneal  and  on  to  the  muscular  coats  of  the  appendix ; 
the  entire  serosa  and  a  portion  of  the  circular  muscular  coat  are 
then  stripped  out ;  the  cavity  left  is  cleansed,  and  closed  with  a 
continuous  suture  of  fine  silk  or  catgut. 

(3)  If  the  appendix  is  adherent  to  or  is  wrapped  in  omentum,  it 
is  best  to  excise  it  with  the  attached  omentum,  for  separation  of 
the  omentum  may  unseal  a  perforation  or  open  a  small  encapsuled 
abscess. 

(4)  If  the  appendix  is  distended  with  fluid,  great  care  is  needed 
in  dealing  with  it,  for  the  fluid  may  be  infected.     Manipulations 
should  be  very  gentle  :  a  free  incision  and  a  good  light  are  essential. 

(5)  Thickening  about  the  base  of  the  appendix  and  the  adjacent 
part  of  the  caecum  may  make  it  difficult  to  deal  satisfactorily  with 
the  stump.     The  crushing  clamp,  if  used  in  these  cases,  is  liable  to 
cut   right   through   the  brittle  tissues,   and  the  sutures  used  in 
ordinary  cases  to  invaginate  the  stump  do  not  hold  well.     Under 
these   circumstances   the   circular-flap  method    of   amputation   is 
usually  best.     The  knife  is  carried  round  the  appendix  about  £  inch 
above   the  caecum,    and  a   cuff  composed  of  the  peritoneum  and 
the  superficial  muscular  layer  is  reflected ;  the  appendix  is  then 
ligatured  at  its  junction  with  the  caecum  and  is  removed  ;  the  cuff 
is  closed  over  the  stump  by  a  fine  silk  ligature. 

A  mistake  which  is  often  made  is  to  leave  a  stump  of  appendix 
J  to  f  inch  long ;  it  is  particularly  easy  to  do  this  in  the  method  of 
amputation  by  a  peritoneal  flap  or  collar.  This  stump  is  capable 
of  reproducing  all  the  symptoms  of  ordinary  appendicitis,  and  there 
have  been  several  cases  in  which  a  fatal  peritonitis  has  originated 
in  a  stump  of  this  nature  months  or  even  years  after  the  operation. 

The  after-treatment     of    these    cases    is    described    in    detail 

S.T.  — VOL.  II.  27 


418  Appendicitis. 

elsewhere.  The  bowels  are  opened  by  an  olive-oil  enema  on 
the  third  day,  and  a  purgative  is  given  on  the  fifth  day.  The 
wound  is  dressed  and  the  stitches  are  removed  on  the  sixth  or 
seventh  day  ;  the  patient  gets  up  between  the  tenth  and  fourteenth 
day,  according  to  the  size  of  the  incision  and  the  condition  of  the 
abdominal  wall.  No  belt  is  required. 

OPERATION   IN   ACUTE   CASES. 

Whilst  preparations  are  being  made  for  the  operation,  the  patient 
should  be  kept  as  quiet  as  possible.  The  skin  is  shaved  and 
prepared  in  the  usual  way,  or  the  iodine  method  of  preparation 
may  be  used.  A  catheter  is  passed  if  the  bladder  is  full  and  the 
patient  is  unable  to  empty  it.  Great  care  must  be  exercised  in  the 
removal  of  the  patient  to  the  operating  table,  for  much  harm  may 
be  done  by  want  of  gentleness. 

The  choice  of  incision  depends  upon  the  circumstances  of  the  case. 
In  early  cases  the  oblique  incision  is  usually  preferable,  as  it  is 
nearer  to  the  periphery  of  the  general  peritoneal  cavity,  and  gives 
better  access  to  the  appendix.  The  rectus  sheath  incision  is  better 
when  the  swelling  is  placed  towards  the  pelvis  or  is  nearer  than 
usual  to  the  middle  line,  when  there  is  any  doubt  as  to  whether  the 
appendix  or  the  right  tube  is  the  cause  of  the  trouble,  and  when  the 
peritonitis  is  diffuse. 

The  peritoneum  is  divided  carefully,  for  bowel  may  be  adherent 
to  it.  If  the  general  peritoneal  cavity  is  not  shut  off  by  adhesions, 
it  is  protected  by  systematically  packing  it  off  with  sterilised  gauze  ; 
a  long  strip  of  broad  ribbon  gauze  is  passed  first  towards  the  pelvis, 
then  towards  the  middle  line,  and  then  upwards  along  the  ascend- 
ing colon,  so  that  coils  of  small  intestine  are  kept  out  of  the  opera- 
tion area. 

The  parts  about  the  appendix  are  then  explored  with  the  finger, 
the  longitudinal  band  on  the  exposed  surface  of  the  caecum  serving 
as  a  guide  to  the  position  of  the  appendix.  The  utmost  gentleness 
is  necessary  in  order  to  avoid  the  sudden  opening  of  an  abscess  or 
the  rupture  of  a  tightly  distended  appendix ;  if  pus  is  present  it  is 
important  that  it  should  be  let  out  gradually,  the  best  plan  being  to 
control  its  flow  and  to  mop  it  away  with  a  series  of  swabs,  so  that 
the  amount  of  soiling  is  limited  as  far  as  possible.  Irrigation 
should  never  be  employed.  As  soon  as  the  pus  has  been  thoroughly 
mopped  up,  the  appendix  is  isolated ;  if  it  is  lying  behind  the  caecum, 
the  caecum  is  displaced  upwards  and  inwards,  and  adhesions  are 
gently  separated. 

The  meso-appendix  is  then  secured  with  one  or  more  pressure 


Appendicitis.  419 

forceps,  and  the  distal  portion  is  divided  so  that  the  appendix  is 
freed.  The  base  of  the  appendix  is  then  thoroughly  crushed  with  a 
stout  pair  of  artery  forceps  or  with  the  special  crushing  clamp,  and 
a  fine  ligature  is  applied  at  its  junction  with  the  caecum  ;  the 
appendix  is  then  amputated,  a  pair  of  forceps  having  been  placed 
just  beyond  the  point  of  section  to  prevent  any  escape  from  its 
interior.  The  stump  is  sterilised  by  the  application  of  liquefied 
carbolic  acid  on  a  probe,  and  is  sunk  into  the  caecum  by  a  purse- 
string  suture. 

The  details  of  the  operation  vary  considerably  in  different  cases. 
The  appendix  may  be  so  deeply  placed  and  its  condition  so  friable 
that  formal  amputation  is  out  of  the  question,  and  in  such  cases  the 
operator  may  have  to  be  content  with  securing  the  stump  with  a 
single  ligature  tied  firmly,  but  not  sufficiently  tightly  to  cut  through. 
Inflammatory  thickening  about  the  caecum  may  make  crushing  of 
the  base  of  the  appendix  undesirable,  and  in  such  cases  removal  by 
turning  back  a  cuff  of  peritoneum  and  muscular  fibres  is  usually 
the  best  plan.  When  the  appendix  runs  up  behind  the  ascending 
colon  and  cannot  be  brought  to  the  surface  easily,  the  most  satis- 
factory plan  is  to  amputate  it  from  the  caecum  before  enucleating  it 
from  the  retro-colic  tissues. 

Drainage  is  necessary  in  the  majority  of  cases  ;  it  may,  however, 
be  dispensed  with  in  many  of  the  cases  which  are  operated  upon 
within  the  first  thirty-six  hours  of  the  attack.  Drainage  is  effected 
by  the  insertion  of  one  or  more  tubes  :  a  tube  passes  directly  into 
the  iliac  fossa,  and  it  is  often  well  to  pass  a  second  tube  towards  or 
into  the  pelvis.  A  gauze  drain  is  placed  by  the  side  of  the  tube ; 
these  drains  should  be  of  ribbon  gauze,  so  that  removal  is  effected 
easily,  and  they  should  be  packed  in  lightly,  for  otherwise  they  prevent 
the  escape  of  discharge.  When  slight  drainage  only  is  required,  a 
strand  of  ribbon  gauze  may  be  placed  inside  a  split  drainage  tube, 
no  other  gauze  drainage  being  used. 

The  wound  is  then  sewn  up  with  through-and-through  sutures  of 
silkworm-gut. 

Full  details  of  the  after-treatment  will  be  found  elsewhere. 

Operation  in  Cases  in  which  Abscess  is  Present. — The 
incision  should  be  made  slightly  to  the  outer  side  of  the  most  pro- 
minent part  of  the  swelling.  The  abscess  may  be  adherent  to  the 
anterior  abdominal  wall ;  this  is  usually  indicated  by  the  inflam- 
matory infiltration  of  the  deeper  layers,  which  may  cause  some 
difficulty  in  the  recognition  of  the  peritoneum  :  a  blunt  dissector 
should  then  be  used,  and  the  opening  should  be  made  well  to  the 
outer  side  of  the  swelling. 

27—2 


42O  Appendicitis. 

Often,  however,  it  is  necessary  to  open  the  general  peritoneal 
cavity  before  the  abscess  is  reached  ;  if  this  is  so,  a  free  incision  is 
necessary  so  that  the  operator  has  a  good  view  of  the  parts,  and  it 
is  essential  that  the  general  peritoneal  cavity  should  be  systematic- 
ally packed  off  with  gauze  ;  if  this  is  properly  done  the  risk  of 
infecting  the  general  cavity  is  remote.  In  fact,  some  surgeons 
recommend  that  even  when  the  abscess  is  adherent  to  the  anterior 
abdominal  wall,  the  general  peritoneal  cavity  should  be  opened  and 
the  abscess  dealt  with  from  its  intra-peritoneal  aspect,  after  careful 
gauze  packing.  It  is  claimed  that  by  this  procedure  the  appendix  can 
be  removed  in  almost  all  cases  of  abscess,  without  additional  risk. 

If  the  abscess  is  large  and  tense,  great  care  must  be  exercised  in 
opening  it ;  any  undue  pressure  must  be  avoided,  for  it  may  cause 
rupture  internally.  Pus  should  be  let  out  gradually,  and  its  flow 
should  be  controlled  by  a  series  of  swabs,  which  mop  it  away  as  fast 
as  it  comes.  As  soon  as  the  main  bulk  of  pus  has  been  evacuated, 
the  abscess  cavity  is  thoroughly  opened  up  and  explored  with  the 
finger.  The  position  of  the  appendix  is  made  out  if  possible,  and 
any  loose  stercolith  is  removed.  Tracks  running  towards  the  pelvis 
should  be  looked  for,  and  if  there  is  a  collection  of  pus  in  the  pelvis 
it  should  be  made  to  drain  freely  into  the  main  cavity.  There  is 
sometimes  a  large  pelvic  abscess  communicating  with  the  cavity 
about  the  appendix  by  a  small  opening  which  is  easily  overlooked ; 
attention  is  usually  called  to  the  existence  of  this  pelvic  abscess,  either 
by  pelvic  examination  before  operation,  or  by  the  fact  that  as  the 
primary  abscess  cavity  is  emptied  more  pus  wells  into  it  from  below. 

Free  drainage  is  essential :  unsatisfactory  results  in  most  of  these 
cases  are  due  to  inefficient  drainage.  A  large  tube  should  be  used, 
and  gauze  drains  are  lightly  packed  in  by  its  side. 

Counter-drainage. — Drainage  through  the  loin  is  indicated  in 
some  cases  of  abscess  lying  to  the  outer  side  of  or  behind  the  colon, 
and  sometimes  it  is  justifiable  to  completely  close  the  anterior 
wound.  Lumbar  drainage  must  be  free  to  be  efficient.  A  large  tube 
should  be  inserted,  so  that  it  just  projects  into  the  abscess  cavity, 
and  especial  care  should  be  taken  to  see  that  the  tube  is  not  com- 
pressed or  kinked  by  the  lumbar  muscles ;  this  kinking  explains 
the  unsatisfactory  drainage  which  is  often  obtained  through  loin 
incisions. 

Large  pelvic  abscesses  resulting  from  appendicitis  may  be 
efficiently  drained  through  the  vagina  or  the  rectum.  A  drainage 
tube  may  be  used  for  a  vaginal  opening,  but  should  not  be  employed 
for  openings  in  the  rectum.  In  the  latter  case  the  opening  is  kept 
patent,  if  necessary,  by  the  occasional  passage  of  the  finger.  The 


Appendicitis.  421 

patient  is  well  propped  up  during  convalescence,  and  quick  healing 
usually  follows. 

Should  the  Appendix  be  Removed  when  an  Abscess  is 
Present  ? — Considerable  divergence  of  opinion  exists  at  the  present 
time  upon  this  point.  Some  advise  that  a  determined  attempt  should 
be  made  in  every  case  to  remove  the  appendix,  others  content  them- 
selves with  simple  drainage  in  the  bulk  of  cases,  and  others  open 
the  abscess  and  remove  the  appendix  a  few  days  later.  In  289 
cases  of  acute  appendicitis  with  abscess  admitted  into  St.  George's 
Hospital  between  1905  and  1910,  the  appendix  was  removed  at  the 
primary  operation  in  209  cases,  or  72  per  cent. ;  in  cases  in  which 
the  appendix  was  removed,  the  mortality  was  8'6  per  cent.,  and  in 
those  in  which  it  was  not  removed,  the  mortality  was  13*7  per  cent. ; 
but  it  has  been  pointed  out  that  the  latter  group  includes  a  larger 
proportion  of  serious  cases,  and  also  many  cases  in  which  a  pro- 
longed attempt  to  find  the  appendix  proved  unsuccessful. 

It  is  obvious  that  if  the  appendix  can  be  removed  at  the  time 
without  involving  additional  risk,  this  is  the  most  satisfactory 
course.  Convalescence  is  likely  to  be  shorter,  complications  are 
uncommon,  there  is  no  risk  of  further  trouble  from  the  appendix, 
and  the  patient  and  his  relatives  are  naturally  more  satisfied  than 
if  the  appendix  has  to  be  left  behind. 

It  must  be  remembered,  however,  that  the  object  of  the  operator 
must  be  to  secure  the  greatest  safety  for  the  patient,  and  there  are 
certain  cases  in  which  the  wisest  course  is  to  empty  and  drain  the 
abscess  cavity,  making  no  attempt  to  remove  the  appendix  at  the 
time.  This  course  should  be  usually  adopted  under  the  following 
circumstances : 

(1)  Large  abscesses. 

(2)  Abscesses  of  several  days'  standing. 

(8)  Cases  in  which  it  is  found  that  the  appendix  is  firmly 
embedded  in  inflammatory  tissues,  so  that  complete  removal  would 
be  a  matter  of  great  difficulty. 

(4)  Cases  in  which  the  appendix  points  inwards  and  upwards 
towards  the  general  peritoneal  cavity. 

(5)  Cases  in  which  the  operator's  experience  is  limited,  and  in 
which   the   surroundings   are    unfavourable   for    surgery,   as,   for 
instance,  when  operation  has  to  be  performed  in  a  small  farmhouse 
without  adequate  assistance. 

(6)  Cases  in  which  the  patient  is  too  ill  to  stand  a  prolonged 
operation. 

Attempts  to  remove  the  appendix  in  these  cases  usually  involve 
risk  of  spreading  infection,  and  of  setting  up  general  peritonitis. 


422  Appendicitis. 

Other  disadvantages  are  that  removal  of  the  appendix  is  often 
incomplete,  and  that  an  unduly  large  opening  through  the  abdominal 
wall  is  necessary.  On  the  other  hand,  there  is  no  doubt  that  when 
the  appendix  has  been  left  behind,  complications  such  as  pleurisy, 
empyema  and  secondary  abscesses  are  much  commoner  than  when 
the  appendix  has  been  removed. 

In  Cases  of  Diffuse  and  General  Peritonitis  a  free  incision 
should  be  made  through  the  outer  part  of  the  right  rectus  muscle, 
and  a  second  incision  in  the  hypogastrium  or  right  loin  may  be 
necessary.  Whenever  the  patient's  condition  allows  it,  the 
appendix  should  be  removed :  cleansing  should  be  effected  by 
swabbing,  and  not,  as  a  rule,  by  irrigation.  Eapid  operating  and 
the  institution  of  free  drainage  are  the  essential  points. 

Irrigation  is  occasionally  indicated  in  diffuse  peritonitis  of 
appendical  origin  ;  for  instance,  in  cases  in  which  there  are  large 
quantities  of  purulent  fluid  without  adhesions  of  intestines  and 
pocketing  of  pus,  a  condition  sometimes  found  in  young  subjects. 
Irrigation  should  then  concern  tbe  right  lower  quadrant  of  the 
abdomen  only,  and  attempts  should  never  be  made  to  wash  out 
the  whole  peritoneal  cavity.  Magnesium  sulphate  may  be  injected 
into  the  caecum  or  ileum,  when  intestinal  paresis  is  present  and  a 
prompt  action  of  the  bowels  is  desired.  An  ounce  of  a  1  in  2 
solution  of  the  salt  is  injected  into  the  bowels  with  a  large 
"  exploring "  syringe,  the  needle  of  which  is  passed  obliquely 
through  the  wall  of  the  bowel  to  prevent  leakage.  In  the  after- 
treatment  of  cases  of  diffused  or  general  peritonitis  the  most 
important  measure  is  the  continuous  infusion  of  saline  into  the 
rectum  (proctoclysis).  There  is  no  doubt  that  this  form  of  treat- 
ment has  saved  many  cases  of  extensive  peritonitis,  and  it  should 
be  employed  in  all  severe  cases  of  appendicitis.  (See  Treatment  of 
General  Peritonitis.) 

Intussusception  of  the  Appendix  must  be  dealt  with  according 
to  circumstances.  In  most  cases  an  incision  into  the  caecum  is 
necessary :  it  may  be  possible  to  reduce  the  invagination,  in 
which  case  the  wound  in  the  caecum  is  closed,  and  the  appendix  is 
removed  in  the  ordinary  way ;  in  some  cases  the  appendix  may  be 
excised  from  within  the  caecum,  and  in  a  few  cases  it  is  advisable  to 
resect  the  appendix  and  the  neighbouring  part  of  the  caecum  in  one 
mass. 

THE    NON-OPERATIVE    TREATMENT    OF    APPENDICITIS. 
This  section  will  deal  with  the  treatment  of  those  cases  in  which, 
for  one  reason  or  another,  immediate  operation  is  not  performed. 


Appendicitis.  423 

These  cases  are  :  (1)  Sub-acute  cases :  (2)  acute  cases  in  which 
the  inflammation  is  obviously  subsiding  when  first  seen  by  the 
surgeon :  (3)  cases  in  which  the  patient  refuses  operation : 
(4)  -cases  in  which  some  co-existing  disease  makes  it  desirable  to 
avoid  operation,  if  possible. 

The  Management  of  Sub-acute  Cases,  and  Acute  Cases  in 
which  the  Inflammation  is  Obviously  Subsiding. — It  has 
already  been  pointed  out  that  great  caution  must  be  exercised  in 
classing  a  case  as  sub-acute,  and  that  in  the  majority  of 
apparently  sub-acute  cases  the  safest  treatment  is  immediate 
operation. 

If,  however,  it  is  decided  that  the  symptoms  are  not  sufficiently 
acute  or  definite  to  demand  immediate  operation,  or  if  the  attack  is 
obviously  subsiding  when  the  patient  is  first  seen,  the  following 
treatment  should  be  adopted. 

The  patient  is  kept  in  bed,  and  is  not  allowed  to  leave  bed  for 
any  purpose  whatever.  The  services  of  a  nurse  should  be  obtained 
at  once.  Nothing  is  given  by  the  mouth  except  small  quantities 
of  plain  water  with  the  chill  taken  off  it,  or  albumen-water ; 
neither  milk  nor  any  more  solid  foods  are  allowed  until  recovery  is 
assured. 

The  bowels  are  cleared  by  small  injections  of  olive  oil  carefully 
given  ;  large  enemata  are  dangerous,  as  they  increase  the  disturb- 
ance about  the  appendix  ;  and  if  there  is  a  perforation,  some  of  the 
injected  fluid  may  find  its  way  through  it  into  the  peritoneal 
cavity. 

Purgatives  should  not  be  given  under  any  circumstances  until 
the  symptoms  have  completely  subsided.  Urgent  symptoms  in 
these  cases  frequently  date  from  a  few  hours  after  the  adminis- 
tration of  a  purgative,  especially  in  children.  The  active  peristalsis 
set  up  by  a  purgative  causes  the  rapid  passage  of  a  large  amount  of 
material  past  the  caecum  ;  it  hinders  the  formation  of  protective 
adhesions,  aggravates  the  local  inflammatory  conditions,  and  may 
actually  cause  an  ulcerated  area  to  become  perforated. 

Pain,  if  slight,  requires  no  special  treatment :  if  severe,  it  may 
be  relieved  by  the  administration  of  10  gr.  of  aspirin  or  phenacetin, 
and  by  hot  fomentations  or  an  ice-bag  locally.  An  ice-bag  has  the 
special  advantage  of  keeping  the  patient  absolutely  quiet.  Poultices 
should  not  be  applied,  as  they  make  the  skin  septic,  and  interfere 
with  the  local  examination,  which  has  to  be  made  frequently. 
Morphia  should  not  be  given  under  any  circumstances ;  the  pain  is 
rarely  severe  enough  to  call  for  its  use,  and  if  it  is  so,  immediate 
operation  is  usually  indicated. 


424  Appendicitis. 

The  Pulse-rate  and  Temperature  should  be  recorded  every  two 
hours,  unless  the  patient  is  sleeping :  the  pulse-rate  is  by  far  the 
more  important  observation,  and  the  surgeon  should  be  informed 
at  once  of  any  increase. 

The  Abdomen  should  be  regularly  examined,  especial  attention 
being  paid  to  the  movement  of  the  abdominal  wall  on  respiration, 
and  to  the  condition  of  the  muscles  overlying  the  appendix  area. 
As  the  tenderness  and  rigidity  in  the  iliac  fossa  disappear,  it  often 
happens  that  definite  thickening  about  the  appendix  becomes  pal- 
pable ;  this  observation  is  of  importance,  for  it  confirms  the 
diagnosis  and  gives  information  as  to  the  position  and  extent  of  the 
inflammation. 

In  these  sub- acute  cases,  immediate  operation  should  be  advised 
if  there  is  not  regular  and  steady  improvement  and  if  the  local 
signs  persist.  It  must  be  remembered  that  a  fall  of  the  tempera- 
ture is  not  a  favourable  sign,  unless  it  is  accompanied  by  a 
corresponding  fall  in  the  pulse-rate. 

The  patient  should  be  kept  in  bed  until  the  temperature  and 
pulse-rate  are  normal,  until  the  tongue  is  clean,  and  all  abnormal 
signs  in  the  right  iliac  fossa  have  disappeared. 

In  acute  cases  in  which  operation  is  refused  by  the  patient,  treat- 
ment should  be  conducted  on  similar  principles.  Symptomatic 
treatment  is  dealt  with  in  the  article  on  the  Treatment  of  Patients 
after  Abdominal  Operations,  p.  262. 

Prophylactic  Treatment. — The  only  satisfactory  prophylaxis 
against  recurrence  of  appendicitis  is  removal  of  the  appendix.  The 
question  of  prophylaxis  may,  however,  arise  in  the  case  of  those 
who  are  unwilling  to  undergo  operation,  or  in  whom  operation  is 
inadvisable.  The  medical  man  may  also  be  consulted  by  persons 
in  whose  family  several  cases  of  appendicitis  have  occurred,  and 
who  fear  that  they  themselves  may  be  affected  by  the  disease. 

Comparatively  little  is  known  of  the  determining  causes  of 
appendicitis.  It  is  generally  admitted,  however,  that  attacks  of  the 
disease  are  frequently  preceded  by  digestive  disorders,  such  as 
constipation,  acute  attacks  of  indigestion  and  diarrhoea.  It  is 
obviously  important,  therefore,  to  regulate  the  functions  of  the 
alimentary  canal.  Especial  attention  should  be  devoted  to  the 
teeth.  Dyspepsia,  if  present,  should  be  treated  and  general  directions 
should  be  given  as  to  diet,  although  special  dieting  should  be 
avoided  unless  there  is  some  definite  reason  for  it :  the  import- 
ance of  regular  daily  action  of  the  bowels  should  be  emphasised. 

Injury  and  certain  forms  of  exercise,  such  as  bicycling,  are  said 
by  some  authors  to  be  responsible  for  a  certain  number  of  cases  of 


Appendicitis.  425 

appendicitis.  Mr.  Battle  and  Mr.  Corner  state  that  of  the  various 
forms  of  exercise,  motor-bicycling  seems  especially  liable  to 
originate  an  attack  in  persons  who  have  latent  appendicitis. 

Those  who  fear  appendicitis,  and  yet  present  no  evidence  of  past 
or  present  inflammation  of  the  appendix,  should  be  firmly  reassured, 
for  it  is  of  great  importance  to  their  general  welfare  that  they 
should  not  be  allowed  to  become  introspective  as  regards  this 
subject. 

T.  CRISP  ENGLISH. 


426 


CCELIAC  DISEASE. 

IT  is  to  Professor  Herter l  that  the  recognition  of  coeliac  disease 
as  one  of  the  important  wasting  diseases  of  childhood  is  largely 
due,  though  it  was  originally  described  by  Gee2  so  long  ago  as  1888. 
Herter  considers  that  the  disease  is  produced  by  the  development 
in  the  intestine  of  an  abnormal  bacillary  growth,  and  he  finds  that 
the  predominant  organisms  are  gram-positive  instead  of  gram- 
negative,  as  is  ordinarily  the  case.  Coeliac  disease  has  been 
defined  by  Hutchison 3  as  "  a  chronic  wasting  disease  of  childhood 
characterised  by  chronic  diarrhoea  with  large  pale  and  offensive 
stools,  running  a  prolonged  course  with  a  great  tendency  to  relapses, 
exhibiting  often  certain  nervous  complications,  such  as  weakness 
of  the  legs  and  tetany,  and  ending  either  in  death  or  in  complete 
recovery,  or  in  partial  recovery  with  great  impairment  of  growth 
and  development  (infantilism)." 

The  symptoms  usually  manifest  themselves  in  the  second  or 
third  year  of  life. 

In  the  treatment  of  coeliac  disease  the  diet  must  be  so  arranged 
as  to  meet  as  far  as  possible  the  inability  of  the  patient  to  digest 
fats  and  starches.  For  this  purpose  the  most  important  article 
of  diet  is  raw  meat  juice  or  raw  minced  meat,  of  which  8  to  14  oz. 
should  be  given  daily  according  to  the  age  of  the  child.  To  this 
may  be  added  whey,  skimmed  milk,  and  rusks  or  malted  bread. 
If  there  is  definite  improvement  the  scope  of  the  diet  may  be 
increased  in  from  four  to  six  weeks,  such  articles  as  Benger's 
f ood,  Horlick's  malted  milk  and  boiled  rice  being  gradually  added. 

Drugs  are  of  but  little  service  in  the  majority  of  cases.  If 
the  diarrhoea  is  excessive  astringents  may  be  employed,  such  as 
bismuth  salicylate  (10  gr.  thrice  daily),  or  silver  nitrate  (^  gr.  in 
piU  form) ;  but  opium  is  often  more  efficacious  for  this  purpose 
(Tr.  opii  2  min.  three  times  a  day  for  a  child  of  two  years). 

It  is  possible  that  sometimes  there  may  be  some  impairment  of 
the  pancreatic  function,  and,  in  cases  where  the  stools  contain 
very  much  unaltered  fat,  Hutchison  advises  the  use  of  pancreatic 
preparations,  such  as  pancreon  sugar  tablets  or  holadin,  after 
each  meal. 

Particular  attention  must  be  directed  to  the  avoidance  of  chill 
and  cold,  and  it  must  be  remembered  that  these  children  are 


Cceliac  Disease.  427 

especially  liable  to  suffer  from  cold  extremities,  a  condition  which 
must  be  corrected  by  suitable  clothing. 


JAMES  TORRENS. 


EEFERENCES. 


1  Herter,  C.  A.,  "  On  Infantilism  from  Chronic  Intestinal  Infection,"  New 
York,  1908. 

2  Gee,  S.  J.,  St.  Bartholomew's  Hospital  Reports,  1888,  XXIV.,  p.  17. 

8  Hutchison,     E.,    "  Cooliac     Disease,"     Practitioner,     1911,     LXXXVII., 
pp.  147 — 152. 


COLIC   IN   CHILDREN. 

COLIC  is  a  frequent  and  troublesome  symptom  in  infants,  more 
especially  during  the  earliest  months  of  life.  The  accompanying 
pain  is  manifested  by  screaming,  restlessness,  sleeplessness,  an 
anxious  expression  of  the  face,  and  the  drawing  up  of  the  lower 
limbs.  In  predisposed  subjects  colic  may  even  induce  convulsions. 
The  part  of  the  bowel  affected  is  usually  the  colon,  but  any  part  of 
the  intestine  may  be  the  seat  of  disturbance  and  pain.  The  local 
changes  associated  with  colic  are  two  in  number  :  (1)  paresis  or 
paralysis  of  a  portion  of  the  bowel  from  over-distension  or  obstruc- 
tion, and  (2)  irregular  and  severe  muscular  contractions  in  the 
bowel  immediately  above.  The  temporary  weakening  of  the  bowel 
wall  is  usually  due  to  over-distension  from  flatulence,  or  from 
irritation  of  the  bowel  contents,  or  from  an  accumulation  in  the 
bowel. 

There  are  various  forms  of  colic  which  must  be  differentiated. 
The  most  common  type  is  that  associated  with  intestinal  dis- 
turbance from  some  dietetic  error.  Another  variety  is  associated 
with  definite  intestinal  obstruction,  e.g.,  from  intussusception  or 
strangulated  hernia.  In  a  third  class  of  case  there  is  no  real  colic, 
but  the  pain  experienced  is  produced  in  some  organ  other  than  the 
bowel,  e.g.,  renal  colic. 

An  acute  attack  of  colic  in  an  infant  calls  for  immediate  relief 
of  the  urgent  symptoms,  and  this  must  be  followed  by  a  careful 
inquiry  into  the  dietetic  and  other  habits,  so  as  to  ascertain  and 
remove  the  cause  of  the  trouble.  The  abdomen  is  usually  distended 
and  hard  from  the  presence  of  much  flatus  in  the  bowel  and  rigidity 
of  the  abdominal  muscles.  At  times,  if  the  abdominal  wall  relaxes, 
it  is  possible  to  feel  the  bowel  wall  standing  out  firmly  in  parts  as 
strong  muscular  contractions  take  place.  It  is  our  aim  under  such 
conditions  to  dispel  the  flatus  and  check  the  excessive  peristalsis. 
With  this  object  an  enema  of  from  10  to  15  oz.  of  hot  water 
should  be  slowly  administered.  The  warmth  tends  to  allay 
the  spasm,  and  a  considerable  amount  of  flatus  will  often  be  passed, 
giving  great  relief.  If  the  bowels  have  not  acted  for  some  time, 
soap  may  be  added  to  the  enema,  so  as  to  produce  an  evacuation 
more  certainly  than  plain  water  will.  The  application  of  fomenta- 
tions to  the  abdomen  will  also  tend  to  check  spasm.  Flannel 


Colic   in    Children.  429 

cloths,  wrung  out  of  boiling  water,  should  be  applied  as  hot  as  they 
can  be  borne  over  the  whole  surface  of  the  abdomen,  back  and 
front,  and  changed  every  quarter  of  an  hour,  until  the  skin  is 
thoroughly  reddened.  In  addition  it  will  be  advisable  to  stop  all 
feeding  for  from  three  to  six  hours  so  as  to  give  the  bowel  a  much- 
needed  rest,  and  to  give  a  dose  of  castor  oil  (1  to  2  drachms)  to 
clear  out  any  irritating  material  that  may  remain.  A  carminative 
mixture  may  be  ordered,  such  as  the  following :  fy  Tincturae 
Belladonnas,  r\\  2 ;  Spiritus  Ammonias  Aromatici,  w[  2  ;  Sodii  Bicar- 
bonatis,  gr.  5  ;  Aquam  Cinnamomi,  ad  5].  Sig. :  One  drachm  every 
six  hours  (for  an  infant  of  six  months).  If  the  pain  is  not  speedily 
relieved,  a  more  powerful  carminative  may  be  added,  such  as  \  drop 
of  laudanum  or  5  drops  of  paregoric. 

The  next  stage  in  the  treatment  is  to  find  out  the  cause  of  the 
colic.      It  will  often  be  found  that  previous  to  the  acute  attack 
there  had  been  numerous  mild  attacks,  which  had  been  treated  in 
the   domestic   circle.     The   diagnosis   had   been  "wind,"  and  the 
treatment  dill-water.     When  the  baby  cried  it  was  thought  to  be 
hungry,  and  more  food  had  been  given.     The  first  points  to  be 
attended  to  are  regularity  in  the  meals   and   a   sufficiently  long 
interval  between  feeds.     The  amount  of  food  must  also  be  inquired 
into.     It  is  not  uncommon  to  find  that  infants  of  three  months  old 
are  taking  from  25  to  30  oz.    of  cows'   milk   in   the   twenty-four 
hours.     This  can  be  indulged  in  for  a  time,  but  sooner  or  later 
a  breakdown  in  the  intestinal  functions  occurs,  and  colic  is  the 
result.     Gulping  down  the  food  rapidly  and  swallowing  air  at  the 
same  time  are  other  conditions  which  may  require  correction.     The 
careless  feeding  with  long-tube  bottles,  when  the  infant  often  gets 
nothing  but  air  to  draw,  is  a  specially  common  cause  of  colic  in 
infants.     In  bottle-fed  babies  the  protein  element,  from  its  indi- 
gestible nature,  is  apt  to  cause  fermentation,  flatulence  and  colic. 
This   must   be   remedied  by  dilution  of  the  milk,  and  by  adding 
citrate    of    soda  /(I  gr.    for    each  1    oz.    of    milk)    to  the    feeds. 
Milk  which  has  become  soured  from  contamination  is  a  frequent 
cause  of  flatulence  and  colic  in  infants.     Another  possible  cause  of 
similar  disturbances  is  the  addition  of  excessive  amounts  of  sugar 
(usually  cane  sugar)  to  the  milk.     In  the  present  day  the  abuse  of 
starchy  food,  which  is  given  to  an  extent  quite  beyond  the  require- 
ments or  even  the  digestive  powers  of   an  infant,  is   frequently 
manifested  by  colic.     From  the  earliest  months  prepared  barley,  or 
the  whole  barley  boiled  down  in  water  to  a  jelly,  is  often  added  to 
the  milk,  or  large  quantities  of  some  patent  (starchy)  food    are 
given.     Barley- water,  if  properly  prepared,  is  a  bland  and  innocuous 


430  Colic    in    Children. 

fluid  containing  about  1  per  cent,  of  starch.  The  infantile  stomach 
does  not  tolerate  comfortably  any  but  the  smallest  quantities  of 
starch,  and  even  when  converted,  as  in  many  patent  foods,  the 
starchy  element  must  be  strictly  limited  in  amount  during  the  first 
nine  months.  It  is  scarcely  necessary  to  add  that  gross  errors  in 
infant  feeding,  such  as  the  giving  of  sausages,  potatoes,  stew,  or  "  a 
bit  of  what  is  going,"  are  very  frequently  followed  by  severe  colic. 
The  correction  of  a  faulty  diet  will  be  found  the  most  effective 
factor  in  the  prevention  and  cure  of  colicky  attacks. 

Many  infants  are  liable  to  colic  through  exposure  to  cold  and 
chilling  of  some  part  of  the  body,  such  as  the  feet,  or  the  thighs,  or 
the  abdomen.  Warm  socks  and  a  hot  bottle  when  necessary  should 
always  be  available.  The  abdomen  should  be  well  protected  from 
cold  by  flannel.  Not  infrequently  one  finds  that  while  the  rest  of 
the  body  is  well  covered  the  knees  and  thighs  are  much  less  so,  and 
are  in  consequence  often  distinctly  chilled.  All  these  forms  of 
surface  chilling  are  apt  to  induce  attacks  of  colic. 

A  physical  examination  of  the  abdomen  may  reveal  the  presence 
of  a  faecal  accumulation  in  the  colon.  This  must  be  treated  by 
enemata  of  soap  and  water,  castor  oil,  etc.  A  condition  of  chronic 
constipation  may  be  present,  leading  to  irregular  contractions  of  the 
bowel  wall,  and  must  be  corrected  (see  Constipation  in  Children, 
p.  432).  If  a  persistent  distension  of  the  bowel  wall  is  present,  a 
condition  of  atonic  dilatation,  it  is  advisable  to  employ  abdominal 
massage  once  or  twice  daily,  which  will  not  only  dispel  the  flatus 
but  will  tone  up  the  bowel  wall. 

The  pain  of  colic  may  be  due  to  a  serious  lesion  as  well  as  to  a 
passing  disturbance.  In  young  infants  intussusception  is  usually 
accompanied  at  the  onset  by  severe  pain  and  screaming,  which 
are  very  similar  to  the  conditions  present  in  simple  colic.  No 
case  should  be  lightly  passed  over  without  an  examination  for 
any  signs  of  intussusception,  •  hernia,  tuberculous  peritonitis,  or 
other  forms  of  obstruction.  A  special  form  of  colic  is  associated 
with  Henoch's  purpura,  in  which  haemorrhage  takes  place  into 
the  bowel  wall,  producing  temporary  paralysis  and  spasm  of  the 
adjoining  part  of  the  intestine.  In  cases  of  angio-neurotic  oedema 
similar  symptoms  are  produced  by  serous  effusion  into  the  bowel 
wall.  With  a  little  care  such  conditions  can  be  distinguished  from 
simple  colic,  and,  of  course,  call  for  very  different  treatment. 

The  third  class  of  case  to  which  reference  has  been  made  is  that 
in  which  colicky  pains  are  produced  in  some  other  organ  than  the 
bowel,  but  may  be  referred  to  the  intestinal  region.  We  may 
find,  even  in  the  youngest  infants,  severe  colic -like  pains,  usually 


Colic   in    Children.  431 

referred  to  the  umbilical  region,  which  are  due  to  the  irritation 
of  the  urinary  passages  by  crystals  of  uric  acid  or  oxalate  of 
lime.  The  seat  of  irritation  is  usually  in  the  kidney,  and  an 
examination  of  the  urine  will  demonstrate  the  cause.  In  older 
children  a  renal  calculus  may  be  present.  Any  form  of  acute 
peritonitis  may  be  characterised  at  the  onset  by  severe  pains,  not 
unlike  colic. 

In  the  case  of  older  children  the  food  factor  is  all-important 
in  the  production  of  colic.  •  The  young  schoolboy  is  apt  to  let 
himself  go  at  times  in  the  matter  of  diet ;  he  often  covets  the 
forbidden  fruit,  and  a  hasty,  surreptitious  and  sumptuous  feast  ma}7 
be  followed  by  a  severe  attack  of  colic.  -Vomiting  may,  of  course, 
anticipate  this  result,  but  if  the  pylorus  does  not  prevent  the 
passage  of  the  food  downwards,  the  bowel  will  probably  resent  the 
presence  of  an  undigested  meal,  and  pain  of  a  colicky  nature 
will  follow.  We  cannot  improve  on  the  old-fashioned  treatment 
by  means  of  a  good  dose  (^  oz.)  of  castor  oil,  of  which  the 
physical  and  moral  benefits  are  undoubted.  This  is  to  be  followed 
by  a  few  days  of  low  feeding,  of  plenty  of  plain  water  to  drink,  and 
if  necessary  for  the  pain,  5-drop  doses  of  chlorodyne  or  laudanum 
[U.S.P.  iri3]  two  or  three  times  a  day. 

G.  A.  SUTHERLAND. 


432 


CONSTIPATION    IN    CHILDREN. 

IN  order  to  secure  the  proper  evacuation  of  the  bowels 
a  certain  regular  habit  must  be  acquired.  This  ought  to  be 
established  in  the  earliest  months  •  of  life,  and  if  it  were  so 
established,  and  if  the  infant  were  properly  fed,  there  would 
not  be  much  necessity  for  medical  advice  as  to  the  treatment 
of  constipation.  As  it  is,  however,  constipation  in  infants  and 
children  is  one  of  the  commonest  conditions  we  are  called  on  to 
treat.  An  infant  will  not  make  any  voluntary  effort  to  empty  the 
bowel  unless  the  rectal  reflex  is  very  active,  and  as  it  easily  becomes 
dulled  the  bo\vel  soon  becomes  overloaded.  It  is  easy  for  the 
mother  to  give  a  dose  of  medicine  and  empty  the  bowel,  but  the 
same  course  of  events  is  quickly  repeated.  Thus  a  vicious  habit  is 
established  which  may  seriously  impair  the  healthy  development  of 
the  bowel  and  intestinal  functions  generally. 

Preventive  Treatment. — In  order  to  prevent  the  development 
of  constipation  in  an  infant,  a  habit  of  soliciting  an  action  of 
the  bowrels  should  be  begun  at  the  age  of  one  or  two  months. 
After  the  morning  bath  and  thorough  general  friction  the  child 
should  be  placed  on  the  chamber.  At  first  there  may  be 
no  result  as  the  bowels  may  have  been  acting,  quite  normally 
for  the  age,  at  irregular  intervals  three  or  four  times  a 
day.  If  there  has  not  been  an  action  for  twelve  hours  then  a 
small  piece  of  soap  or  the  little  finger  dipped  in  glycerine  may  be 
introduced  through  the  anus.  This  will  probably  start  the  rectal 
reflex,  and  an  action  will  follow  :  at  the  same  time  a  mental 
impression  is  conveyed  to  the  child,  which  simply  requires  repetition 
to  become  a  habit.  On  no  account  should  it  be  regarded  as  a 
healthy  state  of  affairs  for  a  young  infant  to  pass  one,  two,  or  three 
days  without  an  evacuation.  Just  as  certainly  as  the  response  to 
the  rectal  reflex  in  the  form  of  an  action  of  the  bowels  becomes  a 
habit,  so  the  dulling  of  the  rectal  reflex  will  become  chronic  if  the 
rectum  is  allowed  to  retain  faecal  matter  for  a  day  or  two.  While  a 
young  infant  will  usually  pass  several  motions  a  day,  the  fact 
that  one  motion  only  is  passed  must  not  be  regarded  as  a  sign  of 
constipation.  It  is  the  bulk  of  the  matter  passed  which  is 
important.  Several  small  motions  a  day  may  be  passed  without 
there  being  any  thorough  evacuation  of  the  bowel,  and  a  condition 


Cqnstipation  in  Children.  433 

of  constipation  is  being  developed.  On  the  other  hand,  one  full 
motion  in  the  day  may  represent  a  normal  and  healthy  action  of 
the  bowel. 

All  babies  do  not  start  life  with  the  same  ease  and  regularity  in 
emptying  the  bowels.  For  those  who  have  any  difficulty  simple 
measures  are  often  sufficient  to  prevent  the  development  of  con- 
stipation. Care  must  be  taken  first  of  all  as  regards  the  food  and 
the  feeding.  Errors  in  this  respect  are  responsible  for  most  of  the 
cases  of  constipation  in  early  life.  In  the  case  of  breast-fed  infants, 
the  habits  of  the  mother  must  be  carefully  regulated,  and  if  she  is 
herself  healthy  and  feeds  her  child  regularly,  the  tendency  to  con- 
stipation in  the  infant  will  not  be  great.  This  constipation  of 
breast-fed  children  is  seen  much  more  amongst  the  poorer  classes, 
and  in  them  the  quality  of  the  milk,  the  state  of  the  mother's 
health,  and  irregularity  in  the  feeding  are  probably  chiefly 
responsible  for  the  condition  of  the  baby.  As  regards  bottle-fed 
children  it  is  equally  necessary  that  proper  food  at  proper  intervals 
should  be  given  if  constipation  is  to  be  avoided  (see  article  on 
Infant  Feeding). 

Some  infants  show  a  tendency  to  constipation  from  birth,  which 
is  not  necessarily  a  pathological  condition,  for  it  can  often  be 
remedied  by  a  slight  alteration  in  the  diet.  Thus  a  few  ounces  of 
plain  or  barley  water  in  the  day,  given  between  feeds,  may  suffice 
to  maintain  a  regular  action.  Orange-juice  or  grape-juice  may  be 
given  with  benefit  and  safety  to  the  youngest  infant  for  the  same 
purpose,  £  to  1  oz.,  diluted  with  water,  and  given  between 
feeds.  In  other  cases  the  milk  may  be  so  thoroughly  digested 
and  absorbed  that  little  residue  is  left  in  the  bowel.  Without  some 
residue  to  act  on  it  is  difficult  for  the  bowel  to  exert  its  peristaltic 
action  effectively.  In  such  cases  we  may  allow  a  small  amount, 
three  or  four  teaspoonfuls  daily,  of  a  starchy  food,  either  uncon- 
verted or  partially  converted,  which  is  sufficient  to  act  as  a 
stimulus  without  acting  as  an  irritant  to  the  bowel.  Again,  a 
tendency  to  constipation  may  be  induced  by  frequent  doses  of 
castor  oil  given  in  early  infancy.  It  cannot  be  too  strongly 
impressed  on  mothers  that  castor  oil  is  not  the  drug  to  give  for 
constipation.  It  finds  its  true  use  in  connection  with  diarrhoea  and 
intestinal  irritation.  The  action  of  castor  oil  as  a  purgative  is 
usually  followed  by  a  period  in  which  constipation  results,  so  that 
no  permanent  progress  is  made.  The  habit  of  drugging  young 
infants  with  castor  oil,  as  if  it  were  an  essential  part  of  healthy 
babyhood,  is  one  of  those  nursery  customs  which  is  responsible  for 
much  constipation. 

S.T.— VOL.  ii.  28 


434  Constipation  in  Children. 

Another  factor  which  sometimes  leads  to  constipation  is  the 
habit  of  depriving  infants  of  facilities  for  the  free  exercise  of  their 
limbs.  A  healthy  child  is  a  very  active  person,  but  if  the  limb 
muscles  are  hampered  by  tight  and  heavy  garments  or  by  heavy 
bedclothes,  those  natural  movements  are  much  curtailed.  It  should 
be  the  daily  practice  to  let  an  infant  be  on  the  bed  or  some  warm 
protected  place  where  it  can  indulge  in  its  natural  muscular  move- 
ments with  perfect  freedom.  At  the  same  time  the  abdominal 
muscles  will  be  strengthened,  and  their  action  has  an  important 
influence  in  securing  natural  evacuations.  It  is  the  custom 
amongst  many  primitive  races  for  the  mothers  to  carry  their 
infants  slung  over  the  back  or  on  the  hip.  The  result  is  a  con- 
siderable amount  of  shaking,  which  acts  on  the  liver  and  induces  a 
flow  of  bile,  just  as  riding  exercise  does.  Perhaps  it  is  impossible 
to  introduce  such  a  custom  amongst  the  advanced  races  here,  but 
it  is  quite  easy  to  give  the  baby  some  exercise  in  the  nursery  which 
will  serve  the  same  purpose,  such  as  jumping  it  up  and  down.  If 
the  period  after  the  morning  bath  is  utilised  in  this  way  it  will 
often  be  found  that  an  action  of  the  bowels  follows. 

After  an  infant  has  cut  some  teeth  the  prolonged  use  of  a  soft, 
pappy  diet  and  the  custom  of  using  pre-digested  foods  are  apt  to  be 
followed  by  constipation.  Intestinal  peristalsis  is  weakened  when 
there  is  no  solid  residue  in  the  bowel  to  call  it  into  action.  Hence  it 
will  be  found  advisable  to  employ  those  foods  which  contain  some 
irritating  and  non-digestible  materials,  such  as  porridge,  whole- 
meal bread,  figs,  etc.,  and  in  the  case  of  older  children,  salads, 
green  vegetables,  tomatoes  and  raw  apples.  At  the  same  time  care 
must  be  taken  that  these  substances  are  not  given  in  excess  of  the 
age  and  requirements,  as  the  result  may  be  impairment  of  the 
digestive  powers  and  diarrhoea.  A  sufficient  amount  of  fatty 
material  must  also  be  part  of  the  diet.  Fats  and  oils  have  a 
lubricant  effect  on  the  bowel  contents,  and  prevent  the  inspissation 
of  the  faeces  which  sometimes  leads  to  constipation.  In  suet 
puddings,  cod-liver  oil  or  olive  oil,  cream  and  butter,  one  finds  the 
necessary  fatty  elements.  In  the  case  of  children  of  school  age  the 
same  principles  apply,  and  the  best  diet  for  the  prevention  of  con- 
stipation is  a  mixed  one,  in  which  all  the  essential  elements  are 
represented,  care  being  taken  that  a  sufficient  amount  of  water  is 
drunk  both  at  and  apart  from  meals. 

LOCAL  CAUSES  OF  CONSTIPATION. 

In  cases  of  constipation  an  abdominal  examination  should  always 
be  carried  out,  and  frequently  a  rectal  examination  is  also  called 


Constipation  in  Children.  435 

for.  By  the  omission  of  such  measures  one  will  be  liable  to 
overlook  cases  of  serious  abdominal  disease  and  local  conditions 
bearing  directly  on  the  cause  of  the  constipation.  Amongst  the 
local  causes  there  may  be  :  (1)  Atonic  dilatation  of  the  bowel ;  (2) 
overloading  of  the  sigrnoid  flexure  with  faeces ;  (3)  anal  fissure  or 
tenderness  ;  and  (4)  a  spasmodic  contraction  of  the  anus. 

(1)  The  chief  cause  of  atonic  dilatation  of  the  bowel  in  young 
children  is  rickets.     At  the  same  time  a  prolonged  course  of  over- 
feeding or  improper  feeding  is  apt  to  be  followed  in  young  persons 
by  atonic  dilatation,  quite  irrespective  of  rickets.     The  abdomen  is 
distended  by  the  dilated  bowel,  which  is  incapable  of  driving  on  its 
contents   properly.      The   first   and  most   important   part   of   the 
treatment  is  to  put  the  patient  on  a  spare  and  digestible  diet  so  as 
to  restore  the  muscular  tone  of  the  bowel  wall.      For  the  same 
object  massage  of  the  abdominal  wall  may  be  carried  out  twice 
daily.     The  muscles  of  the  abdominal  wall  should  be  well  pounded, 
and  pressure  exerted  from  the  right  iliac  region  along  the  course  of 
the  colon  to  the  sigmoid  flexure.      A  firm  flannel  binder  should  be 
applied  round  the  abdomen.      During  this  period  of  toning-up  the 
bowel  wall  it  may  be  necessary  to  use  regularly  a  mild  aperient, 
such  as  the  following  :    1^  Tincturae  Nucis  Vomicae,  nt  2 ;  Tincturae 
Belladonnas,     111 3 ;    Tinctures     Aloes,     n\_  3 ;     Glycerini,     TTJ.  10 ; 
Aquam,  ad  5J.     [U.S. P.  1^  Tincturao  Nucis  Vomicse,  rr|.4 ;  Tincturse 
Belladonnae,  HT,4 ;  Tincturae  Aloes,   rn,l  ;  Glycerini,  ntlO;  Aquam, 
adsj.].     T.d.s. 

(2)  An     overloaded    condition   of    the    sigmoid    does    not 
necessarily  manifest  itself  by  constipation.      On  enquiry  one  may 
be  told  that  the  bowels  act  daily,  but  on  examination  it  will  be 
found  that  the  motions  are  usually  small  and  lumpy.      There  is 
never  a  complete  evacuation  of  the  bowel.      Irregular  attacks  of 
abdominal  pain,  of  vomiting,  and  of  diarrhoea  are  common  mani- 
festations  of  this  condition.      The  loaded  bowel  can  be  palpated 
easily  in  the  left  iliac  region.      Sometimes   the  accumulation   is 
enormous  and  extends  into  the  rectum,  as  well  as  throughout  the 
whole  of  the  colon,  in  the  form  of  hard  masses.     In  extreme  cases 
the  rectal  accumulation  is  so  hard  that  it  must  be  mechanically 
broken  down.     In  less  severe  cases  it  is  advisable  to  give  an  enema 
of  2  or   3   oz.   of    olive   oil   at    night,   to    be    retained,    and    to 
follow  this  with  a  soap-and-water  enema  in  the   morning.      This 
procedure  should  be  repeated  for  three  days,  or  longer  if  the  bowel 
has  not  been  cleared.     When  the  lower  bowel  has  been  emptied,  a 
dose  of  2  drachms  of  castor  oil  should  be  administered  on  con- 
secutive nights,  so  as  to  empty  thoroughly  the  parts  of  the  colon 

28-2 


436  Constipation  in  Children. 

beyond  the  reach  of  enemata.  One  has  then  to  give  a  course  of 
mild  aperients  to  prevent  the  recurrence  of  such  a  condition.  This 
form  of  constipation  is  often  the  result  of  want  of  regularity  in 
soliciting  an  action  of  the  bowel  on  the  part  of  the  child.  It  may 
have  been  as  the  result  of  difficult  and  painful  defecation  or  of 
neglect  of  the  calls  of  nature  that  the  rectal  reflex  has  become 
blunted  and  then  lost.  In  many  schools,  and  not  only  those  for 
the  poorer  classes,  this  is  too  often  neglected,  and  much  preventable 
constipation,  both  in  boys  and  girls,  is  brought  about.  Full 
facilities  should  be  provided  at  schools  for  the  performance  of  these 
natural  functions,  and  both  meals  and  work  should  be  so  arranged 
that  no  boy  or  girl  can  plead  want  of  time. 

(3)  A  small  anal  fissure  or  abrasion  may  be  the  result  of  hard 
and  inspissated  motions.     The  presence  of  blood  in  the  fseces  even 
in  the  youngest  infants  is  quite  common,  and  is  due  to  the  irritation 
of  hard  scybala  in  the  rectum.   Whenever  a  movement  of  the  bowels 
becomes  painful  a  child  will  instinctively  try  to  avoid  an  action,  and 
constipation  follows.     If  small,  a  fissure  will  usually  heal  under  the 
local  use  of  boracic  ointment ;  if  at  all  deep,  it  must  be  divided 
freely.     At  the  same  time  the  action  of  the  bowels  should  be  ren- 
dered easy  by  the  daily  use  of  olive-oil  enemata,  (4  to  6  oz.).      The 
enema  should  be  retained  for  five  or  ten  minutes,  and  the  action 
following  will  cause  little  pain. 

(4)  In  some  cases  of  constipation,  on  making  a  rectal  examination 
one  may  find  a  spasmodic  contraction  of  the  sphincter  ani,  which 
resists  the  entrance  of  the  finger.     Such  a  condition  of  spasm  in  the 
sphincter   is  usually  accompanied  by   imperfect  emptying  of  the 
rectum.     This  spasm  may  exist  quite  apart  from  fissure  or  other 
local  irritation,  and  is  sometimes  very  difficult  to  cure.     In  such 
cases  we  may  employ  locally  the  injection  of  hot  water  for  its  seda- 
tive effect,  and  also  try  the  effect  of  bromides  and  belladonna,  given 
by  the  mouth,  for  their  anti-spasmodic  action. 

In  the  case  of  children  the  treatment  of  constipation  by  means 
of  enemata  and  drugs  ought  to  occupy  a  very  secondary  place.  Bad 
habits  have  not  become  fixed,  and  the  errors  of  youth  have  not  had 
time  to  impair  the  normal  working  of  the  bowel.  Nevertheless,  a 
medical  man  will  often  be  consulted  after  constipation  has  existed 
for  some  time,  and  until  it  is  cured  there  must  be  an  interval  during 
which  drugs  or  enemata  must  be  employed  to  maintain  a  healthy 
state  of  the  intestinal  functions,  and  through  them  of  the  system 
generally.  It  is  well  to  remember  that  strong  aperient  medicines 
should  not  be  used  in  the  treatment  of  constipation,  but  reserved  for 
occasional  use  only.  When  mild  aperients  are  used  for  constipation 


Constipation  in  Children.  437 

they  are  much  more  efficacious  when  given  in  divided  doses,  three 
times  daily,  rather  than  as  one  dose  at  night.  As  regards  the 
dosage,  children  require  much  larger  amounts  of  such  drugs  as 
senna  and  cascara  than  would  be  considered  necessary  from  a  com- 
parison of  their  body-weight  with  that  of  adults.  Some  parents 
will  stuff  their  children  with  porridge,  prunes,  bananas,  apples,  etc., 
in  order  to  relieve  constipation,  but  will  object  to  a  dose  of  senna  or 
cascara  because  it  is  a  medicine,  and  in  their  opinion  weakening  to 
the  bowel.  As  a  matter  of  fact,  there  is  no  such  difference  of  nature 
or  action,  and  a  healthy  tone  of  the  bowel  wall  and  healthy  intes- 
tinal secretions  can  be  secured  much  more  quickly  and  effectively 
by  cascara  than  by  prunes. 

Enemata  are  called  for  in  those  cases  in  which  the  motions  are 
hard  or  there  is  a  chronic  difficulty  in  emptying  the  rectum — the 
condition  to  which  Dr.  Hertz  has  given  the  name  dyschezia.  The 
choice  lies  between  plain  water  (which  is  not  efficient  unless  given 
in  considerable  amount),  soap  and  water,  olive  or  other  simple  oil, 
and  glycerine.  Glycerine  suppositories  are  so  slow  and  uncertain 
in  their  action  that  plain  glycerine  is  to  be  preferred :  1  drachm 
of  glycerine  is  sufficient  to  produce  a  speedy  action.  If  any  pain 
follows  it  may  be  avoided  in  future  by  giving  equal  parts  of  glycerine 
and  water.  When  the  rectal  wall  seems  to  require  a  gentle  stimulus 
to  provoke  the  dulled  reflex,  plain  warm  water  up  to  £  pint  may  be 
employed.  When  the  rectum  is  overloaded  with  faeces  soap  and 
water  may  be  used,  with  or  without  a  preliminary  injection  of  olive 
oil.  When  the  motions  have  been  hard  and  the  evacuations  incom- 
plete an  enema  of  from  4  to  6  oz.  of  olive  oil  will  procure  an  easy 
evacuation.  In  giving  enemata  only  soft  rubber  should  be  used  for 
introduction  into  the  bowel,  as  any  hard  substance  is  apt  to  cause 
abrasions  about  the  anus. 

Amongst  the  mild  aperients  cascara  and  senna  are  specially  suit- 
able for  children.  Cascara  may  be  given  in  the  form  of  the  fluid 
extract  or  "  cascara  evacuant,"  the  latter  being  more  palatable  and 
equally  effective.  An  ordinary  dose  for  a  child  of  five  years  is  from 
5  to  15  drops  three  times  daily.  The  best  preparation  of  senna 
is  a  fresh  infusion  of  the  pods,  made  by  pouring  3  oz.  of  boiling 
water  over  four  or  six  pods,  and  standing  for  twelve  hours.  Of  this 
1  oz.  can  be  given  three  times  a  day.  A  fresh  infusion  of  the  pods 
may  be  prescribed,  to  be  made  of  the  strength  of  one  in  six,  flavoured 
and  preserved  with  chloroform,  and  of  this  £  drachm  may  be 
given  thrice  daily.  This  preparation  should  be  made  fresh  twice  a 
week.  Senna  is  also  the  active  ingredient  in  syrup  of  figs  (£ 
drachm  thrice  daily)  -and  of  "  laxative  fruit  pastilles  "  (one  thrice 


438  Constipation  in  Children. 

daily).  In  prescribing  senna  or  cascara  it  will  often  be  found  useful 
to  meet  certain  indications  by  the  addition  of  other  substances. 
Thus  if  the  hepatic  action  seems  to  be  defective  we  add  tincture  of 
rhubarb  iri.5  to  irtlO  [U.S.P.  in.3  to  Tri5],if  spasm  of  the  bowel 
and  colic  are  present  we  add  tincture  of  belladonna  TTi.5  to  nilO 
[U.S.P.  111 6  to  nil2],  and  when  the  muscular  tone  of  the  bowel  is 
weak  we  add  tincture  of  nuxvomica  Tri2  to  nt4  [U.S.P.  Tit4  to  nt8]. 
The  use  of  an  aperient  may  have  to  be  continued  for  from  one  to 
six  weeks,  according  to  the  length  of  time  the  constipation  has  lasted. 
The  best  plan  is  to  begin  with  doses  sufficiently  large  to  produce 
complete  evacuation  of  the  bowels,  without  looseness,  and  gradually 
to  diminish  the  amount  of  the  dose  as  the  normal  action  of  the 
intestine  becomes  re-established. 

G.  A.  SUTHERLAND. 


439 


CONSTIPATION   IN  ADULTS. 

FOR  the  rational  treatment  of  constipation  it  is  necessary  to 
distinguish  between  the  two  great  classes  of  cases :  (1)  That  in 
which  the  passage  through  the  intestines  is  delayed,  whilst 
defecation  is  normal — intestinal  constipation ;  and  (2)  that  in 
which  there  is  no  delay  in  the  arrival  of  faeces  in  the  pelvic  colon, 
but  their  final  excretion  is  not  adequately  performed — pelvi-rectal 
constipation  or  dyschczia. 

THE  HYGIENE  OF  THE  BOWELS. 

Neglect  of  the  hygiene  of  the  bowels  is  not  only  often  the  sole 
cause  of  dyschezia,  but  it  is  also  an  important  factor  in  the  majority 
of  cases  of  constipation  of  every  variety.  When  there  is  delay  in 
the  passage  of  faeces  through  the  intestines,  the  resulting  constipa- 
tion is  frequently  aggravated  by  neglecting  to  make  a  proper  effort 
to  evacuate  the  dry  faeces  collected  in  the  bowel  below  the  splenic 
flexure.  Consequently  this  part  of  the  intestine  is  never  completely 
emptied,  and  an  increasing  degree  of  faecal  obstruction  is  produced, 
which  materially  increases  the  difficulty  the  intestine  has  in 
adequately  performing  its  excretory  functions. 

Instruction  in  the  hygiene  of  the  bowels — how  to  defaecate  most 
efficiently — is  an  essential  part  of  the  treatment  of  the  majority  of 
constipated  individuals,  whatever  be  the  cause  of  their  constipation. 
In  some  cases  of  slight  constipation  attention  to  the  hygiene  of  the 
bowels  may  be  all  that  is  necessary  in  order  to  relieve  the  condition. 

An  attempt  should  be  made  every  day  at  the  same  hour  to  open 
the  bowels.  The  best  time  is  immediately  after  breakfast,  as  under 
normal  conditions  most  of  the  contents  of  the  alimentary  canal  are 
then  collected  in  the  pelvic  colon,  and  food  taken  into  a  completely 
empty  stomach  is  such  a  powerful  stimulus  to  intestinal  activity  that 
some  of  the  contents  of  the  pelvic  colon  are  propelled  into  the  rectum, 
where  they  give  rise  to  the  "  call  to  defsecation."  The  muscular 
activity  involved  in  getting  up  and  dressing,  in  some  people  a  cold 
bath  and  a  glass  of  cold  water  drunk  before  breakfast,  and  in  others 
a  cup  of  coffee  and  a  pipe  or  cigar,  help  to  make  the  early  morning 
the  most  suitable  time  for  the  daily  action  of  the  bowels.  Even 
when  the  natural  stimuli  have  produced  no  call  to  defsecation,  the 
patient  should  make  an  attempt,  as  the  increased  intra-abdominal 


440  Constipation  in  Adults. 

pressure  produced  by  the  voluntary  contraction  of  the  abdominal 
muscles  and  diaphragm  may  force  faeces  into  the  rectum,  and  so 
produce  the  desire  to  defaeeate. 

In  addition  to  the  attempt  to  defaecate  in  the  early  morning, 
a  call  to  defaecation  felt  at  any  other  time  in  the  day  should  be 
obeyed  at  once.  Otherwise  it  soon  disappears,  although  the  fasces 
which  give  rise  to  the  sensation  remain  in  the  rectum,  the  sensi- 
bility of  which  becomes  impaired,  and  the  first  step  is  taken  towards 
the  loss  of  the  defaecation  reflex.  It  is  particularly  important  to 
impress  upon  girls  that  no  feeling  of  shyness  should  prevent  prompt 
obedience  to  the  call  to  defaecation,  at  whatever  inconvenient  time 
it  may  occur.  Sufficient  time  should  always  be  spent  over  the  act 
of  defaecation,  as  it  is  rare  for  a  single  effort  to  be  sufficient  to 
evacuate  all  the  accumulated  faeces.  One  or  more  additional 
attempts  to  defaecate  should  be  made  after  a  short  pause,  whatever 
the  result  of  the  first  effort ;  by  this  means  any  faeces  left  behind 
after  the  first  evacuation  may  be  expelled.  The  activity  of  the 
defaecation  reflex  varies  in  different  individuals :  the  active  rectum 
works  without  delay,  but  the  lethargic  rectum  requires  solicitation. 
For  the  latter  it  is  often  advisable  to  pay  two  visits  to  the  closet  at 
short  intervals,  perhaps  before  and  after  breakfast. 

In  order  to  prevent  the  temptation  to  hurry  over  defecation  the 
closet  should  be  clean,  devoid  of  smell,  well  lit  and  properly  warmed 
in  winter.  There  should,  moreover,  be  a  sufficient  number  of  closets 
in  every  house,  as  a  single  one  is  quite  inadequate  for  a  family  of 
four  or  five  individuals,  particularly  if  several  of  them  have  to  hurry 
away  to  business  or  to  school  immediately  after  breakfast.  The 
hour  of  rising  and  of  breakfast  should  be  regulated,  so  as  to  allow 
sufficient  time  for  the  evacuation  of  the  bowels  to  be  efficiently 
carried  out  before  the  business  of  the  day  begins. 

In  all  cases  of  dyschezia,  and  whenever  the  sluggish  passage  of 
faeces  through  the  intestines  has  caused  them  to  become  so  hard 
and  dry  that  a  special  effort  is  required  in  order  to  expel  them 
completely,  it  is  most  important  that  a  proper  position  should  be 
assumed  for  performing  the  act  of  defaecation.  This  is  quite 
impossible  with  the  high  seat  of  the  majority  of  water-closets.  A 
wooden  footstool  9  inches  lower  than  the  seat  should  therefore  be 
provided,  or  a  bed-pan  raised  slightly  above  the  floor  should  be  used. 
Bed-ridden  patients  should,  whenever  possible,  be  allowed  to  sit  erect 
on  a  bed-pan,  or,  better  still,  be  moved  on  to  a  commode  placed  at 
the  side  of  the  bed,  as  the  constipation,  from  which  they  are  likely 
to  suffer  for  various  reasons,  is  certain  to  be  increased  if  they  are 
compelled  to  defaecate  whilst  lying  down. 


Constipation  in  Adults.  441 

PYSCHOTHERAPY. 

Psychical  treatment  consists  primarily  in  the  eradication  of  two 
ideas  which  inhibit  intestinal  action  and  defaecation.  One  of 
these  is  the  conviction  that  constipation  will  inevitably  result  if  no 
artificial  means  are  taken  to  produce  the  regular  action  of  the 
bowels,  so  that  the  habit  is  established  of  using  purgatives  or 
enemata,  although  they  are  not  really  required.  In  such  cases  an 
attempt  should  be  made  to  persuade  the  patient  that  his  constipa- 
tion is  merely  a  faulty  habit,  which  can  be  readily  and  completely 
overcome  without  recourse  to  purgatives  or  enemata  by  attention 
to  the  hygiene  of  the  bowels  and  by  some  slight  changes  in 
diet. 

The  second  idea  which  must  be  eradicated  is  that  the  attempt  to 
defecate  will  prove  ineffectual.  The  patient  is  so  frightened  that 
he  will  not  get  his  bowels  opened  that  by  the  violence  of  his  efforts 
he  inhibits  the  involuntary  reflex  part  of  the  act.  The  patient's 
fears  should  be  allayed,  and  he  should  be  instructed  to  make  less 
strenuous  efforts,  and  perhaps  to  divert  his  attention  from  the  act 
by  reading. 

After  the  patient  has  been  thoroughly  examined,  he  should,  if 
no  organic  disease  is  found,  be  told  that  with  perseverance  in 
treatment  he  will  get  well,  but  that  much  depends  on  his  own 
co-operation.  Throughout  the  period  of  treatment  the  patient 
should  be  encouraged,  and  the  most  should  be  made  of  any 
improvement.  If  he  is  disappointed  that  his  improvement  is  not 
faster,  he  should  be  reminded  of  his  condition  before  the  treatment 
was  begun,  so  that  he  may  realise  that  he  is  already  a  little  better, 
and  can  hope  to  obtain  finally  complete  relief  by  steady  per- 
severance. 

Much  treatment  applied  locally  to  the  intestines,  such  as 
enemata,  electricity — especially  when  intra-rectal — and  massage, 
tends  to  confirm  the  hypochondriacal  tendencies  of  neurotic 
patients.  Such  patients  should  be  encouraged  to  think  as  little  as 
possible  about  their  illness,  and  be  forbidden  to  make  minute  daily 
examinations  of  their  excreta.  I  have  often  found  that  X-ray  and 
sigmoidoscopic  examinations  are  of  value  for  their  mental  effect  in 
demonstrating  the  absence  of  any  organic  obstruction,  the  dread  of 
which  is  frequently  a  source  of  great  worry  to  hypochondriacal 
patients. 

DIETETIC    TREATMENT. 

Errors  of  diet  are  among  the  commonest  of  all  the  causes  of  con- 
stipation, and  frequent!}7  complete  relief  can  be  obtained  by  a 


442  Constipation  in  Adults. 

change  in  diet  without  any  other  treatment.  In  all  cases,  in  which 
the  motor  activity  of  the  intestines  is  deficient  or  the  constipation 
is  a  result  of  the  faeces  being  too  dry,  considerable  improvement 
results  from  dietetic  treatment.  In  dyschezia  a  change  in  diet  is 
oftgn  of  value,  even  when  the  motor  activity  of  the  intestines  is 
normal,  as  it  hastens  the  passage  of  the  intestinal  contents  to  the 
rectum,  which  they  reach  in  a  comparatively  soft  condition,  so  that 
the  force  required  to  expel  them  is  diminished. 

In  the  first  place  it  is  important  to  see  that  sufficient  food  is 
taken,  as  constipation  is  often,  especially  in  nervous  patients,  as 
much  due  to  the  insufficient  quantity  as  to  the  unsuitable  quality 
of  the  food. 

The  principles  upon  which  a  suitable  dietary  for  constipation 
should  be  framed  can  be  readily  gathered  from  a  consideration  of 
the  normal  stimuli  to  intestinal  activity.  The  mechanical  stimula- 
tion of  the  intestinal  movements  depends  on  the  direct  irritant 
action  of  cellulose,  and  on  the  distension  produced  by  the  food ;  the 
latter  is  mainly  due  to  the  indigestibility  of  cellulose,  which  also 
diminishes  the  digestion  of  vegetable  proteins  and  starch,  and  so 
adds  to  the  bulk  of  the  intestinal  contents.  The  intestinal  juice 
and  bacteria,  both  of  which  are  increased  by  vegetable  food, 
further  increase  the  distension  of  the  intestines.  The  chief 
mechanical  stimulants  of  intestinal  activity  are  sugars,  the  organic 
acids  and  salts  of  vegetable  food,  fats,  the  extractives  of  meat,  and 
the  products  of  the  digestion  and  bacterial  decomposition  of 
carbohydrates,  fats  and  to  a  less  extent  of  proteins. 

Thus  the  main  consideration  in  choosing  a  diet  for  constipation 
is  to  increase  the  quantity  of  vegetable  foods,  especially  those 
which  contain  much  cellulose,  organic  acids  and  sugar,  and  of  fat. 
The  following  is  a  list  of  the  articles  of  diet  which  are  of  most  value 
in  the  treatment  of  constipation : 

Diet  for  Constipation. — Wholemeal  bread.  Porridge,  made 
with  coarse  oatmeal ;  oatcake.  Vegetables  twice  a  day,  especially 
green  vegetables,  of  which  spinach  and  cabbage  are  best ;  asparagus 
and  onions  ;  carrots,  parsnips,  turnips  and  artichokes  ;  tomatoes, 
watercress  and  lettuce ;  olives.  Fruit,  except  bananas  and  bil- 
berries, three  times  a  day,  raw  or  cooked ;  especially  fresh  plums, 
greengages  and  peaches ;  raspberries,  currants,  gooseberries, 
strawberries  and  figs  ;  pears,  apples,  oranges,  grapes  and  melons. 
Dried  figs,  raisins,  prunes,  dates  and  ginger.  Jam  and  marmalade 
with  bread  and  puddings  ;  honey ;  treacle.  Butter  with  bread  and 
vegetables ;  oil  in  salad ;  cream  with  porridge  and  stewed  fruits ; 
bacon  fat ;  suet  pudding ;  cod-liver  oil.  Lemonade,  cider,  beer. 


Constipation  in  Adults.  443 

No  claret  or  port.  Tea,  preferably  China,  only  allowed  if  freshly 
prepared  and  drunk  with  cream  or  milk,  and  not  more  than  three 
cups  a  day.  It  may  be  replaced  by  an  equivalent  amount  of 
cafe  au  lait,  but  black  coffee  is  not  allowed. 

Although  there  are  no  solid  foods  which  have  a  directly  consti- 
pating action,  it  is  advisable  to  prohibit  certain  articles  of  diet  on 
account  of  their  extreme  digestibility,  which  deprives  them  of  all 
mechanically  stimulating  properties  and  is  not  compensated  for  by 
the  presence  of  any  chemically  stimulating  constituents.  Rice, 
tapioca,  sago,  semolina,  vermicelli  and  macaroni  contain  only 
traces  of  cellulose,  and  are  quite  without  effect  on  the  intestinal 
movements.  The  same  is  true  of  white  bread  and  brown  bread, 
from  which  the  bran  has  been  removed,  blancmange  and  mashed 
potatoes.  It  is,  therefore,  advisable  to  replace  these  articles  of  diet 
by  others  of  a  more  stimulating  character.  Stewed  fruit  with 
cream  should  replace  rice  and  similar  puddings,  wholemeal  bread 
should  replace  white  bread,  and  green  vegetables  potatoes.  In  mild 
cases  milk  puddings  and  blancmange  need  not  be  prohibited,  but 
they  should  only  be  eaten  with  stewed  fruit  or  with  jam. 

It  is  important  that  sufficient  fluid  should  be  drunk.  In  addition 
to  that  taken  with  or  immediately  after  meals,  a  glass  of  cold 
water,  which  has  a  more  powerful  effect  on  intestinal  peristalsis 
than  hot  water,  should  be  drunk  before  breakfast,  another  half 
an  hour  before  dinner,  and  a  third  just  before  retiring  to  bed. 
Hard  water  has  often  been  stated  to  be  constipating,  but  it  is 
scarcely  conceivable  that  the  minute  quantity  of  lime  it  contains, 
amounting  only  to  0'002  per  cent,  can  have  any  effect  on  intestinal 
activity. 

Sour  milk  has  a  slightly  stimulating  action  on  the  bowels  owing 
to  the  lactic  acid  it  contains.  Its  inhibitory  influence  on  the 
development  of  intestinal  organisms  is  indisputable,  so  that  in 
cases  of  colitis  associated  with  constipation,  especially  when  the 
stools  are  alkaline  and  offensive,  sour  milk  should  be  given. 

A  non-irritating  diet  is  generally  recommended  for  spastic  con- 
stipation and  muco-membranous  colitis.  It  may  indeed  relieve 
pain,  but  it  tends  to  aggravate  the  constipation,  and  at  the  same 
time  to  increase  still  further  the  malnutrition  which  is  often 
present.  The  most  satisfactory  diet  for  the  majority  of  patients  is 
exactly  the  same  as  that  given  for  other  forms  of  constipation. 
The  accumulation  of  faeces  in  the  colon  having  been  removed, 
retention  of  further  quantities  is  prevented  by  the  efficient  stimula- 
tion of  peristalsis  afforded  by  this  diet,  so  that  the  exciting  cause  of 
the  spasm  is  removed. 


444  Constipation  in  Adults. 

MEDICINAL    TREATMENT. 

The  majority  of  cases  of  constipation  can  be  cured  without  drugs 
if  proper  treatment  is  instituted  at  a  sufficiently  early  stage.  In 
dyschezia  purgatives  are  either  absolutely  useless  or  they  only 
have  an  effect  when  fluid  stools  are  produced,  a  considerable 
quantity  of  fluid  and  nutritive  material  being  thereby  wasted. 

In  mild  cases  of  constipation,  which  require  nothing  more  than 
increased  attention  to  the  hygiene  of  the  bowels,  and  perhaps  some 
slight  change  in  diet,  the  patient  generally  thinks  the  matter  is  of 
such  slight  importance  that  he  treats  himself  with  purgatives  on  his 
own  initiative.  It  is  only  when  increasing  doses  fail  to  produce  a 
satisfactory  result  that  he  seeks  medical  advice,  and  then,  the 
underlying  condition  being  more  advanced,  treatment  by  simple 
hygienic  measures  and  diet  is  less  likely  to  be  successful ;  moreover, 
the  constant  irritation  of  the  intestinal  mucous  membrane  so 
greatly  diminishes  its  excitability  that  treatment  both  by  diet  and 
by  drugs  becomes  comparatively  ineffective. 

Although  the  indiscriminate  use  of  purgatives  may  have  serious 
results,  their  dangers  have  been  exaggerated  by  some  authorities, 
who  recommend  that  drugs  should  only  be  given  as  a  last  resource, 
when  all  other  methods  have  failed.  It  is  indeed  doubtful  whether 
more  harm  does  not  result  from  the  excessively  irritating  diet 
sometimes  recommended  than  from  properly  regulated  doses  of 
aperients. 

INDICATIONS    FOR    PURGATIVES. 

It  is  most  unwise  to  give  purgatives  to  every  patient  who 
complains  of  constipation.  The  cause  and  nature  of  the  constipa- 
tion should  first  be  ascertained,  and  drugs  should  only  be  given 
for  certain  definite  indications. 

1.  Symptomatic  Constipation — When  constipation  occurs  as  a 
symptom  of  an  acute  illness,  an  occasional  purge  is  useful  and 
does  no  harm,  as  with  convalescence  the  normal  condition  of  the 
bowels  returns  spontaneously.  In  incurable  diseases,  such  as 
inoperable  cancer,  in  which  the  expectation  of  life  is  short,  con- 
stipation is  also  best  treated  by  purgatives.  In  chronic  diseases  of 
the  kidneys,  in  diabetes  and  in  insanity,  which  are  aggravated  by 
the  constipation  which  is  commonly  present,  purgatives  should  be 
regularly  given.  When  constipation  is  a  symptom  of  a  curable  con- 
dition, such  as  chlorosis,  upon  which  it  exerts  a  directly  injurious 
action,  aperients  should  be  ordered  in  the  early  stage  of  treatment, 
in  addition  to  the  drugs  and  other  therapeutic  measures  directed  to 
the  cure  of  the  primary  disease.  Finally,  purgatives  are  useful  for 


Constipation  in  Adults.  445 

making  the  stools  soft,  when  defecation  is  painful  as  a  result  of 
inflamed  haemorrhoids,  anal  ulcer,  or  diseases  of  the  pelvic  organs, 
and  when  straining  at  stool  is  accompanied  by  danger,  as  in 
patients  liable  to  cerebral  haemorrhage. 

2.  Constitutional  and  Senile  Constipation. — The  regular  use 
of  purgatives  for  prolonged  periods  is  most  permissible  in  the  cases 
which  appear  to  depend  on  a  congenital  hypoplasia  or  an  acquired 
atrophy  of  the  intestinal  musculature,  the  former  being  probably 
the  cause  of  some  cases  of  hereditary  and  so-called  constitutional 
constipation,  and  the  latter  of  senile  constipation. 

3.  Intractable  Constipation. — In  the  comparatively  small  num- 
ber of  cases  of  constipation  in  which  non-medical  treatment  proves 
insufficient,  purgatives  must  be  used,  but  an  effort  should  always 
be  made  to  dispense  with  drugs  at  the  earliest  possible  moment. 

4.  Cumulative  Constipation. — Many  individuals,  particularly  if 
they  lead  a  sedentary  life  and  eat  excessively,  are  in  the  habit  of 
taking  a  purge  once  a  week  or  at  other  regular  intervals,  even  if 
they  are  not  obviously  constipated.     The  undoubted  benefit  they 
derive  from  this  practice  suggests  that  they  are  really  suffering  from 
cumulative   constipation,    although   their  bowels   may   be  opened 
daily,  and  that  the  purging  gets  rid  of  the  excess  of  faeces  accumu- 
lated during  the  week.     They    would,  of   course,  be  in   a   more 
healthy  condition,  and  would  no  longer  require  their  weekly  purge, 
if  they  ate  more  wisely  and  took  more  exercise;  but  it  is  often 
impossible   to   persuade    such   individuals   to   make    any    radical 
alteration  in  their  mode  of  life. 

CHOICE  AND  DOSAGE  OF  PURGATIVES, 
The  stool  produced  by  an  aperient  should  be  normal  in  size  and 
consistence,  and  should  not  deprive  the  body  of  any  water,  salt  or 
nutritive  material,  which  ought  to  be  absorbed.  The  dose  should  be 
so  regulated  that  one  stool  is  passed  every  day,  and  the  desire  to 
defalcate  is  felt  immediately  after  breakfast  and  not  at  an  inconve- 
nient time,  which  would  interrupt  the  day's  occupations  or  disturb  the 
night's  rest.  This  is  usually  accomplished  by  giving  a  single  dose 
of  the  drug  in  the  evening  or  on  rising,  according  to  the  rapidity  of 
its  action.  But  it  is  really  more  rational  to  divide  the  dose  into 
three  parts,  to  be  taken  before  or  after  meals ;  the  stimulating  action 
of  the  purgative  is  equally  effective,  and,  being  spread  through  the 
whole  day,  it  is  less  violent  and  therefore  less  liable  to  cause  colic  or 
catarrh.  The  aperient  should  cause  no  pain  or  discomfort  and  should 
not  irritate  the  intestinal  mucous  membrane  sufficiently  to  produce 
any  inflammatory  changes.  It  should  exert  no  harmful  action  on  the 


446  Constipation  in  Adults. 

stomach,  kidneys  or  other  organs.  If  it  is  probable  that  the  purga- 
tive will  be  required  permanently,  one  should  be  chosen  which 
experience  has  shown  can  in  favourable  cases  maintain  its  good 
effect  without  requiring  any  increase  in  the  dosage. 

From  time  to  time  attempts  should  be  made  to  reduce  the  dose. 
If  the  constipation  does  not  improve  and  the  drug  begins  to  lose  its 
effect,  it  is  advisable  to  try  some  other  aperient  before  increasing 
the  dose.  It  is  often  found  that  no  addition  to  the  doses  is 
required  if  two  drugs  are  given  alternately  for  periods  of  a  week 
each. 

1.  Alkaloids  :  (a)  XHX  Vomica,  Strychnine.  —  Strychnine  in- 
creases the  reflex  excitability  of  the  peripheral  as  well  as  the 
central  nervous  system.  The  tone  of  the  intestines,  which  probably 
depends  to  a  great  extent  on  the  constant  slight  stimulation  of 
Auerbach's  plexus  (the  peripheral  nerve-centre  situated  in  the 
muscular  coat),  isiherefore  increased  by  strychnine.  At  the  same 
time  the  increased  excitability  of  Auerbach's  plexus  causes  the  action 
of  a  stimulating  diet  and  of  those  purgatives,  which  act  by  means 
of  a  peripheral  reflex,  to  be  more  effective.  Hence  in  the  forms 
of  constipation,  which  depend  on  depression  of  the  central  and  peri- 
pheral nervous  system,  strychnine  and  nux  vomica  are  of  great 
value,  whether  given  alone  or  in  combination  with  vegetable  or 
saline  aperients. 

(ft)  Belladonna,  Atropine. — Atropine  paralyses  the  nerve-endings 
of  the  vagus  and  pelvic  nerves  in  involuntary  muscles.  Hence  its 
action  on  the  intestinal  musculature  is  to  diminish  its  tone  and 
contractile  force,  and  to  regulate  the  intestinal  movements  if  they 
were  previously  irregular.  It  is  therefore  of  use  in  cases  of  spastic 
constipation,  as  it  diminishes  the  excessive  excitability  of  the  peri- 
pheral nerve-centres,  and  so  permits  orderly  intestinal  contractions 
to  return. 

The  constipation  associated  with  lead  colic  results  from  irrita- 
tion of  the  vagus  ;  it  is  therefore  sometimes  relieved  by  the 
partial  paralysis  of  the  vagal  nerve-endings  produced  by  atropine. 
More  frequently,  however,  atropine  relieves  the  colic  without  open- 
ing the  bowels.  It  should  then  be  given  with  a  purgative,  such 
as  magnesium  sulphate  or  castor  oil,  which  by  itself  generally 
increases  the  colic  without  producing  a  thorough  aperient  action. 

Most  vegetable  purgatives  give  rise  to  more  or  less  griping.  This 
can  often  be  entirely  overcome  by  combining  the  drug  with  a  small 
dose  of  belladonna. 

(y)  Opium,  Morphia,  Codeine. — Opium  is  of  value  in  those 
cases  of  constipation  which  are  associated  with  pain,  especially 


Constipation  in  Adults.  447 

when  it  results  from  disease  of  the  pelvic  or  abdominal  viscera. 
The  analgesic  effect  of  opium,  and  its  paralysing  action  on  the 
central  nervous  system,  which  leads  to  a  diminution  in  the  reflex 
activity  of  the  inhibitory  nerves  to  the  intestines,  may  result  in  the 
bowels  being  opened.  In  spastic  constipation  opium  is  at  first 
even  more  effective  than  atropine,  but  as  the  condition  is  often 
chronic  or  recurrent  it  is  advisable  to  employ  it  as  little  as 
possible. 

Opium  and  its  alkaloids  should  only  be  used  in  acute  or  incurable 
cases,  as  in  chronic  conditions  the  morphia  habit  may  develop. 
Moreover,  the  initial  good  effects  are  generally  replaced  before  long 
by  the  ordinary  constipating  action ;  this  is  less  marked  with 
codeine  than  with  opium  or  morphia. 

Opium,  morphia  and  codeine  may  therefore  be  used  in  acute 
painful  conditions  associated  with  constipation,  such  as  biliary 
and  renal  colic,  and  in  rapidly  curable  forms  of  intestinal  colic, 
such  as  that  due  to  lead  poisoning.  They  are  generally  most 
effective  when  given  in  combination  with  a  saline  purgative. 

2.  Vegetable  Purgatives. — Vegetable  purgatives  irritate  the 
intestinal  mucous  membrane  and  thereby  give  rise  to  a  local  reflex 
in  Auerbach's  plexus,  which  results  in  increased  motor  activity. 
This  diminishes  the  time  during  which  absorption  of  fluids  taken 
by  mouth  or  secreted  into  the  alimentary  canal  can  take  place ;  there 
is  no  evidence  to  show  that  vegetable  purgatives  stimulate  the  secre- 
tion of  the  digestive  juices.  Those  most  commonly  used  do  not 
irritate  the  stomach,  as  some,  such  as  aloes,  only  act  after  they 
have  become  dissolved  in  the  bile,  and  others,  such  as  castor  oil, 
after  they  have  been  split  into  active  substances  by  the  pancreatic 
ferments. 

(a)  Anthracene  Purgatives. — Aloes,  cascara  sagrada,  senna  and 
rhubarb  owe  their  purgative  action  to  certain  irritant  com- 
pounds of  anthracene.  A  considerable  quantity  of  tannic  acid  is 
present  in  rhubarb,  so  that  its  aperient  action  is  generally 
followed  by  constipation  ;  for  this  reason  it  is  not  suitable  for  regular 
use. 

(i.)  Aloes  can  in  many  cases  be  taken  regularly  for  years  with- 
out producing  any  bad  result  and  without  losing  its  efficacy.  It 
acts  more  slowly  than  any  other  aperient,  requiring,  as  a  rule,  ten 
or  twelve  hours  to  produce  a  result,  it  is  commonly  supposed  to 
irritate  the  rectum,  but  the  evidence  that  it  does  so  is  not  conclusive, 
though  perhaps  it  is  best  to  avoid  it  when  haemorrhoids  are  present. 
The  action  of  aloes  is  said  to  be  increased  by  the  addition  of  iron 
salts  ;  it  is  therefore  often  prescribed  with  ferrous  sulphate.  It  is, 


448  Constipation  in  Adults. 

however,  not  clear  that  the  iron  is  really  of  value  except  in  the  con- 
stipation of  chlorosis,  when  it  acts  upon  the  cause  of  the  constipa- 
tion. It  has  already  been  explained  how  the  efficacy  of  vegetable 
purgatives  can  be  increased  by  the  addition  of  nux  vomica  and 
belladonna  ;  one  of  the  best  pills  for  use  in  chronic  constipation  is 
composed  of  J  gr.  of  extract  of  nux  vomica  and  \  gr.  of  extract  of 
belladonna,  with  from  ^  to  2  gr.  of  aloin.  This  pill  may  be  given 
three  times  a  day,  or,  in  mild  cases,  only  after  the  evening  meal ; 
the  exact  dose  should  be  carefully  adjusted  so  as  to  produce  a  single 
formed  stool  each  morning. 

(ii.)  Cascara  Sagrada  closely  resembles  aloes  in  its  action  ; 
the  dose  of  the  extract  is  from  1  to  5  gr.,  and  it  is  best  given  in  a  pill 
or  tabloid  with  nux  vomica  and  belladonna.  When  it  is  necessary 
for  a  purgative  to  be  taken  regularly  for  long  periods,  it  is  a  good 
plan  to  give  a  cascara  and  an  aloes  pill  alternately  for  a  week  at 
a  time. 

(iii.)  Senna. — Although  the  official  preparations  of  senna  are 
made  from  the  leaves  of  cassia,  the  pods  contain  an  equal  quantity 
of  cathartic  acid,  which  is  the  active  principle.  Amongst  the 
former  are  the  compound  powder  of  liquorice  and  confection  of  senna, 
which  are  mild  laxatives,  particularly  suitable  for  children.  Senna 
contains  a  resinous  substance,  which  tends  to  cause  griping  and 
nausea.  As  this  is  insoluble  in  water,  an  aqueous  extract  is  the 
best  preparation.  The  requisite  number  of  senna  pods  are 
allowed  to  stand  in  cold  water  for  six  hours,  and  the  infusion  is 
drunk  last  thing  at  night,  or  some  senna  leaves  contained  in  a 
muslin  bag  may"  be  stewed  with  prunes  without  spoiling  their 
flavour.  Senna  pods  have  the  great  advantage  over  other 
vegetable  aperients  in  the  ease  with  which  the  dose  can  be 
regulated  from  day  to  day.  A  patient  may  start  with  six  pods 
each  evening ;  he  can  rapidly  increase  or  diminish  the  number 
until  a  satisfactory  result  is  obtained,  after  which  he  should 
gradually  reduce  the  dose  by  one  pod  at  a  time  as  improve- 
ment in  his  condition  occurs. 

3.  Castor  Oil. — On  account  of  its  mild  but  certain  action,  and 
the  absence  of  gastric  irritation  and  of  griping,  castor  oil  is 
perhaps  the  most  valuable  of  all  purgatives  for  occa- 
sional use,  a  dose  of  ^  or  1  oz.  being  generally  required.  The 
regular  administration  of  £  or  1  dr.  at  night,  or  night  and 
morning,  is  one  of  the  best  methods  of  treating  senile  constipation, 
and  it  is  often  the  only  purgative  which  is  effective  in  spastic 
constipation  and  in  muco-membranous  colitis,  especially  when 
opium  or  belladonna  is  given  simultaneously. 


Constipation  in  Adults.  449 

The  great  disadvantage  of  castor  oil  is  its  nastiness,  which, 
however,  is  comparatively  slight  in  the  best  preparations. 

4.  Synthesised    Purgatives. — Numerous     synthesised    purga- 
tives have  been  introduced,  but  the  only  one  that  has  proved   of 
much    value    is    phenoiphthaleiti,    which    has    been    sold    under 
various  names,  such  as  purgen,  purgatol  and  laxine.     It  appears 
to  stimulate  both  peristalis  and  secretion  in  the  intestine  without 
producing  pain,  and  it  has  no  action  on  any  other  organs.     The 
dose  varies  between  1  and  15  gr.      It  is  best  taken  alone  in  tablet 
form  or  in  capsules.     Large  doses  are  said  to  give  rise  to  catarrhal 
colitis,  but  in  moderate  doses  it  is  a  safe  and  efficient  aperient. 

5.  Saline    Purgatives. — We     have    recently,  proved    that  the 
commonly  accepted  theory  of  the  physical  action  of  saline  purga- 
tives  is  erroneous.     They  act   after   absorption   from   the   small 
intestine  by  stimulating  the  motor  and  secretory  activity  of  the 
colon.     They    should    be    taken    before    breakfast,    because    the 
stomach    is    then    empty,    and    they    are    consequently    rapidly 
absorbed.     When  a  dose  of  a  saline  purgative,  sufficient  to  produce 
a  single  copious  and  semi-liquid  stool,  is  given,  the  whole  of  the 
large   intestine    from    the   caecum    to    the   rectum    is   completely 
emptied.      Salts   are   therefore    particularly  indicated  when   it  is 
desired  to  produce  a  complete   evacuation  of   the  colon   without 
interfering  with  digestion  in  the   small  intestine.     They  have  the 
advantage  in  such  cases  over  many  vegetable  purgatives,  such  as 
cascara  sagrada  and  castor  oil,  in   that  they  produce  none  of  the 
acceleration  in  the  passage  of  chyme  through  the  small  intestine, 
which  leads  to  diminished  digestion  by  the  pancreatic  and  intes- 
tinal juices. 

Many  individuals  find  salts  the  most  pleasant  form  of  aperient, 
their  action  being,  as  a  rule,  very  reliable  and  unaccompanied  by 
disagreeable  symptoms.  They  tend,  however,  to  produce  depres- 
sion in  nervous  individuals,  owing  to  the  loss  of  a  considerable 
amount  of  fluid,  for  they  differ  from  vegetable  purgatives  in 
increasing  the  secretory  as  well  as  the  motor  activity  of  the  large 
intestine.  The  softness  of  the  stools,  which  result  from  the  use  of 
saline  purgatives,  renders  them  particularly  useful  for  patients 
with  hcernorrhoids,  anal  ulcer  and  painful  pelvic  conditions. 

The  xnli)lt<(1< '.s  <>i  xoila.  <tn<]  iiiajinesia  are  equally  reliable,  but 
the  latter  has  the  disadvantage  of  possessing  an  unpleasant 
bitter  taste.  Sodium  sulphate  is  best  taken  either  by  itself,  or 
mixed  with  sodium  bicarbonate  and  tartaric  and  citric  acids  as 
the  pharmacopoeial  effervescent  salt,  in  a  tumbler  of  cold  water, 
which  should  be  slowly  drunk  whilst  dressing.  One  drachm  is 

S.T. — VOL.  ii.  29 


450  Constipation  in  Adults.     . 

generally  the  best  dose  to  begin  with,  but  the  quantity  requires 
regulating  until  the  desired  effect  is  produced.  Sodium  sulphate 
can  also  be  given  three  times  a  day,  in  doses  varying  between 
20  gr.  and  2  drachms.  Its  efficacy  can  then  be  greatly  increased 
by  the  addition  of  5  min.  of  liquor  strychninae  [U.S.P.  strychnin, 
hydrochlor.  gr.  ^]  to  each  dose.  When  a  purgative  is  required 
in  cases  of  chlorosis,  sodium  sulphate  can  be  added  to  an  iron  and 
arsenic  mixture. 

6.  Mercurial    Purgatives. — Large    doses    of    mercurial    salts 
produce  congestion,  necrosis  and  ulceration  of  the  intestinal  mucous 
membrane,  especially  in  the  colon  ;  watery,  blood-stained  stools  are 
passed,  and  intense  pain  and  tenesmus  are  present.    In  small  doses 
the  irritation  leads  merely  to  a  slight  increase  in  the  motor  and 
secretory  activity   of  the   intestine,  a  soft   stool   being   produced 
without  pain. 

Mercurial  purgatives  were  formerly  believed  to  act  by  increasing 
the  flow  of  bile,  but  observations  on  animals  and  on  men  with 
biliary  fistulse  have  shown  conclusively  that  they  have  no  action  on 
the  liver. 

Only  the  insoluble  preparations  of  mercury  are  used  as  purgatives, 
as  the  others  are  absorbed  to  too  great  an  extent.  The  former  are 
partly  dissolved  in  the  intestines,  and  then  exert  their  action  on  the 
mucous  membrane.  Calomel  is  the  mercurial  most  commonly  used 
at  the  present  day,  but  metallic  mercury  in  the  form  of  blue  pill 
[U.S.P.  mass  of  mercury]  or  grey  powder  is  still  often  given. 

Mercurial  purgatives  are  very  valuable  for  occasional  use, 
particularly  in  so-called  "  biliousness,"  in  which  the  furred  tongue, 
anorexia,  general  malaise,  headache,  discoloured  conjunctivas  and 
constipation  result  really  from  gastro-intestinal  disorder  and  not 
from  any  hepatic  condition.  They  are  also  valuable  in  diarrhoea 
resulting  from  excessive  putrefaction,  in  which  they  act  mainly  as 
evacuants,  but  to  some  extent  as  intestinal  antiseptics. 

Mercurial  purgatives  should  never  be  employed  in  the  treatment 
of  chronic  constipation,  as  they  produce  too  much  irritation  of  the 
intestinal  mucous  membrane,  and  their  constant  use  is  likely  to 
result  in  symptoms  of  mecurial  poisoning. 

7.  Substances  which  Increase  the  Bulk  of  the  Faeces. — It 
might  be  supposed  that  the  form  of  constipation,  which  is  due  to 
absorption  by  the  intestine  being  so  active  that  very  little  faeces 
remain  to  be  excreted,  required  no  treatment.     But  the  occurrence 
of  symptoms  in  severe  cases   makes  it  probable   that   the  small 
quantity  of  faeces  formed  remains  so  long  in  the  intestines  before 
sufficient  accumulates  in  the  pelvic  colon  to  produce  an  effective 


Constipation  in  Adults.  451 

stimulus  to  defaecation  that  an  abnormally  large  proportion  of  the 
poisonous  constituents  of  the  faeces  is  absorbed.  It  is  therefore 
advisable  to  attempt  to  obtain  an  evacuation  at  least  every  other 
day.  This  can  best  be  done  by  increasing  the  bulk  of  the  faeces  by 
the  administration  of  some  substance,  such  as  agar-agar  or  paraffin, 
which  passes  through  the  intestines  without  undergoing  decomposi- 
tion or  absorption. 

(i.)  Ayar-agaria  prepared  from  certain  East  Indian  seaweeds,  and 
consists  mainly  of  hemi-cellulose,  which  is  unaffected  by  the 
digestive  juices  and  is  for  the  most  part  unabsorbed.  It  readily 
takes  up  about  four  times  its  weight  of  water,  so  that  a  compara- 
tively small  quantity  taken  by  mouth  yields  a  considerable  volume 
of  material  for  excretion.  Pure  agar-agar  can  be  obtained  as  an 
almost  tasteless  powder  and  in  shreds.  It  should  be  taken  two  or 
three  times  a  day  in  porridge,  mashed  potatoes,  puddings,  stewed 
apples  or  other  food.  The  patient  may  begin  with  doses  of  one 
teaspoonful,  and  the  amount  should  be  increased  or  diminished  to 
suit  each  case.  Many  patients  can  after  a  time  dispense  with  it 
entirely,  others  have  to  use  it  permanently.  The  agar-agar  can  be 
added  to  the  food  by  the  patient  himself,  or  it  can  be  incorporated 
with  it  in  the  cooking.  In  the  latter  case  it  should  be  soaked  in 
water  at  from  100°  to  150°  F.  until  quite  soft,  after  which  as  much 
of  the  water  as  possible  should  be  drained  away;  it  can  then  be 
mixed  with  the  other  ingredients  of  the  various  articles  of  diet 
already  mentioned,  or  with  gelatine  in  the  preparation  of  jellies. 
The  addition  of  a  small  quantity  of  an  aqueous  extract  of  cascara 
sagrada  has  been  recommended  in  order  to  replace  the  stimulating 
decomposition  products  of  the  food,  which  are  present  in  these 
cases  in  abnormally  small  amount.  The  dose  of  cascara  is  quite 
insufficient  by  itself  to  produce  any  purgative  action.  The  com- 
bination of  agar-agar  with  cascara  is  sold  under  the  name  of 
re;  i  a  I  in.  It  has  the  disadvantage  of  possessing  an  unpleasant 
bitter  taste.  The  addition  of  1  gr.  of  phenolphthalein  to  each 
drachm  of  agar-agar  is  equally  effective,  and  does  not  alter  the 
tasteless  character  of  the  latter. 

(ii.)  Liquid  Paraffin,  is  non-irritating,  and  is  not  absorbed  in  the 
alimentary  canal.  It  is  particularly  valuable  when  the  fasces  are 
very  hard  and  dry,  and  is  therefore  useful  in  certain  other  forms  of 
constipation  besides  that  due  to  a  greedy  colon,  as,  for  example,  in 
diabetes.  In  dyschezia  also  the  soft  stools  which  result  from  its 
use  are  expelled  with  less  difficulty  than  ordinary  faeces.  From 
1  dr.  to  \  oz.  should  be  taken  with  two  or  three  meals  every  day. 
It  occasionally  gives  rise  to  nausea,  but  on  the  whole  I  have  found 

29-2 


452  Constipation  in  Adults. 

it  much  more  useful  than  agar-agar,  which  not  infrequently  causes 
disturbances  in  gastric  digestion. 

ENEMATA  AND  SUPPOSITORIES.    REMOVAL  OF  IMPACTED 

FAECES. 

Enemata  are  used  in  the  treatment  of  constipation  with  the 
object  of  (1)  producing  an  immediate  evacuation  of  the  large 
intestine,  and  (2)  softening  hard  accumulations  of  faeces,  so  that 
they  may  subsequently  be  more  easily  evacuated. 

Enemata  as  Evacuants. — Enemata  empty  more  or  less  of 
the  large  intestine  by  stimulating  its  movements  (a)  mechanically, 
(b)  thermally,  and  (c)  chemically. 

(a)  Mechanical    Stimulation. — The    distension    of    the    intestine 
with  fluid  acts  as  a  powerful  stimulus  to  contraction,  the  strength 
of  which  depends  on  the  volume  of  fluid  injected  and  the  method 
of   injection,  the  latter  being  the  more  important  factor.     If  no 
obstruction  is  present,  two  pints  of  water  can  be  run  into  the  colon 
under  low  pressure  without  stimulating  its  movements  at  all,  as, 
most  of  the  large  intestine  being  normally  almost  empty,  the  bulk 
of  its  contents  can   be  greatly  increased   without    distending   it. 
When,  on  the  other  hand,  an  enema  is  given  with  a  syringe,  the 
rapid  intermittent  increase  in  pressure  in  the  lowest  part  of  the 
intestine  stimulates  it  to  contract. 

(b)  Thermal   Stimulation. — The  stimulating   action  of   enemata 
can  be  considerably  increased  by  using  fluid  which  is  not  at  the 
body  temperature.     As  water  at  a  temperature  more  than  a  few 
degrees  above  that  of  the  body  is  injurious  to  mucous  membranes, 
the  effect  of  the  hottest  enema  which  can  be  safely  given  differs  little 
from  that  of  one  which  is  thermally  indifferent,  and  indeed  there 
is  some  evidence  to  show  that  it  exerts  a  slight  sedative  influence. 
On  the  other  hand,  water  at  a  temperature  of  as  much  as  60°  F. 
below   that  of   the  body   does   not  injure  the   intestinal   mucous 
membrane.     As  the  application  of  cold  stimulates  peristalsis,  the 
efficacy  of  enemata  can  be  greatly  increased  by  using  cold  instead 
of  hot  water.     The  stimulation  produced  by  water  between  60°  and 
70°  F.  is,  however,  generally  sufficient,  as  colder  water  is  liable  to 
produce  such  violent  contractions  that  severe  colic  results  and  the 
enema  is  at  once  rejected. 

In  spastic  constipation  and  in  muco-membranous  colitis,  injections 
at  the  body  temperature  or  slightly  above  it  help  to  relieve  the 
spasm  in  addition  to  emptying  the  colon.  On  the  other  hand,  cold 
enemata  increase  the  spasm  and  may  cause  considerable  pain. 

(c)  Chemical   Stimulation. — Water     and    normal  saline   solution 


Constipation  in  Adults.  453 

do  not  produce  any  chemical  stimulation  of  the  intestines.  The 
presence  of  soap  in  enemata  is  supposed  to  increase  the  efficacy 
of  enemata  to  a  slight  extent  by  mildly  stimulating  the  intestinal 
mucous  membrane. 

Owing  to  its  power  of  abstracting  water  from  tissues,  glycerine 
acts  as  an  irritant  to  mucous  membranes.  The  injection  of  1  or 
2  drachms  of  glycerine  into  the  rectum  acts  as  a  powerful 
stimulus,  which  gives  rise  to  a  defecation  reflex,  often  sufficiently 
strong  to  cause  the  bowels  to  be  at  once  thoroughly  opened.  As  a 
rule  its  action  is  painless,  but  it  often  causes  some  tenesmus,  which 
can  be  prevented  by  mixing  the  glycerine  with  an  equal  quantity  of 
water. 

Glycerine  Suppositories  are  as  effective  as  glycerine  enemata, 
and  have  the  advantage  that  they  can  be  very  easily  introduced 
by  the  patient  himself.  They  rapidly  dissolve  in  the  rectum,  and 
generally  act  within  a  few  minutes.  One  or  2-drachm  supposi- 
tories can  be  used  for  adults,  and  J  or  ^-drachm  for  children.  The 
solid  suppository  produces  a  mechanical  stimulus  in  addition  to 
the  chemical  stimulus  of  the  glycerine,  and  the  stimulus  it 
exerts  is  often  so  strong  that  an  action  is  obtained  before 
sufficient  time  has  elapsed  for  more  than  a  small  part  to 
dissolve. 

On  account  of  their  irritant  action  glycerine  enemata  and  supposi- 
tories should  not  be  used  by  patients  with  haemorrhoids.  It  is  also 
unwise  to  use  them  regularly  for  long  periods,  as  they  are  likely 
to  give  rise  to  catarrhal  proctitis.  But  they  are  very  valuable  for 
occasional  use,  when  fceces  have  become  impacted  in  the  rectum 
and  an  attempt  to  open  the  bowels  naturally  has  failed.  A  glycerine 
suppository  will  then  often  produce  a  single  evacuation  without 
delay,  the  stool  being  of  normal  consistence,  so  that  no  nutrient 
material  or  excess  of  fluid  is  lost.  Under  such  circumstances  they 
are  more  convenient  than  either  purgatives  or  enemata.  They  are 
very  useful  before  parturition,  as  they  are  more  cleanly  and  more 
sure  of  action  than  the  enemata  usually  employed. 

Cases  of  dyschezia,  in  which  the  defecation  reflex  is  impaired, 
can  often  be  cured  by  a  course  of  treatment  with  glycerine  enemata 
or  suppositories.  An  effort  to  defalcate  having  proved  unsuccessful  or 
the  result  insufficient,  the  glycerine  is  at  once  introduced.  In  the 
case  of  enemata  the  treatment  should  begin  with  pure  anhydrous 
glycerine ;  every  day  the  strength  is  slightly  reduced  by  replacing 
an  increasing  proportion  of  glycerine  by  water.  Finally  the  injec- 
tion is  so  dilute  that  it  no  longer  exerts  any  chemical  stimulus,  the 
result  being  due  simply  to  the  slight  mechanical  stimulation 


454  Constipation  in  Adults. 

produced  by  the  introduction  of  the  syringe  and  the  injection  of 
2  drachms  of  an  indifferent  fluid.  If  suppositories  are  used,  a  series 
should  be  employed  containing  respectively  95,  75,  60,  50,  40,  30 
and  15  per  cent,  of  glycerine. 

As  vegetable  purgatives  act  by  directly  stimulating  the  intes- 
tinal mucous  membrane,  their  addition  to  an  enema  increases  its 
efficacy.  Castor  oil,  however,  has  no  action  on  the  intestines  until 
it  is  split  into  glycerine  and  ricinoleic  acid ;  when  given  as  an 
enema  it  is  generally  retained  too  short  a  time  for  this  to  occur,  so 
that  it  has  no  more  effect  than  a  non-purgative  oil,  such  as  olive 
oil. 

Bile  stimulates  the  motor  activity  of  the  colon,  but  not  of  the 
small  intestine ;  it  has,  therefore,  a  mild  purgative  action  if  added 
to  an  enema,  and  a  small  quantity  of  undiluted  bile  gives  rise  to  a 
defecation  reflex,  which,  however,  is  much  feebler  than  that  pro- 
duced by  glycerine. 

Turpentine  stimulates  peristalsis  ;  when  added  to  enemata  it  is 
supposed  to  be  specially  efficacious  in  causing  the  expulsion  of 
flatus  from  the  rectum,  but  why  the  contractions  it  gives  rise  to 
should  act  particularly  on  the  gaseous  rather  than  the  solid  con- 
tents of  the  intestines  has  never  been  explained. 

Varieties  of  Enemata  depending  on  Method  of  Administra- 
tion and  Amount  of  Fluid  Used. — According  to  the  method  of 
administration  and  the  amount  of  fluid  used,  enemata  may  act 
on  (1)  the  whole  colon,  (2)  the  pelvic  colon  and  rectum,  or  (3)  the 
rectum  alone. 

(1)  High  Enemata. — If  fluid  is  run  under  a  constant  pressure 
of  not  more  than  3  feet  of  water  from  a  funnel  or  douche-can 
through  an  indiarubber  tube  into  the  intestine,  it  reaches  the 
caecum  without  difficulty.  It  is  quite  unnecessary  to  assume  any 
of  the  special  positions  or  series  of  positions  which  have  often 
been  recommended,  as  the  fluid  runs  in  equally  easily  when  the 
patient  lies  on  his  back  or  on  either  side. 

When  a  large  injection  under  low  pressure  has  to  be  made, 
difficulty  is  sometimes  experienced  in  introducing  the  fluid  beyond 
the  pelvi-rectal  flexure  ;  this  can  generally  be  overcome  by 
increasing  the  pressure  for  a  moment.  It  is  useless  to  introduce 
the  tube  more  than  3  inches,  as  when  it  reaches  the  pelvi- 
rectal  flexure  its  end  turns  backwards  towards  the  anus,  from 
which  it  may  finally  project. 

If  between  1^  and  3  pints  of  water  are  introduced  into  the 
colon  in  this  way,  the  whole  of  it  is  slightly  distended.  If 
a  desire  to  defecate  is  not  felt  at  once,  the  fluid  should  be 


Constipation  in  Adults.  455 

retained  for  a  quarter  of  an  hour.  An  effort  should  then  be  made 
to  defaecate ;  the  increased  intra-abdominal  pressure,  acting 
on  the  filled  large  intestine,  stimulates  it  to  such  an  extent 
that  strong  contractions  occur  throughout  its  length,  and  the  water 
is  expelled,  carrying  with  it  most  of  the  contents  of  the  colon.  On 
the  rare  occasions  in  which  all  the  water  is  retained,  a  further 
quantity  should  be  injected,  when  a  second  effort  to  defaecate  will 
almost  certainly  be  successful.  There  is  no  danger  of  over-dis- 
tending the  gut  so  long  as  the  fluid  is  introduced  at  a  low 
pressure. 

It  is  important  that  a  proper  position  should  be  assumed  during 
defecation  after  the  administration  of  an  enema.  The  full  benefit 
of  treatment  with  euemata  is  sometimes  not  obtained  owing  to 
the  common  practice,  especially  in  hospitals,  of  letting  the  patient 
lie  or  half-sit  on  a  bed-pan,  so  that  it  is  quite  impossible  for  him 
to  make  a  proper  effort  to  defaecate,  instead  of  allowing  him  to  get 
out  of  bed  and  use  the  water-closet. 

(2)  Low    Enemata. — When   an  enema   is   administered   in   the 
ordinary  way  by  means  of  Higgiuson's  syringe  the  rectum  and 
pelvic   colon    are   stimulated    to  contract   so    quickly  that    it   is 
generally  difficult  to  inject    more  than  a   pint  of   fluid,   and  not 
much  of   this  gets  beyond    the   pelvic  colon.      This  is,  therefore, 
an  effective  method  of   emptying  the    rectum   and    pelvic    colon, 
except  in  severe  cases  of   dyschezia,  in  which  the  atonic  rectum 
and  pelvic  colon  do  not  respond    to  the  mechanical  stimulation, 
but  simply  become  over-distended  by  the  fluid,  the  atonic  dilata- 
tion being  thereby  aggravated. 

(3)  Rectal   Enemata. — When  not  more   than  4  oz.  of  fluid  are 
injected  they   do  not,   as   a  rule,  reach  beyond  the  rectum.     As 
their  mechanical  effect  is  very  small,  they  must  either  be  cold,  so 
as   to    produce   a    thermal   stimulus,  or  contain   some   chemical 
stimulant,  such  as  glycerine,  ox-gall  or  aloin.     In  either  case  the 
stimulus  may  give  rise  reflexly  to  defaecation. 

Enemata  as  Solvents. —  The  force  required  to  propel  hard 
faeces  along  the  last  part  of  the  large  intestine  and  to  expel  them 
in  the  act  of  defaecation  is  sometimes  so  great  that  it  becomes 
necessary  to  soften  them  before  any  other  treatment  can  be 
effective. 

Enemata  of  olive  oil  and  bile  have  been  most  commonly 
used  for  this  purpose,  but  I  have  proved  experimentally  that 
they  have  very  little  softening  action  on  faeces.  On  the  other 
hand,  I  found  that  contact  with  water  at  the  body  temperature 
for  four  hours  caused  the  hardest  scybala  to  crumble  completely 


456  Constipation  in  Adults. 

away  when  shaken.  Considerable  softening  of  the  whole  mass 
occurred  already  in  half  an  hour,  and  even  in  a  quarter  of  an 
hour  a  greater  effect  was  achieved  than  oil  could  produce  in 
twelve  hours. 

Water  is  too  rapidly  absorbed  from  the  rectum  for  a  single 
injection  to  have  much  effect  in  softening  faeces.  It  is,  therefore, 
best  to  give  a  series  of  injections  at  short  intervals,  each  being 
retained,  if  possible,  for  twenty  minutes  or  half  an  hour.  The 
water  should  be  at  the  body  temperature,  and  the  amount 
regulated  according  to  whether  the  faecal  mass  is  in  the  rectum 
only,  in  the  rectum  and  pelvic  colon,  or  in  the  proximal  parts 
of  the  colon.  It  should  be  injected  at  a  pressure  not  exceeding 
3  feet.  The  number  of  injections  required  varies ;  but,  as  a 
rule,  an  effort  to  defaecate  after  the  second  or  third  injection  is 
successful. 

Although  the  softening  action  of  oil  on  faeces  is  negligible,  it 
detaches  scybala  from  the  intestinal  walls  and  lubricates  the 
mucous  membrane,  so  that  the  expulsion  of  the  fasces  is  facili- 
tated. It  is  only  absorbed  from  the  colon  to  a  very  small 
extent;  consequently  its  injection  in  the  evening  prevents  the 
absorption  of  water  from  the  fasces  collected  in  the  pelvic  colon, 
with  the  result  that  no  increase  in  their  hardness  occurs  during 
the  night.  Oil  has  also  a  soothing  effect  upon  the  mucous  mem- 
brane when  catarrh  is  present,  and  it  diminishes  the  tendency  to 
spasm  of  the  intestines  and  the  sphincter  ani  in  spastic  constipa- 
tion. Lastly,  if  oil  is  retained  in  the  intestine  for  some  hours,  it 
is  partly  decomposed  into  glycerine,  fatty  acid  and  soap,  which  act 
as  mild  stimulants  to  the  motor  activity  of  the  pelvic  colon  and 
rectum.  Oil  enemata  are  therefore  specially  indicated  in  spastic 
constipation  and  in  muco-membranous  and  other  forms  of  colitis, 
which  are  secondary  to  constipation. 

Injections  of  olive  oil  are  best  given  at  night,  and  they  should 
be  retained  until  the  morning.  About  5  oz.  should  be  used  on 
the  first  occasion.  If  the  treatment  has  to  be  repeated,  the  amount 
should  be  gradually  increased  to  10  or  15  oz.  The  oil,  which 
must  be  absolutely  pure,  is  warmed  to  100°  F.  and  is  then 
slowly  introduced  into  the  colon  from  a  funnel  or  douche- can 
suspended  2  or  3  feet  above  the  level  of  the  body.  A  little 
cotton-wool  should  be  placed  between  the  buttocks  during  the 
night  in  case  a  few  drops  escape  from  the  anus.  In  the 
morning  the  bowels  are  sometimes  satisfactorily  opened  without 
further  assistance,  but  often  the  injection  of  a  high  enema  of 
water  is  required. 


Constipation  in  Adults.  457 

GENERAL    INDICATIONS    FOR    THE    USE    OF    ENEMATA. 

(1)  In    Intestinal   Constipation. — The    majority  of    cases    of 
moderately  severe  constipation  are  more  or  less  cumulative,  excess 
of  faeces  being  always  present  in  the  large  intestine.  It  is  therefore 
necessary  that  the  colon  should  be  completely  evacuated  before 
other  methods  of  treatment  are  adopted. 

It  is  generally  possible  to  empty  the  bowels  completely  by 
means  of  a  dose  of  castor  oil  or  calomel,  followed,  if  necessary,  by 
a  saline  purge.  In  severe  cases,  however,  especially  if  the  consti- 
pation is  of  long  standing,  it  is  necessary  to  remove  the 
accumulation  of  faeces  from  the  large  intestine  by  enemata  before 
other  treatment  is  attempted.  When  the  improvement  is  slow,  it 
is  often  advisable  to  give  occasional  enemata  for  some  weeks.  A 
good  rule  to  follow  is  that  an  enema  should  be  used  whenever  a 
really  satisfactory  stool  has  not  been  procured  for  two  consecutive 
days  in  spite  of  the  regular  application  of  other  methods  of 
treatment.  In  cases  of  this  sort  a  high  enema  of  1£  or  2  pints  of 
warm  water  should  be  used.  An  attempt  should  be  made  to 
retain  it  for  J  or  J  hour  in  order  that  it  may  have  time  to  soften 
the  faeces.  It  is  often  advisable  to  give  a  second  similar  injection 
immediately  after  the  first  has  been  expelled.  It  need  not  be 
retained  for  more  than  a  couple  of  minutes,  and  its  stimulating 
action  can  be  increased  by  giving  it  cold. 

When  a  satisfactory  result  is  not  obtained  by  the  two  enemata 
owing  to  the  hardness  of  the  faeces,  a  series  should  be  given  in 
the  manner  already  described,  or,  if  there  is  any  catarrh  or  spasm 
of  the  colon,  an  olive-oil  injection  should  be  given  the  previous 
evening  and  retained  during  the  night.  It  is  often  necessary  to 
repeat  the  treatment  for  two,  three  or  more  consecutive  days  before 
the  colon  is  completely  evacuated. 

The  occasional  enemata  given  after  the  regular  treatment  has 
been  begun  can  be  of  the  same  sort  ;  but  a  smaller  quantity  of 
fluid,  injected  with  a  Higginson's  syringe,  is  often  effective  if 
used  before  any  considerable  amount  of  faeces  has  had  time  to 
re-accumulate. 

When  the  constipation  is  accompanied  by  much  flatulence,  1  oz. 
of  turpentine  may  be  added  to  each  pint  of  the  enema. 

(2)  In  Dyschezia. — The  most  important  part  of  the  treatment  of 
dyschezia  is  to  keep  the  rectum  and  pelvic  colon  empty,  so  that 
they  may  in  time  regain  their  normal  tone  and  contractile  power. 
This  can  only  be  accomplished  by  the  regular  use  of  enemata  or 
suppositories. 

The  belief  that  the  regular  use  of  enemata  is  always  harmful  is 


458  Constipation  in  Adults. 

erroneous,  and  in  many  cases  of  dyschezia  it  is  the  only  treatment 
which  can  lead  to  complete  recovery.  Even  in  the  most  obstinate 
cases  the  ultimate  result  of  the  treatment  is  often  very  satisfactory, 
although  the  enemata  may  have  to  be  given  regularly  for  a  year  or 
longer  before  the  rectum  and  pelvic  colon  return  to  their  normal 
condition.  In  very  exceptional  cases  the-  atony  and  paralysis  of 
the  rectum  are  so  complete  that  recovery  is  impossible  ;  in  such 
cases  treatment  by  enemata,  though  it  does  not  cure,  is  the  only 
way  in  which  a  regular  evacuation  can  be  obtained. 

The  use  of  enemata  should  be  discontinued  as  soon  as  the  power 
to  empty  the  bowels  completely  without  artificial  aid  has  returned. 
The  exact  moment  when  this  occurs  can  only  be  recognised  by 
instructing  the  patient  to  make  an  attempt  to  defecate  every  day 
before  he  has  an  enema,  even  if  he  never  experiences  a  desire  to  do 
so.  If  the  attempt  is  completely  unsuccessful,  or  if  only  a  small 
proportion  of  the  faeces  in  the  rectum  is  evacuated,  an  enema  must 
be  given. 

In  slight  cases,  in  which  the  contractile  power  of  the 
rectum  and  pelvic  colon  is  not  greatly  impaired,  stimulation 
of  the  anal  mucous  membrane  is  generally  sufficient  to  produce 
reflexly  an  efficient  defecation.  For  this  purpose  a  glycerine 
enema  or  the  more  convenient  glycerine  suppository  should  be  used, 
the  strength  of  the  glycerine  being  regulated  in  the  manner  already 
described.  When  glycerine  fails  to  act,  the  muscle  can  often  still 
be  caused  to  contract  by  the  mechanical  stimulus  produced  by  the 
injection  of  about  1  pint  of  water  by  means  of  a  Higginson's 
syringe.  If  plain  warm  water  is  ineffective,  the  stimulus  can  be 
increased  by  using  cold  water,  or  by  the  addition  of  soap  or  senna 
to  it. 

In  the  severest  cases  the  muscular  power  of  the  pelvic  colon  and 
rectum  is  so  feeble  that  it  can  never  contract  in  response  to  any 
stimulus  with  sufficient  force  to  expel  all  its  contents.  Under  these 
circumstances  a  high  enema  should  be  given  at  very  low  pressure  ; 
on  then  making  an  effort  to  defecate,  the  large  intestine  above  the 
pelvic  colon,  being  normal,  contracts  on  the  fluid  it  contains  with 
sufficient  force  to  expel  the  greater  part  through  the  anus,  the 
water  carrying  with  it  most  of  the  faeces  collected  in  the  pelvic  colon 
and  rectum. 

Some  nervous  patients  complain  of  exhaustion  or  abdominal 
pain  after  an  enema  has  been  administered.  This  drawback  can  be 
avoided  by  giving  the  enema  just  before  the  patient  retires  to  bed 
instead  of  in  the  morning,  or  by  the  introduction  of  a  belladonna 
suppository  half  an  hour  before  the  enema  is  injected. 


Constipation  in  Adults.  459 

Removal  of  Impacted  Faeces.  —  It  is  generally  unwise  to 
give  purgatives  when  faeces  have  become  impacted  in  the  intestines, 
as  the  colic,  which  is  usually  present,  indicates  that  the  intestinal 
musculature  is  already  contracting  very  actively,  and  that  it  is 
unlikely  that  any  additional  stimulation  will  result  in  a  sufficient 
increase  in  the  force  of  the  contractions  to  overcome  the  obstruc- 
tion. 

The  rational  treatment  of  faecal  impaction  is  by  means  of  enemata. 
Occasionally,  however,  they  fail  to  act,  and  it  becomes  necessary  to 
remove  the  faeces  piecemeal  by  a  finger  introduced  into  the  rectum. 
This  is  much  more  effective  and  much  less  likely  to  injure  the 
rectal  mucous  membrane  than  removal  by  means  of  a  metal  scoop 
or  the  handle  of  a  spoon.  When  digital  evacuation  is  required  it 
is  generally  necessary  to  give  an  anaesthetic,  as  the  dilatation  of 
the  sphincter  and  the  manipulation,  which  is  often  very  prolonged, 
are  always  painful.  The  evacuation  is  much  facilitated  by  simul- 
taneously irrigating  the  intestine  with  water  through  a  tube 
inserted  into  the  rectum  by  the  side  of  the  finger.  In  this  way 
small  fragments  of  faeces  are  washed  out  while  the  large  masses 
are  being  broken  by  the  finger.  When  the  accumulation  is  not 
confined  to  the  rectum  it  is  sometimes  possible,  by  a  hand  placed 
on  the  abdomen,  to  press  the  faeces  from  the  pelvic  colon  into  the 
rectum  after  the  latter  has  been  evacuated. 

HYDROTHERAPY. 

Cold  applied  to  any  part  of  the  skin,  but  particularly  to  the  abdo- 
men, reflexly  stimulates  the  muscular  coat  of  the  entire  alimentary 
canal.  Hence  a  cold  bath  taken  every  morning  is  a  very  valuable 
addition  to  the  series  of  stimuli  which  lead  to  the  morning  evacua- 
tion. If  a  hydrotherapeutic  institute  is  available,  a  trial  may  be 
made  of  the  Scotch  douche,  in  which  hot  and  cold  water  are  alter- 
nately played  on  the  abdomen  from  a  distance  for  ten  seconds  each, 
the  pressure  being  gradually  increased  if  the  patient  is  able  to 
tolerate  it. 

The  spasm  in  spastic  constipation  is  often  benefited  by  a  hot 
bath  or  by  a  hot  compress  applied  to  the  abdomen.  When  con- 
stipation is  due  to  some  painful  pelvic  condition,  the  latter  and 
the  associated  spasm  of  the  sphincter  ani  may  be  relieved  by  the 
use  of  a  hot  sitz-bath. 

EXERCISE  AND  SWEDISH  GYMNASTICS. 

Regular  exercise  is  one  of  the  most  important  means  of  prevent- 
ing constipation,  especially  in  individuals  who  follow  a  sedentary 


460  Constipation  in  Adults. 

occupation.  It  increases  the  appetite,  it  strengthens  the  voluntary 
muscles  of  defecation,  and  it  stimulates  the  intestinal  movements  by 
producing  rapid  changes  in  the  intra-abdominal  pressure.  Moreover, 
it  has  a  most  important  mental  effect,  as  it  takes  the  thoughts  away 
from  business  cares  and  household  worries,  the  depressing  influence 
of  which  on  the  nervous  system  is  an  important  factor  in  the  pro- 
duction of  many  cases  of  constipation. 

It  is  necessary,  however,  to  avoid  taking  too  much  exercise,  as 
the  harm  produced  by  great  fatigue  more  than  outweighs  the  good 
done  by  the  exercise  which  causes  it.  People  who  are  unac- 
customed to  exercise  and  are  advised  to  take  it  for  constipation 
should  therefore  begin  with  a  mild  form  for  periods  of  short 
duration.  Rest  rather  than  exercise  is  required  when  constipation 
is  due  to  reflex  inhibition  of  the  intestinal  movements  by  disease  of 
some  abdominal  or  pelvic  organ,  as  the  latter  may  be  aggravated 
by  exercise  and  the  inhibition  consequently  strengthened. 

Walking  on  the  level  may  improve  the  appetite,  but  it  is  too  mild 
an  exertion  to  have  much  effect  on  the  intra-abdominal  pressure, 
and  it  does  not  do  much  to  strengthen  any  of  the  muscles  con- 
cerned in  defaecation.  Bicycling  is  very  little  better.  Climbing,  on 
the  other  hand,  is  most  valuable,  as  the  diaphragm  and  abdominal 
muscles  are  brought  into  great  activity,  and  the  thighs  inter- 
mittently exert  considerable  pressure  on  the  abdomen.  Walking  in 
a  hilly  neighbourhood,  quite  apart  from  actual  climbing,  is  much 
more  useful  than  walking  on  the  level.  No  forms  of  exercise  are 
more  valuable  for  all  the  muscles  of  the  body  than  rowing,  skipping, 
and  swimming,  and  the  latter  has  the  additional  advantage  of  afford- 
ing a  thermal  stimulus  to  intestinal  activity.  For  those  who  require 
some  less  strenuous  exertion,  riding  is  of  value  for  the  diaphragm 
and  abdominal  muscles,  and  the  constant  bending  in  gardening 
and  when  playing  bowls  makes  these  recreations  useful  for  the 
abdominal  muscles.  Gymnastics  have  the  serious  disadvantage 
that  they  must  be  done  indoors,  as  one  of  the  most  important 
effects  of  exercise  is  the  stimulating  influence  it  has  on  the  appetite, 
and  this  is  most  marked  when  it  is  taken  in  the  open  air. 

Swedish  Gymnastics. — When  any  of  the  voluntary  muscles  of 
defaecation  are  weak,  considerable  benefit  can  be  gained  by  the 
regular  performance  of  Swedish  exercises.  At  first  each  move- 
ment may  be  repeated  six  times  morning  and  evening,  the  number 
being  gradually  increased  as  the  muscles  become  stronger ;  but  the 
exact  time  to  spend  over  the  exercises  varies  in  each  case  and 
depends  upon  the  amount  of  fatigue  produced,  for  the  patient 
should  always  stop  before  he  feels  very  tired.  It  is  generally 


Constipation  in  Adults.  461 

necessary  to  continue  the  exercises  for  several  months,  but  after  a 
time  the  number  done  can  be  slowly  diminished. 

The  abdominal  muscles  are  those  which  most  frequently  require 
strengthening,  and  it  is  important  to  remember  that  exercises  are 
just  as  essential  for  the  transversalis,  internal  and  external  oblique 
muscles  as  for  the  recti.  The  following  list  gives  the  most 
generally  useful  exercises,  but  they  require  modification  to  suit 
individual  cases. 

(1)  Lying. — (a)  Slowly  sit  up  with  the  arms  stretched  forwards 
until  the  finger-tips  touch  the  feet,  then    slowly  lie  down  again. 
When  the  muscles  are  very  weak  it  may  be  necessary  at  first  to 
have    the    shoulders    supported    at    the    commencement   of    the 
movement. 

(b)  Clasp  the  hands  together  behind  the  neck ;  raise  the  extended 
legs  as  high  as  possible,  and  slowly  let  them  fall ;  raise  them  again 
before  they  reach  the  ground.     Here  again  it  is  often  necessary 
at  first  to  have  the  legs  supported. 

(c)  Sharply  draw  in  the  abdomen,  let  it  out  again,  and  then  push 
it  out  by  contracting  the  diaphragm. 

(d)  With  one  foot  laid  over  the  other  raise  the  pelvis  as  high  as 
possible.     This  may  be  done  against  the  opposition  of  an  attendant, 
who  presses  downwards  with  his  hands  on  the  crests  of  the  ileum. 

(2)  Standing. — (a)  Extend  the  arms  above  the  head  and  keep  the 
legs  stiffly  extended  ;  bend  the  trunk  forwards  and  try  to  touch  the 
toes  with  the  finger-tips. 

(b)  Hang   the   arms  by  the  side  and  keep  the  thighs  and  legs 
stiffly   extended  ;  bend  first   to  one  side  and  then  to  the  other, 
trying  to  touch  the  foot  with  the  hand  of  the  same  side. 

(c)  With  the  hands  on  the  hips,  twist  the  body  round  as  far  as 
possible,  first  in  one  direction  and  then  in  the  other. 

(d)  With  the  hands  on  the  hips,  lean  back  as  far  as  possible,  and 
slowly   move   the   body  round   the  fixed  pelvis,  so  that  the  head 
describes  a  large  circle. 

(e)  Raise  the  legs  alternately  as  high  as  possible,  so  as  to  com- 
press the  abdomen  with  the  thighs.     This  exercise  can  be  replaced 
by  going  slowly  upstairs  two  steps  at  a  time. 

(f)  With  the  hands  on  the  hips,  stand  on  the  toes  and  slowly 
bend  the  knees  outwards  with  the  body  bent  forwards,  so  as  to 
assume  a  squatting  position,  with  the  buttocks  touching  the  heels, 
and  the  thighs  pressing  on  the  abdomen ;  then  slowly  rise  again. 

Patients  in  whom  injury  to  the  pelvic  floor  has  led  to  dyschezia 
should  be  instructed  to  make  the  movement  they  would  do  were 
they  trying  to  restrain  a  commencing  defalcation ;  by  this  means 


462  Constipation  in  Adults. 

the  levator  ani  muscles  are  contracted.     They  should  be  alternately 
contracted  and  relaxed  thirty  times  every  morning  and  evening. 

Abdominal  Supports. — Dyschezia  is  most  often  associated  with 
visceroptosis,  both  being  due  to  weakness  of  the  abdominal  muscles. 
In  such  cases  a  proper  support  is  of  the  greatest  value.  It  has 
sometimes  been  taught  that  a  support  should  only  be  worn  when  the 
abdominal  muscles  are  so  weak  that  their  recovery  is  deemed 
unlikely,  as  it  is  supposed  to  cause  disuse-atrophy  of  the  muscles. 
This  view  is,  however,  erroneous ;  by  supporting  the  viscera  a 
well-fitting  belt  or  "  visceroptosis  truss  "  prevents  the  abdominal 
muscles  from  being  stretched  ;  it  consequently  becomes  possible 
for  them  to  regain  some  of  their  former  strength. 

MASSAGE. 

Whenever  constipation  is  due  to  want  of  activity  of  the  intestinal 
musculature,  the  condition  of  the  latter  may  be  improved  by 
abdominal  massage,  which  exerts  a  directly  stimulating  action 
upon  it.  In  dyschezia  the  atonic  and  paretic  pelvic  colon  and 
rectum  cannot  be  influenced  by  massage  owing  to  their  situation  in 
the  pelvis,  but  massage  is  beneficial  in  the  numerous  cases  which 
result  from  weakness  of  the  abdominal  muscles. 

Massage  has  sometimes  been  recommended  with  the  object  of 
directly  forcing  faeces  along  the  colon.  Not  only  do  X-ray  observa- 
tions show  that  this  can  only  rarely  be  done,  but  if  much  force  is 
used  there  is  considerable  danger  of  injuring  the  intestinal  wall  in 
the  attempt.  It  is,  however,  possible  to  soften  faecal  masses  in  the 
descending  and  iliac  colon  by  pressure,  so  that  their  subsequent 
removal  by  enemata  is  greatly  facilitated. 

Massage  should  never  be  employed  if  there  is  any  evidence  of 
inflammatory  complications,  and  spastic  constipation  is  generally 
made  worse  rather  than  better  by  this  treatment. 

The  bladder  should  be  emptied  immediately  before  the  massage  ; 
the  patient  should  be  recumbent  and  his  knees  raised  by  a  pillow 
in  order  to  relax  the  abdominal  muscles  as  much  as  possible.  The 
massage  should  be  repeated  daily,  and  should  be  continued  regularly 
for  several  weeks  at  least.  The  best  time  is  before  breakfast,  as 
the  stomach  is  then  empty,  and  the  massage,  being  added  to  the 
natural  morning  stimuli  to  defalcation,  may  at  once  result  in  a 
normal  evacuation.  Only  when  there  is  insufficient  time  in  the 
morning  should  the  massage  be  done  on  retiring  for  the  night.  Its 
duration  should  at  first  not  exceed  five  minutes,  but  it  can  be 
gradually  increased  up  to  half  an  hour.  If  it  causes  much  fatigue 
the  time  spent  in  the  treatment  should  be  diminished,  and  it  may 


Constipation  in  Adults.  463 

be  necessary  to  limit  it  to  three  times  a  week.  It  is  also  advisable 
to  discontinue  the  massage  during  the  menstrual  periods.  Abdo- 
minal massage  should  not  cause  any  pain ;  the  production  of  pain 
is  an  indication  that  the  massage  is  not  being  done  skilfully,  or 
that  the  condition  is  one  which  should  not  be  treated  in  this 
way. 

When  it  is  desired  to  act  directly  on  the  bowel,  it  is  usual  to  begin 
with  massage  of  the  csecum  and  pass  along  the  colon,  finishing 
immediately  above  the  pubes,  although  it  is  generally  impossible 
to  manipulate  the  pelvic  colon.  A  preliminary  examination  with 
the  X-rays  is  of  great  value,  as  it  shows  the  exact  position  of  the 
colon  and  also  the  part  in  which  the  sluggishness  is  most  marked. 

In  cases  of  dyschezia  due  to  weakness  of  the  abdominal  muscles, 
the  whole  surface  of  the  abdomen  should  be  massaged  without 
regard  to  the  probable  position  of  the  colon,  as  the  superficial 
muscles  and  not  the  intestinal  musculature  require  treatment. 

In  mild  cases  good  results  may  be  obtained  when  the  patient 
massages  himself.  This  has  the  great  advantage  of  costing  nothing 
and  causing  very  little  trouble,  so  that  the  treatment  is  more 
likely  to  be  thoroughly  carried  out  for  a  sufficient  period  than  if 
massage  by  a  professional  masseur  is  advised.  "  Auto-massage  " 
is  best  done  by  means  of  a  cannon-ball,  weighing  from  3  Ib.  to  10  Ib. 
and  covered  with  chamois-leather  or  flannel ;  it  is  rolled  by  the 
patient  over  the  abdomen  along  the  course  of  the  colon,  the  same 
precautions  being  taken  and  the  duration  of  treatment  being  the 
same  as  when  the  treatment  is  given  by  hand. 

If  a  professional  masseur  or  masseuse  is  employed,  it  is  important 
to  give  definite  instructions  as  to  whether  direct  stimulation  of  the 
colon  is  required,  in  addition  to  the  more  superficial  massage 
suitable  for  the  abdominal  muscles,  and  the  situation  of  the  colon 
and  the  part  in  which  delay  is  most  marked  should  be  indicated. 
When  possible  the  masseur  should  give  the  first  treatment  with  his 
hands  under  the  fluorescent  screen  after  a  bismuth  meal  has 
rendered  the  colon  visible.  By  this  means  he  learns  how  he  can 
best  manipulate  the  colon,  as  he  can  watch  it  move  under  his 
fingers. 

The  results  obtained  with  vibratory  massage  applied  by  means 
of  a  more  or  less  elaborate  electrical  apparatus  hardly  warrant  the 
trouble  and  expense  involved  in  carrying  out  the  treatment,  as  it  is 
not  clear  that  it  can  do  anything  which  simple  massage  by  the 
hand  cannot  accomplish.  Moreover,  it  is  possible  to  combine  a 
certain  amount  of  vibration  with  the  other  manipulations  when  the 
massage  is  done  by  hand. 


464  Constipation  in  Adults. 

ELECTRICAL   TREATMENT. 

I  have  found  by  experiments  on  animals  that  galvanism  has 
much  more  effect  than  faradism  on  intestinal  movements.  When 
the  kathode  is  placed  on  the  back,  the  passage  of  the  anode  over 
the  course  of  the  colon  causes  a  wave  of  contraction  to  occur.  If 
one  electrode  is  introduced  into  the  rectum,  the  rectum  can  also  be 
caused  to  contract.  Faradism  has  no  effect  except  to  cause  the 
abdominal  muscles  to  contract,  and,  when  the  abdominal  wall  is 
thick,  even  galvanism  probably  exerts  no  action  on  the  intestines 
unless  a  stronger  current  is  used  than  can  comfortably  be  borne. 
The  good  results  sometimes  obtained  with  electricity  are  probably 
due  to  a  large  extent  to  suggestion,  the  patient  being  persuaded 
that  electricity  is  certain  to  do  him  good. 

(1)  Intestinal  Constipation. — In    severe    cases   of    this    kind 
electricity   may   be   tried   in    addition   to   other   treatment,  when 
the  latter  proves  insufficient  alone.     The  large  kathode  is  placed 
on    the    back,   and    the    smaller    anode   is   moved    slowly    along 
the  colon,  starting  at  the  caecum ;  the  electrode  should  be  kept 
longest  and  be  pressed  most  deeply  over  that  part  of  the  large 
intestine  where  the  delay  is  greatest.     As  strong  a  current  as  the 
patient  can  bear  with  comfort  should  be  used,  and  the  treatment 
may  be  given  for  a  quarter  of  an  hour  every  morning. 

(2)  Dyschezia. — When  the  tone  and  contractile  power  of  the 
rectum  and  pelvic  colon  are  so  impaired  that  spontaneous  evacua- 
tions do  not  return  after  some  months  of  treatment  with  enemata, 
intra-rectal   galvanism  should   be  tried.     A  thick  wire  electrode, 
insulated  by  a  soft   indiarubber   tube   except   at  its   olive-shaped 
end,   is   introduced   3  or  4  inches   into   the   rectum.     The   other 
electrode,  which  should  be  large  and  flat,  is  placed  on  the  lower  part 
of  the  abdomen.     The  treatment  should  be  given  daily  for  from  five 
to  twenty  minutes  shortly  after  breakfast.     In  favourable  cases  it 
produces  a  desire  to  defaecate,  which  is  likely  to  be  most  effective 
if  it  occurs  at  the  natural  time.     In  other  cases  the  patient  is  able 
to  defaecate  shortly  afterwards,  or  the  improvement  is  only  noticed 
after  some  days.    Unfortunately,  however,  many  of  the  worst  cases 
derive  no  benefit  whatever  from  the  treatment. 

Great  care  is  required  in  treating  constipation  by  intra-rectal 
galvanism,  owing  to  the  danger  of  injuring  the  rectal  mucous 
membrane  by  electrolysis,  where  the  bare  metal  of  the  electrode  is 
in  contact  with  it.  The  danger  can  be  greatly  diminished  by 
introducing  through  the  tube  containing  the  electrode  a  pint  of 
normal  saline  solution,  which  is  retained  during  the  treatment. 
The  electrode  is  then  generally  not  in  contact  with  the  mucous 


Constipation  in  Adults.  465 

membrane,  and  the  current  is  diffused  over  a  considerable  area  by 
the  water,  which  acts  as  a  large  electrode.  The  danger  of  electro- 
lysis can  be  further  diminished  by  frequently  reversing  the  current. 
Its  strength  is  slowly  increased  to  a  maximum  of  30  or  40  milli- 
amperes,  according  to  the  sensation  it  produces,  and  then  slowly 
diminished  to  zero.  After  reversing  the  direction  of  the  current  it 
is  again  slowly  increased. 

(3)  Dyschezia  with   Weak  Abdominal  Muscles. — When  the 
abdominal  muscles  are  weak  they  undoubtedly  derive  benefit  from 
the  active   contractions  produced   by  faradism  or  labile  kathodal 
galvanism.     As  exercises  and  massage  are  equally  efficacious  and 
are  generally  more  convenient,  electrical  treatment  should  only  be 
recommended  when  special  facilities   for   its  employment  are  at 
hand.    A  large  electrode  is  placed  over  the  lumbar  spine ;  a  smaller 
one   is   moved   slowly   over   the   abdomen.     Either    faradism    or 
galvanism  may  be  used,  and  the  current  should  be  as  strong  as  the 
patient  can  bear  without  discomfort. 

(4)  Neurasthenic  Constipation. — When  constipation  is  secon- 
dary to  neurasthenia,  static  electricity,  which  may  be  given  for  half 
an  hour  three  times  a  week,  is  often  of  value. 

SPA  TREATMENT. 

Many  patients,  who  are  unwilling  to  undergo  any  systematic 
treatment  for  constipation  at  home,  are  very  willing  to  devote 
a  few  weeks  in  the  year  to  a  "  cure  "  in  some  popular  health  resort. 
The  removal  from  business  and  household  worries,  daily  exercise 
in  the  open  air,  regular  hours  and  the  change  from  rich  food  to 
a  suitable  diet  are  of  much  more  importance  than  the  drinking  of 
waters,  which  could  be  done  equally  well  at  home  if  they  were 
really  needed.  In  most  of  the  resorts  which  are  regarded  as 
suitable  for  constipated  patients,  excellent  arrangements  are  at 
hand  for  hydrotherapy,  massage  and  electrical  treatment,  which 
can  rarely  be  applied  satisfactorily  at  home  from  lack  of  time  and 
the  requisite  apparatus  and  skilled  attendants.  Lastly,  better 
results  are  obtained  from  intestinal  lavage  in  such  places  as 
Harrogate  than  is  generally  possible  at  home. 

When  constipation  is  associated  with  definite  neurasthenia, 
complete  rest  from  the  ordinary  occupations  is  essential.  In  mild 
cases  the  patient  should  leave  home  and  spend  a  quiet  time  in  the 
country  or  by  the  seaside.  In  winter  nothing  gives  such  good 
results  as  a  visit  to  the  Swiss  mountains.  In  other  cases  some 
English  or  foreign  spa  may  be  visited,  where  general  hydrothera- 
peutic  and  perhaps  electrical  treatment  may  hasten  the  recovery. 

S.T.— VOL.  II.  30 


466  Constipation  in  Adults. 

In  severe  cases,  especially  when  anorexia  and  emaciation  are 
present,  improvement  may  only  begin  when  the  patient  is  removed 
from  his  home  surroundings  and  remains  in  bed  for  a  few  weeks, 
as  in  the  Weir-Mitchell  treatment.  At  the  same  time,  the  patient 
is  made  to  eat  an  increased  quantity  of  suitable  food.  This  often 
results  in  a  rapid  recovery  from  the  constipation  without  any  local 
treatment  at  all,  but  hydrotherapy,  massage  and  electricity  often 
hasten  the  improvement. 

As  the  natural  aperient  waters  and  the  intestinal  lavage  may  be 
regarded  as  the  special  features  of  spa  treatment,  these  must  be 
described  in  greater  detail. 

(1)  Natural  Aperient  Waters. — Sodium  sulphate  is  the  chief 
ingredient  of  the  hot  Karlsbad  and  the  cold  Elster,  Marienbad, 
Franzenbad  and  Tarasp  waters ;  it  is  associated  with  magnesium 
sulphate  in  the  much  weaker  Cheltenham  water  and  in  the  strong 
imported  bitter-waters,  such  as  Franz -Joseph,  ^sculap,  Hunyadi- 
Janos,  Friedrichshall,  Rubinat,  Apenta  and  Seidlitz.1 

There  is  no  evidence  to  show  that  these  natural  waters  have 
any  advantage  over  a  simple  solution  of  sodium  sulphate  or  over 
artificial  Karlsbad  salts,  although  it  is  conceivable  that  waters  taken 
at  the  source  have  some  unknown  specific  action  which  is  of  value. 
It  is,  indeed,  a  common  experience  to  find  that  drinking  the  waters 
at  one  of  the  popular  Continental  health  resorts  produces  nothing 
more  than  temporary  improvement,  which  lasts  no  longer  than 
the  period  of  the  "  cure."  An  attempt  has,  however,  recently 
been  made  to  put  the  spa  treatment  of  constipation  on  a  more 
scientific  basis.  In  the  old-fashioned  four  weeks'  "  cure"  sufficient 
water  was  drunk  to  give  the  largest  possible  stool  every  day.  The 
treatment  is  now  divided  into  three  periods.  In  the  first  the  dose 
is  varied  until  the  minimum  quantity  required  to  produce  one 
normal  stool  every  morning  is  discovered.  During  the  second 
period  the  patient  is  taught  to  accustom  himself  to  obtain  with  this 
dose  a  satisfactory  evacuation  every  morning  at  the  same  hour. 
When  he  no  longer  experiences  any  difficulty,  the  third  period  is 
begun,  in  which  the  dose  of  saline  aperient  is  gradually  diminished 
by  substituting  a  weaker  water  and  finally  ordinary  water  for  the 
strong  water  first  used.  It  is  often  necessary  to  continue  this 
third  period  for  some  weeks  or  even  months  after  the  patient  has 
returned  home.  The  waters  should  always  be  taken  on  an  empty 
stomach  in  the  early  morning. 

1  Artificial  seidlitz  powders  bear  no  resemblance  to  the  genuine  Seidlitz 
water,  as  they  depend  for  their  activity  on  sodium  tartrate  instead  of  magnesium 
sulphate. 


Constipation  in  Adults.  467 

(2)  Intestinal  Lavage. — Until  recently  lavage  was  only  practised 
at  Plombieres  and  Chatel-Guyon,  but  since  1905  the  same  treat- 
ment has  been  efficiently  carried  out  at  Harrogate  Bath  and 
Llandrindod  Wells.  There  is  probably  no  specific  action  in  either 
the  simple  thermal  water  of  Plombieres  or  the  alkaline  sulphur 
water  of  Harrogate,  the  mechanical  removal  of  fseces  and  mucus 
being  all  that  is  required.  But  the  systematic  and  skilful  perform- 
ance of  intestinal  lavage  combined  with  the  accessory  treatment 
obtainable  in  these  health  resorts  gives  very  good  results  in  many 
cases  of  constipation  associated  with  faecal  retention,  especially 
when  it  has  become  complicated  with  muco-membranous  colitis. 

Between  1  and  2  pints  of  the  natural  water  at  a  temperature 
of  100°  F.  are  introduced  into  the  colon  through  a  long  india- 
rubber  tube  from  a  douche-can,  suspended  at  a  height  of  1  or 
2  feet  above  the  couch  on  which  the  patient  lies.  The  water  is 
retained  for  ten  or  fifteen  minutes,  after  which  the  patient  gets  up 
and  evacuates  it,  together  with  scybala  and  mucus.  The  proceeding 
is  then  repeated,  a  smaller  quantity  of  fasces  but  more  membranes 
(in  cases  of  muco-membranous  colitis)  than  after  the  first  injection 
being  generally  expelled.  The  irrigation  is  followed  by  a  bath  at 
100°  F.,  and  a  douche  at  110°  F.  is  played  through  the  cooler 
water  of  the  bath  on  to  the  abdomen  with  a  finely-perforated  nozzle. 
The  treatment  is  continued  for  about  three  weeks. 

OPERATIVE  TREATMENT. 

When  constipation  is  the  result  of  definite  organic  obstruction 
of  the  intestine,  operative  treatment  is  plainly  indicated.  Various 
operations  have  recently  been  introduced  for  the  relief  of  severe 
constipation  in  the  absence  of  any  such  clear  indications,  but  the 
results  hitherto  obtained  have  not  been  sufficiently  good  to  warrant 
surgical  interference  except  under  most  exceptional  conditions. 

(1)  Division     of    Adhesions. — In   the   belief    that   peritoneal 
adhesions,  especially  at  the  hepatic  flexure,  are  a  frequent  cause  as 
well  as  a  result  of  constipation,  the  effect  of  dividing  adhesions  in 
constipated  patients  has  been  tried,  but  the  results  obtained  were 
unsatisfactory.     This  is  due  to  the  fact  that  the  adhesions  are  not 
as  a  rule  either  a  cause  or  a  result  of  constipation  ;  moreover,  it  is 
always  exceedingly  difficult  to  prevent  the  re-formation  of  adhesions 
after  they  have  been  divided. 

(2)  Short-circuiting  Operations. — In  the  very  exceptional  cases 
of   severe   constipation   associated  with  pain  or  well-marked  con- 
stitutional  symptoms,    which   are  unrelieved  by  all  other  means, 
and   which   are   not   the   result   of   dyschezia,    a   short-circuiting 

30—2 


468  Constipation  in  Adults. 

operation  may  be  required.  Before  resorting  to  surgery,  however, 
a  thorough  skiagraphic  investigation  should  be  made,  in  order  to 
exclude  dyschezia  and  to  discover  in  what  part  of  the  large 
intestine  the  delay  takes  place,  so  that  only  the  part  of  the  colon  in 
which  stasis  is  occurring  should  be  short-circuited  instead  of  the 
whole  of  the  colon,  as  in  ileo-siginoidostomy. 

(3)  Exclusion   of  the    Colon. — After    the    failure    to    relieve 
constipation   by    division    of    peritoneal   adhesions,    the   effect   of 
exclusion  of  the  colon  by  division  of  the  end  of  the  ileum,  which 
was  implanted  into  the  pelvic  colon  or  rectum,  was  tried.     But 
trouble  was  often  caused  by  the  collection  of  faecal  material  in  the 
blind  end  of  the  colon,  owing  to  the  accumulation  of  the  secretion 
of  the  large  intestine,  which  is  insufficient  in  bulk  and  in  irritating 
constituents  to  stimulate  the  caecum  and  colon  to  empty  themselves 
without  the  aid  of  the  contents  of  the  ileum. 

(4)  Colectomy. — The  more  radical  operation  of  colectomy  has 
therefore  been  performed  on  a  large  number  of  constipated  patients 
during  the  last  few  }'ears.     But  the  mortality  is  high,  even  in  the 
hands  of  the  most  experienced  surgeons.     Moreover,  the  principle 
of  the  operation  is  wrong,  as  it  is  assumed  that  the  whole  of  the 
large   intestine   is   not   performing  its   functions    normally.      My 
X-ray   observations   have  proved   that  in  a  large  number  of  the 
severest  cases  of  constipation  there  is  no  delay  in  the  passage  of 
faeces  through  the  colon  at  all,  but  that  dyschezia  is  present,  the 
act  of   defaeeation   being   inefficient,    largely    owing    to   abnormal 
conditions  of  the  pelvic  colon  and  rectum.     When  colectomy  is 
performed   in  such   cases,    a  normal   colon   is   removed,   and   an 
abnormal   rectum   and  often   an   abnormal   pelvic  colon  are    left 
behind.     The    cases   in   which    constipation   has   remained   after 
colectomy  were  probably  of  this  nature.     In  severe  cases  of  con- 
stipation not  due  to  dyschezia,  the  delay  is  generally  confined  to 
a   single   segment   of  the   colon,  such   as  the  splenic  flexure,   in 
the   case   of   which   an   unoffending   caecum   and  ascending  colon 
would    be    removed    by    the   operation.      It   is    therefore    much 
wiser  to  perform  the  safer  and  more  rational  operation  of  lateral 
anastomosis,  in  order  to  short-circuit  the  part  affected   and  that 
part   alone,  as  already  suggested,  than  to  perform  an  operation 
which,  even  in  the  most  skilful  hands,  has  a  high  mortality,  and  in 
which  the  prospects  of  complete  relief  are  by  no  means  certain. 

(5)  Appendicostomy. — Appendicostorny    has     recently    been 
recommended  as  a  method  of  treating  chronic  constipation ;  the 
patient  is  taught  to  pour  a  saline  purgative  or  cascara,  dissolved 
in  a  pint  of  hot  water,  through  a  catheter  introduced  by  way  of 


Constipation  in  Adults.  469 

the  appendix  into  the  caecum.  By  this  means  it  is  said  that  a 
painless  action  of  the  bowels  can  be  readily  obtained.  This  opera- 
tion has  more  to  be  said  in  its  favour  than  colectomy,  as  it  is 
comparatively  simple  and  does  not  appear  ever  to  have  been 
fatal.  It  is,  moreover,  reasonable  to  expect  that  the  colon  can  be 
more  effectively  washed  out  from  above  than  below.  But  when  it  is 
remembered  that  fecal  accumulations  occur  much  more  frequently 
in  the  distal  than  in  the  proximal  part  of  the  colon  and  in  cases  of 
dyschezia  in  the  rectum  and  pelvic  colon  alone,  it  is  clear  that 
water  has  less  distance  to  traverse  in  order  to  reach  the  accumu- 
lations when  introduced  through  the  anus  than  when  introduced 
through  the  appendix.  Moreover,  faeces  often  stick  so  tenaciously 
to  the  mucous  membrane  that  it  is  difficult  to  clear  the  colon  even 
with  a  really  strong  current  of  water.  Lastly,  it  is  not  clear  what 
advantage  can  be  gained  by  giving  a  saline  purgative  or  cascara  by 
the  appendix  instead  of  by  the  mouth,  particularly  as  it  has  now 
been  demonstrated  that  the  former  acts  only  after  absorption  into 
the  blood. 

ARTHUR  F.  HERTZ. 

REFERENCES. 

Discussion  on  "  The  Treatment  of  Constipation  "  in  the  Medical  Section  of 
the  British  Medical  Association,  July,  1910.  Brit.  Med.  Journ.,  1910,  II., 
pp.  1041—46. 

Hertz,  A.  F.,  "Constipation  and  Allied  Intestinal  Disorders,"  London,  1909. 

Froussard,  "  Le  Traitement  de  la  Constipation,"  Paris,  1903. 

Goodhart,  Sir  J.  F.  ;  Lancet,  1902,  II.,  p.  1244. 


470 


THE  OPERATIVE  TREATMENT  OF  CHRONIC  CON- 
STIPATION DUE  TO  DISEASE  OR  ABNORMALI- 
TIES OF  THE  COLON. 

THE  cases  which  require  operation  are  those  in  which  the  patient 
is  becoming  seriously  ill  from  auto-intoxication,  and  in  which  the 
bowels  cannot  be  made  to  act  regularly  either  by  enemata,  aperients 
or  massage.  Here  an  operation  is  certainly  the  best  treatment,  and 
is  quite  justified. 

Three  methods  have  been  advised,  viz. :  (1)  To  perform  appendi- 
costomy  in  order  that  the  colon  may  be  washed  out  daily  and  the 
accumulation  of  faecal  material  within  it  thereby  prevented ;  (2)  to 
short-circuit  the  colon  by  performing  ileo-sigmoidostomy ;  (3)  to 
resect  the  entire  colon. 

Appendicostomy. — It  is  obvious  that  the  material  which  is 
retained  in  the  colon  causes  the  auto-intoxication.  If  we  can 
prevent  this  retention  we  shall  be  able  to  stop  the  chronic  poison- 
ing from  which  the  patient  suffers.  If  an  appendicostomy  is 
performed  the  patient  is  able  to  wash  out  the  colon  daily  and  so 
prevent  accumulation.  The  results  have  in  most  cases  been 
extremely  encouraging,  and  the  daily  irrigation  has  caused  rapid 
and  marked  improvement  in  the  patient's  general  condition. 
Further,  in  several  cases  after  irrigation  has  been  carried  out 
continuously  for  some  time,  there  have  been  signs  that  the  colon 
was  recovering  its  lost  functions,  the  bowels  having  begun  to  act 
regularly  without  the  irrigation.  Appendicostomy  has  an  advantage 
over  the  other  two  operations  mentioned,  in  that  it  is  practically 
unattended  by  any  risk  to  life,  and  that  it  does  not  in  any  way 
mutilate  the  patient  or  leave  a  condition  which  may  at  some  later 
period  cause  trouble. 

Ileo-sigmoidostomy. — In  October,  1900,  Mr.  Mansell  Moullin 
published  a  case  in  which  he  had  performed  this  operation  for 
chronic  constipation,  and  Mr.  Arbuthnot  Lane  published  a  paper 
advocating  it  in  1904. 

Mr.  Lane,  who  has  performed  a  number  of  these  operations, 
found  that  the  results  were  satisfactory,  but  that  the  partially 
excluded  colon  was  a  source  of  danger,  and  this  has  led  him  to 
advocate  complete  resection  of  the  colon,  the  ileum  being 
implanted  into  the  sigmoid  flexure  or  rectum. 

P.  LOCKHART  MUMMERY. 


DIARRHCEAL    DISEASES    IN    CHILDREN* 

ONE  of  the  commonest  symptoms  of  intestinal  disturbance  in 
early  life  is  diarrhoea,  which  may  result  from  many  different  causes. 
In  some  cases  it  is  led  up  to  by  constitutional  disease,  such  as 
rickets ;  or  it  may  be  due  to  irritation  from  the  bowel  contents, 
for  example,  a  mass  of  indigestible  food  ;  or  it  may  be  due  to  a 
lesion  of  the  bowel  wall,  such  as  ulceration  ;  or  it  may  be 
the  result  of  excessive  peristalsis  of  nervous  origin,  as  in  lienteric 
diarrhoea.  In  the  most  marked  and  fatal  form,  known  as  acute 
summer  diarrhoea  of  infants,  we  have  a  definite  diarrhoeal  disease 
clearly  due  to  an  acute  infective  inflammation  of  the  alimentary 
tract.  In  the  case  of  a  symptom  with  such  a  multiplicity  of  causes 
it  is  essential  for  successful  treatment  that  a  careful  examination 
should  be  made  as  to  the  diet,  the  condition  of  the  abdomen,  and 
the  presence  or  absence  of  constitutional  disease  or  symptoms,  in 
order  to  determine  the  etiological  factor  or  factors. 

A  large  number  of  cases  of  diarrhoea,  both  in  infancy  and  in 
childhood,  will  be  found  to  be  associated  with  improper  feeding. 
The  chief  faults  are  over-feeding,  too  frequent  feeding,  bad  food,  and 
unsuitable  food.  The  diarrhoea  may  be  acute  and  occasional,  or 
chronic  and  persistent.  It  may  be  accompanied  by  vomiting,  by 
colicky  pains,  and  by  the  passage  of  blood  and  mucus.  The 
stools  are  often  green,  offensive,  and  contain  undigested  particles 
of  food.  The  affection  may  be  apyrexial  in  the  milder  cases,  but 
in  the  more  severe  the  temperature  may  be  raised  for  some  time,  due 
to  active  inflammation  of  the  bowel  or  to  the  absorption  of  toxins. 

The  immediate  treatment  of  such  cases  of  diarrhoea  consists  in 
diminishing  the  amount  of  food  taken,  in  seeing  that  it  is  fresh 
and  sound,  and  in  clearing  out  any  irritating  material  left  in  the 
bowel.  In  the  milder  cases  the  amount  of  milk  taken  may  be 
safely  diminished  by  one-half,  while  in  the  more  severe  cases  it  is 
advisable  to  give  only  some  weak  veal  or  chicken  broth.  If 
vomiting  is  at  all  marked  it  is  a  good  rule  to  stop  the  milk  for 
a  time  and  to  wash  out  the  stomach  with  warm  saline  solution. 
The  great  essential,  rest  to  the  bowel,  cannot  be  secured  unless  the 
amount  of  food  is  severely  curtailed,  while  the  essential  needs  of  the 
infant  can  be  met  by  giving  it  freely  plain  water  or  barley-water  to 
drink. 


472          Diarrhoeal  Diseases  in  Children. 

The  bowels  should  be  cleared  by  repeated  small  doses  of  castor  oil 
( 1)1 10  to  irtl5)  every  four  hours  or  of  magnesium  sulphate  (5  gr.  to 
10  gr.)  every  four  hours,  for  a  few  days.  In  cases  accompanied  by 
pain  and  vomiting  one  may  substitute  a  mercurial  preparation, 
such  as  the  following :  1^  Hydrargyri  cum  Greta,  gr.  \ ;  Pulveris 
Ipecacuanhas  Compositi,  gr.  \\  Pulveris  Cretae  Aromatic!,  gr.  1. 
[U.S.P.  !£  Hydrargyri  cum  Greta,  gr.  \\  Pulveris  Ipecacuanhas 
et  opii,  gr.  \  ;  Pulveris  Aromatici,  gr.  T^  ;  Pulveris  Cretae  Compositi, 
gr.  1.].  Sig. :  One  powder  every  six  hours.  When  the  diarrhoea  is 
definitely  lessened,  and  appetite  is  present,  the  amount  of  food  may 
be  increased.  Equal  parts  of  milk  and  lime-water  or,  in  the  case  of 
infants  over  nine  months,  Benger's  food  and  milk  may  be  given, 
but  the  feeds  should  be  small  and  the  intervals  between  feeding  at 
least  two-and-a-half  hours.  Such  attacks  of  food  diarrhoea  in  older 
children  are  best  treated  by  a  full  initial  dose  of  calomel  (2  gr.  to 
3  gr.),  or  castor  oil  (5J  to  5ij),  so  as  to  ensure  the  removal  of  any 
irritating  masses  in  the  bowel.  A  similar  course  of  low  feeding  for 
a  few  days  is  ordered,  and  a  mixture  containing  sodium  bicarbonate 
5  gr.,  sodium  sulphocarbolate  5  gr.,  and  infusion  of  gentian  is  to 
be  ordered.  In  some  cases  where  the  irritation  seems  to  persist, 
after  the  bowels  have  been  thoroughly  emptied,  bismuth  in  full 
doses  (10  gr.  to  15  gr.)  may  be  given  every  four  hours. 

In  the  preventive  treatment  of  infantile  diarrhoea  special 
attention  must  be  directed  to  the  purity  and  freshness  of  the  milk. 
Whatever  views  one  may  hold  as  to  the  relative  advantages  of 
boiled  and  unboiled  milk,  it  may  safely  be  asserted  that  in  hot 
weather  all  cows'  milk  for  children's  use  should  be  boiled  for  two 
or  three  minutes  and  then  kept  on  ice  in  a  closed  or  covered  vessel. 
The  greatest  cleanliness  should  be  observed  in  connection  with  the 
feeding  bottles,  and  no  "  dummy  "  soothers  should  be  allowed  in 
the  infant's  mouth.  A  mild  attack  of  diarrhoea  in  summer  pre- 
disposes to  the  more  grave  infective  forms.  The  tendency  to  give 
young  infants  some  fruit,  which  is  so  common  with  nurses  in  the 
fruit  season,  should  be  severely  discouraged  as  very  dangerous. 
As  chilling  of  the  surface  of  the  trunk  or  limbs  often  directly 
induces  diarrhoea,  care  must  be  taken  that  the  child  is  sufficiently 
clothed  and  is  not  exposed  to  chills.  In  hot  weather  the  danger 
often  lies  not  in  too  few  but  in  too  many  clothes.  If  a  child  is  at 
all  delicate  or  subject  to  "  colds,"  it  is  customary  to  overload  it  with 
clothing  in  summer,  with  the  result  that  the  skin  is  constantly 
damp  from  sweating,  and  chilling  of  the  surface  of  the  body  can 
scarcely  be  avoided.  Such  a  chill  lowers  the  resisting  powers  of 
the  tissues  generally,  and  of  the  alimentary  canal  more  especially 


Diarrhoeal   Diseases  in  Children.  473 

so  that  an  attack  of  diarrhoea  often  follows.  The  clothing  should 
be  light  and  loose,  and  a  flannel  binder  ought  always  to  be  worn. 
These  precautions  are  specially  necessary  in  the  case  of  rickety 
infants. 

In  no  disease  of  early  life  will  the  therapeutic  resources  of  the 
practitioner  be  tested  more  fully  than  in  the  case  of  acute  summer 
diarrhoea  of  infants.  As  the  name  implies,  it  is  a  disease  of  hot 
weather,  and  interesting  observations  have  been  made  as  to  its 
association  with  a  certain  temperature  of  the  soil  as  the  summer 
heat  increases.  The  essential  point,  however,  is  that  the  disease  is 
due  to  contaminated  food,  and  more  especially  milk.  If  an  infant 
is  entirely  breast-fed  and  does  not  get  the  poison  introduced  into 
its  mouth  by  such  means  as  infected  "  comforters  "  or  toys,  there 
is  no  risk  of  the  development  of  this  disease.  The  exact  organism 
causing  this  form  of  disease  is  at  present  unknown,  although 
several  have  been  described,  and  Gaertner's  bacillus  has  been  found 
in  many  cases  of  the  disease.  A  large  mass  of  evidence  has  now 
been  brought  forward  in  support  of  the  view  that  contamination  of 
the  food  is  chiefly  brought  about  through  the  agency  of  the 
common  house-fly.  Bearing  infection  from  some  polluted  source, 
the  house-fly  settles  on  the  milk  supply  of  the  infant  and  infects  it 
with  the  particular  organism,  which  seems  to  flourish  abundantly 
in  all  forms  of  milk.  Having  this  in  mind,  a  wise  householder 
will  be  particularly  careful  in  summer  to  keep  his  house  and 
neighbourhood  free  from  all  breeding  and  feeding  places  for  flies, 
and  to  prevent  any  possibility  of  flies  reaching  the  milk  supply. 
All  rubbish,  such  as  bones,  stale  vegetables  or  fruit,  will  attract 
flies,  and  should  therefore  be  burned  at  once  or  kept  in  a  closed 
dustbin.  All  food  in  the  house  should  be  kept  covered  up  and 
protected  from  flies.  More  especially  does  this  apply  to  milk, 
and  it  is  not  sufficient  security  to  boil  the  milk,  for  boiled  milk 
will  be  contaminated  as  quickly  as  that  which  is  unboiled.  The 
experience  of  institutions  has  shown  that  the  disease  may  spread 
rapidly  amongst  young  infants.  Each  case,  therefore,  should  be 
treated  as  a  possible  source  of  infection,  and  special  feeding  vessels 
should  l>e  reserved  for  each  individual  patient,  while  all  the  stools, 
diapers,  etc.,  should  be  thoroughly  disinfected  as  in  the  case  of 
typhoid  fever. 

The  onset  of  an  attack  of  acute  summer  diarrhoea  is  usually 
sudden,  although  there  may  have  been  slight  gastro-intestinal 
disturbance  for  a  few  days  beforehand.  Vomiting  occurs,  the 
temperature  rises  rapidly,  and  the  motions  become  loose,  the 
emptying  of  the  bowel  being  often  accompanied  by  the  pain  of  colic. 


474  Diarrhoeal  Diseases  in  Children. 

The  condition  rapidly  becomes  worse  within  a  few  hours.  The 
motions,  at  first  loose  but  with  yellow  matter  in  them,  become  more 
watery.  Some  grey  or  green  material  may  be  present,  but  the 
chief  constituent  is  mucus  or  blood-stained  mucus.  Great  con- 
stitutional weakness  comes  on  ;  the  pulse  is  feeble  and  rapid,  the 
extremities  are  blue  and  cold,  and  the  whole  of  the  tissues  seem  to 
be  shrivelling  up. 

As  regards  the  treatment,  the  disease  is  so  acute  in  its  course, 
and  presents  so  many  and  such  diverse  symptoms,  that  no  one  line 
of  treatment  can  be  laid  down  as  suitable  for  all  cases.  In  the 
present  day  the  form  of  treatment  which  is  most  generally  adopted 
may  be  described  as  evacuant  and  eliminative.  The  first  object  is 
to  remove  the  poison  from  the  seat  of  its  active  production,  namely, 
the  gastro-intestinal  tract,  and  to  eliminate  from  the  blood  and 
tissues  the  organisms  and  toxins  which  have  found  an  entrance. 
At  the  same  time  one  must  prevent  the  introduction  into  the  body 
of  further  doses  of  the  poison,  or  of  food  materials  which  ma}'  prove 
a  suitable  medium  for  the  growth  of  these  organisms. 

Diet.  The  use  of  milk  in  any  form  must  be  stopped  at  once.  It  is 
especially  dangerous  in  this  disease,  as  it  adds  fuel  to  the  fire  which  is 
already  going  on  in  the  intestinal  tract.  We  have  therefore  to  find 
some  temporary  substitute  during  the  time  that  an  effort  is  being 
made  to  obtain  a  thorough  clearing  out  of  the  bowel.  In  very  acute 
cases  the  best  plan  is  to  stop  all  food  entirely,  and  to  give  only 
boiled  water  or  barley-water  or  rice-water  for  twenty-four  or  forty- 
eight  hours.  As  thirst  is  usually  a  marked  symptom,  this  water 
should  be  administered  frequently,  every  hour  or  two  hours,  but  in 
small  quantities  (2  to  3  oz.),  so  that  vomiting  should  not  be 
induced.  If  vomiting  is  a  severe  symptom,  it  may  be  necessary  to 
give  only  one  or  two  teaspoonfuls  of  water  at  intervals  of  fifteen  or 
twenty  minutes.  A  little  brandy  will  be  found  beneficial  if  given 
well  diluted,  a  teaspoonful  in  J  pint  of  water  during  the  day, 
and  the  same  amount  during  the  night.  At  the  end  of  thirty-six  or 
forty-eight  hours,  or  when  sufficient  time  has  been  allowed  for  the 
aperient  medicines  to  act,  a  beginning  should  be  made  with  feeding 
in  the  shape  of  albumin- water,  or  weak  veal,  mutton  or  chicken 
soup.  Here  the  rule  must  be  to  proceed  very  slowly  and  gradually, 
watching  the  effect.  Albumin-water  may  be  made  at  first  of  the 
strength  of  £  oz.  of  white  of  egg  to  \  pint  of  water,  and 
this  may  be  rendered  more  palatable  by  the  addition  of 
'2  drachms  of  extract  of  malt.  Similarly,  1  oz.  of  ordinary  soup 
may  be  diluted  with  5  oz.  of  water.  This  modified  diet,  with 
small  feeds  at  intervals  of  two  or  three  hours,  may  be  carried  on  for 


Diarrhceal  Diseases  in  Children.  475 

one  or  two  days,  until  the  diarrhcea  is  somewhat  lessened,  and  the 
motions  are  not  of  a  purely  mucous  or  watery  character.  The  third 
stage  is  reached  when  we  commence  tentatively  a  return  to  milk 
food.  A  trial  of  milk  in  one  or  other  form  should  be  made  by 
alternating  it  with  a  feed  of  soup  or  albumin-water.  Of  the  various 
forms  in  which  milk  may  be  used  at  this  time  the  following  repre- 
sents a  scale  of  digestibility  :  (1)  peptogenised  milk,  made  with 
peptogenic  milk  powders ;  (2)  whey ;  (3)  condensed  milk,  diluted 
with  twenty-four  parts  of  water ;  and  (4)  citrated  milk,  containing 
2  grains  of  citrate  of  soda  in  each  ounce  of  milk.  It  is  not  necessary 
to  take  every  infant  through  these  four  stages,  and  the  experience 
of  the  doctor  and  the  condition  of  the  patient  must  decide  which 
form  is  to  be  used.  If  milk  in  any  form  provokes  a  recurrence  of 
vomiting  or  diarrhoea,  its  use  must  be  suspended  fora  time.  Tolera- 
tion will  not  readily  be  established,  and  in  no  case  must  an  attempt 
be  made  to  feed  up  the  patient  rapidly.  The  chief  points  about  the 
dietetic  treatment  are :  (1)  to  give  no  food  until  the  stomach  can 
retain  and  digest  it ;  (2)  to  begin  with  very  weak  foods,  and  very 
small  meals  ;  and  (3)  to  let  the  patient  have  as  much  water  as  he  can 
retain,  so  as  to  compensate  for  the  great  loss  of  fluid  from  the 
tissues  and  to  wash  out  the  bowel. 

The  first  part  of  the  medicinal  treatment  consists  in  the  thorough 
cleansing  of  the  intestinal  tract  as  quickly  as  possible.  The  best 
drug  is  castor  oil,  which  is  more  effective  if  given  in  small  repeated 
doses.  From  5  to  10  drops  of  oleum  ricini  may  be  given  every 
four  hours  for  a  day  and  a-half ,  and  then  less  frequently.  It  is  usually 
well  tolerated  by  infants ;  but  if  there  is  much  gastric  disturbance 
and  vomiting,  it  may  be  necessary  to  wash  out  the  stomach  first 
Instead  of  castor  oil  small  doses  of  mercury  may  be  given,  especially 
if  the  vomiting  is  severe.  Grey  powder  (in  J-gr.  doses) 
or  calomel  (in  ^-gr.  doses)  may  be  given  every  two  hours 
until  six  doses  have  been  taken.  When  the  acute  symptoms  are 
subsiding  and  the  motions  are  becoming  less  frequent,  a  sedative 
and  astringent  mixture  may  be  given  as  follows :  fy .  Acidi  Sulphurici 
Aromatici,  in2  ;  Tr.  Camph.  Co.,  nt.4  ;  Tr.  Chlorof.  Co.,  ni2 ;  Tr. 
Goto,  irt3 ;  Syr.  Aurantii  Floris,  1118;  Aq.  Menth.  Pip.,  ad  33. 
Sig. :  One  drachm  every  six  hours.  fy.  Or,  Sp.  Aminon.  Arorn., 
in  4 ;  Tr.  Catechu,  111 3 ;  Tr.  Cardam.  Co.,  in.3;  Tr.  Opii,  rrt^  ; 
Mist.  Gretas,  ad  5]  [U.S.P.  1^.  Sp.  Ammon.  Arom.,  n\_4 ;  Tr. 
Gambir.  Co.,  in.12;  Tr.  Cardam.  Co.,  in.3  ;  Tr.  Opii,  irt|;  Mist. 
Cretae,  5ss;  Aquam,  ad  5j].  Sig. :  One  drachm  every  six  hours. 

Various  symptoms  may  be  present  which  call  for  special  treatment. 
When  vomiting  is  severe  the  stomach  should  be  washed  out  with  a 
weak  solution  of  Coudy's  fluid,  or  of  bicarbonate  of  soda  (gr.  10  to 


476          Diarrhoeal  Diseases  in  Children. 

1  pint).  Until  this  has  been  done  it  is  often  impossible  to  adopt 
any  effective  treatment.  The  substitution  of  rectal  feeding  for 
stomach  feeding  is  useless,  as  the  bowel  is  not  in  a  condition  to 
retain  or  absorb  anything.  The  sedative  effect  of  washing  out  the 
stomach  will  be  increased  by  the  application  of  hot  fomentations  to 
the  abdomen.  When  severe  colicky  pain  is  present,  associated  with 
tenesmus,  4  or  5  minims  of  paregoric  may  be  given  to  secure 
relief.  The  use  of  opium  in  this  affection  is  not  without  danger, 
and  it  should  not  be  given  if  the  patient  is  in  a  collapsed  or  semi- 
conscious condition.  Opium  should  not  be  given  in  a  solid  form,  as 
in  Dover's  powder,  as  it  probably  will  not  be  absorbed.  If  opium  is 
contra-indicated,  pain  may  be  relieved  by  giving  the  tincture 
of  belladonna  in  doses  of  2  or  3  minims  every  four  hours. 
Washing  out  the  lower  bowel  with  hot  water  will  also  tend  to  relieve 
the  straining  pain,  and  will  at  the  same  time  clear  out  a  consider- 
able amount  of  irritating  matter.  The  water  should  flow  from  a 
fountain  syringe  at  a  height  of  2  feet,  and  should  enter  through 
a  soft  rubber  catheter  introduced  as  high  as  possible  into  the  bowel. 
The  motions  are  sometimes  so  offensive  as  to  render  the  air  of 
the  room  most  unpleasant.  The  addition  of  1  or  2  gr.  of  salol 
to  the  castor-oil  mixture  will  help  materially  in  reducing  the  offen- 
siveness  of  the  motions.  By  its  use  also  the  stools  will  be  rendered 
less  acrid  and  irritating  to  the  anus  and  buttocks.  The  restlessness 
and  sleeplessness  of  the  acute  stage  will  be  greatly  relieved  by  the 
use  of  hot  baths  or  hot  packs.  The  effect  of  the  bath  may  l»c 
increased  by  the  addition  of  1  or  2  drachms  of  mustard.  The 
value  of  hot  baths  in  this  affection  cannot  be  over-estimated.  In 
addition  to  calming  the  nervous  system,  and  thereby  inducing 
much-needed  sleep,  they  are  stimulating,  and  by  their  action  on  the 
skin  help  to  eliminate  the  poison  from  the  system.  The  great  loss 
of  fluid  produced  by  the  diarrhoea  often  leads  to  a  condition  of 
collapse,  of  shrivelling  up  of  the  tissues,  and  of  cardiac  weakness. 
This  condition  is  best  treated  by  the  subcutaneous  injection  of 
normal  saline  fluid.  From  6  to  8  oz.  may  be  injected  at  a  time 
into  the  loose  tissues  of  the  axilla  or  the  abdominal  wall,  and 
the  warm  fluid  should  be  allowed  to  enter  slowly,  so  as  to  avoid  the 
risks  of  sloughing  or  haemorrhage.  The  benefit  thus  obtained  may 
be  increased  by  giving  small  doses  of  brandy,  nux  vomica,  or  strych- 
nine. Injections  of  saline  fluid  serve  a  further  beneficial  purpose 
in  aiding  the  elimination  of  the  toxins  from  the  blood  and  tissues, 
and  should  be  repeated  as  often  as  necessary  to  reinforce  the  fluids 
of  the  body.  Strychnine  is  of  undoubted  advantage  in  collapse 
from  cardiac  weakness,  and  is  best  administered  hypoderinically  in 


Diarrhceal   Diseases  in  Children.  477 

doses  of  ^  minim  of  the  liquor  strychninae  [U.S.P.  strychnin, 
hydrochlor.  gr.  ^Jn]  every  four  hours.  The  reaction  of 
infants  to  strychnine  in  the  toxic  condition  present  is  very 
much  less  than  in  healthy  subjects,  and  full  doses  may  safely 
be  given.  The  value  of  brandy  as  a  stimulant  is  undoubted 
if  given  in  small  doses,  but  it  is  very  questionable  if  large  doses  are 
beneficial  in  this  affection.  For  an  infant  of  six  months  suffering 
from  summer  diarrho?a  \  oz.  of  brandy  daily  is  a  maximum 
amount.  If  the  beneficial  effect  of  brandy  is  not  clearly  evident, 
it  is  better  to  limit  the  amount  to  1  or  2  drachms  a  day.  After 
the  subsidence  of  the  attack,  a  prolonged  period  of  convalescence 
follows,  characterised  by  impaired  nutrition  and  intestinal  weakness. 
The  feeding  must  be  very  carefully  regulated,  and  a  change  to  the 
country  or  seaside  is  advisable  in  the  case  of  town-dwellers. 

The  astringent  treatment  of  summer  diarrhtea  has  its  advocates, 
but  is  not  to  be  recommended  during  the  acute  stage.  Such  drugs 
as  catechu,  coto,  tannigen,  chalk,  etc.,  will  be  found  useful  in  some 
cases  after  the  bowel  has  been  thoroughly  emptied  and  the  diarrhoea 
is  lessening.  The  antiseptic  treatment  has  also  failed  to  prove  a 
specific  for  this  disease.  Carbolic  acid,  creosote  and  perchloride  of 
mercury  have  been  tried  as  a  means  of  destroying  the  organisms  in 
the  alimentary  canal,  but  without  definite  success.  Both  serum 
and  vaccine  treatment  are  at  present  on  trial.  These  cannot  be 
expected  to  prove  practical  methods  of  cure  until  the  organism 
which  is  the  etiological  factor  has  been  isolated  and  cultivated.  So 
far  Shiga's  bacillus,  Gaertner's  bacillus  and  Morgan's  bacillus  have 
all  been  claimed  as  the  causa  causans,  but  the  serums  produced 
have  not  fulfilled  the  hopes  of  the  discoverers.  It  is  probably  on 
this  line  of  investigation,  however,  that  one  may  look  for  a  specific 
curative  treatment. 

The  Lienteric  Form  of  Diarrhoea  is  characterised  by  a  chronic 
looseness  of  the  bowels  or  frequency  of  action.  The  immediate 
stimulus  is  the  taking  of  food,  fluid  or  solid,  into  the  stomach,  and 
there  is  probably  a  reflex  passing  from  the  stomach  to  the  lower 
bowel  in  which  the  nervous  control  is  unstable.  This  quick  action 
on  the  taking  of  food  leads  to  the  common  description  "  that  the 
food  passes  right  through  him."  In  such  cases  it  is  not  necessary 
to  put  the  child  on  a  milk  or  sloppy  diet,  for  digestion  is  usually 
quite  normal.  If  on  physical  examination  the  abdominal  condition 
calls  for  no  special  treatment,  the  patient  may  be  put  on  an  ordinary 
plain  mixed  diet,  care  being  taken  that  there  is  no  overloading  of 
the  stomach.  The  sufferers  are  usually  nervous  little  subjects,  so 
that  a  quiet  life  should  be  ordered.  Much  benefit  will  usually 


478          Diarrhoeal  Diseases  in  Children. 

follow  from  a  course  of  arsenic  and  bromide.  Two  drops  of 
Fowler's  solution  and  5  gr.  of  potassium  bromide  may  be 
given  three  times  a  day  after  meals.  If  this  fails  to  check  the 
trouble,  2  or  3  drops  of  liquor  opii  sedativus  may  be  added  to 
the  mixture.  Eelapses  are  not  uncommon,  but  may  be  met  by 
another  course  of  treatment,  as  described  above.  The  nervine 
tonics,  nux  vomica  and  iron,  may  be  given  with  advantage  after 
the  special  treatment  is  ended. 

G.  A.  SUTHERLAND. 


479 


ENTERITIS  (ACUTE  AND  CHRONIC)  IN  ADULTS. 

THIS  condition  is  recognised  clinically  as  diarrhoea,  and  if  we 
restrict  enteritis  to  inflammation  of  the  small  intestine  the 
diarrhoea  is  characterised  by  the  presence  of  bile  or  particles  of 
food  and  the  absence  of  mucus.  It  may  be  either  acute  or 
chronic. 

Treatment  of  Acute  Diarrhoea. — This  may  be  directed  to  three 
objects :  (1)  To  remove  the  cause ;  (2)  to  heal  the  anatomical  lesion  ; 
and  (3)  to  remove  or  alleviate  symptoms. 

Under  the  first  of  these  headings  we  have  to  consider  the  very 
large  number  of  causes  to  which  acute  enteritis  may  be  due.  There 
are  the  primary  causes,  including  improper  food,  such  as  uncooked 
fruit  and  vegetables,  imperfectly  converted  starch,  as  well  as  seed 
husks  and  bran  ;  the  various  organic  poisons  in  decomposing  milk, 
meat  or  fruit ;  inorganic  poisons,  such  as  antimony  ;  the  action  of 
specific  organisms  taken  with  the  food  but  not  killed  by  the  action 
of  the  gastric  juice;  changes  of  temperature,  and  perhaps  nervous 
influences  giving  rise  to  the  acute  diarrhoea  from  which  recruits  in 
battle  or  candidates  at  examinations  sometimes  suffer. 

Then  there  are  the  numerous  secondary  causes,  including  the 
various  infectious  diseases  in  which  enteritis  is  symptomatic,  such 
as  typhoid  fever  and  septicaemia  ;  inflammation  extending  from 
neighbouring  parts  and  that  depending  upon  circulatory  disturb- 
ances ;  congestion  of  the  portal  system  from  liver,  lung  or  heart 
disease ;  various  cachectic  conditions,  such  as  Bright's  disease  and 
diabetes  ;  and,  lastly,  the  catarrh  that  may  be  set  up  by  intestinal 
parasites,  e.g.,  tape  worms  or  round  worms. 

Obviously  all  these  conditions  require  appropriate  treatment  and 
this  presupposes  accurate  diagnosis.  It  would  be  outside  the  pur- 
pose of  the  present  writer  to  pursue  this  subject  further ;  it  must 
suffice  to  say  that  the  cause  in  each  case  must  be  sought  for  and 
where  possible  removed. 

The  second  object  of  treatment  is  to  heal  the  anatomical  lesion. 
In  acute  diarrhoea  we  endeavour  to  do  this  by  keeping  the  parts  at 
rest,  and  this  we  seek  to  effect  by  sending  the  patient  to  bed.  Food 
should  be  withheld  which  may  cause  irritation  either  by  its 
mechanical  condition  or  its  chemical  properties  ;  only  bland  liquid 
or  semi-liquid  diet,  such  as  milk  and  lime-water,  should  be  allowed  ; 


480     Enteritis  (Acute  and  Chronic)  in  Adults. 

a  hot  poultice  or  a  hot  fomentation  or  a  Priessnitz  compress  should 
be  applied  over  the  abdomen  ;  the  last  is  a  towel  folded  lengthways 
and  wrung  out  of  hot  water,  wrapped  round  the  abdomen  and 
covered  with  a  double  layer  of  thick  flannel  to  prevent  the  escape  of 
heat. 

Lastly,  the  removal  or  alleviation  of  symptoms  is  ensured  best  by 
opium  or  by  one  of  its  preparations  combined  with  carminatives  ; 
by  this  means  pain  is  allayed,  and  by  checking  peristalsis  the 
frequency  of  the  stools  is  diminished.  A  mixture  of  milk  and 
lime-water  in  equal  parts  should  be  prescribed ;  1  oz.  every 
hour.  This  quantity  may  be  increased  to  2  oz.  if  desired, 
should  it  be  retained  and  cause  no  pain  or  discomfort.  In  hot 
weather  it  may  be  iced.  To  relieve  thirst  it  is  better  not  to  increase 
the  amount  of  milk  but  to  give  a  lemonade  containing  dilute 
sulphuric  acid:  R.  Tr.  Limonis,  £Jss  ;  Ac.  Sulph.  Aromat., 
5ss ;  Aq.,  ad  Oj.  [U.S.P.  1^.  Tr.  Limonis,  5vj  ;  Acid.  Sulph. 
Aromat.,  iri.20 ;  Aq.,  ad.  Oj.].  Sig.  :  To  be  taken  freely. 

The  following  anodyne  and  astringent  mixture  may  be  given 
every  four  hours:  1^.  Bismuthi  Carb.,  Sodii  Bicarb.,  aa  gr.  10; 
Tr.  Opii,  irilO;  Muc.  Tragacanth.,  rn.10  ;  Sp.  Chloroformi, 
iri,15;  Aq.,  ad  jj  [U.S.P.  1^.  Bismuth.  Carb.,  Sodii  Bicarb.,  aa 
gr.  10;  Tr.  Opii,  111,6;  Muc.  Tragacanth,  ir[2  ;  Sp.  Chloroformi, 
tril2;  Aq.,  ad  jj]. 

Where  there  is  vomiting  nothing  should  be  given  by  the  mouth, 
but  Inject.  Morphinae  Hypoderm.,  gr.  •£,  administered,  or  enema 
opii,  gij,  given  by  the  rectum. 

Diarrhoea  caused  by  mushroom  poisoning  should  be  treated  by 
belladonna  or  atropine :  1^.  Tr.  Belladonnse,  ir|.15  ;  Sp.  Chloroformi, 
m20;  Aq.,  ad  jj  [U.S.P.  3.  Tr.  Belladonna,  in.20;  Sp. 
Chloroformi,  ni!6  ;  Aq.,  ad  31].  Inj. :  Atropinee  Hypoderm.,  wi4 
[U.S.P.  Atropin  Sulph.,  gr.  ^J.  A  dose  every  hour  until  dryness 
of  the  throat  or  dilatation  of  the  pupils  comes  on. 

Treatment  of  Chronic  Diarrhoea. — The  objects  of  treatment 
are  the  same  as  in  acute  diarrhoea  though  the  causes  may  differ, 
but  the  principle  holds  good  that  these  must  be  sought  for  and 
removed  wherever  possible.  Secondly,  the  anatomical  conditions 
are  usually  less  amenable  to  treatment,  or  show  less  tendency  to 
recover  spontaneously,  but  depend  upon  more  or  less  permanent 
conditions  and  are  associated  with  gross  anatomical  alterations, 
where  it  is  useless  to  expect  a  restitutio  ad  intcgrum.  The  most  that 
can  be  hoped  for  is  by  avoiding  irritation  to  diminish  congestion  and 
restrain  exudation  or,  by  checking  abnormal  fermentations  and  the 
growth  of  pathogenic  microbes,  to  determine  healthier  action  in  the 


Enteritis  (Acute  and  Chronic)  in  Adults.     481 

structures  concerned,  to  promote  the  healing  of  ulcers,  and  to  restore 
the  lining  of  the  bowel  so  far  as  possible  to  its  former  healthy  state. 
The  chief  place  in  this  treatment  must  be  assigned  to  diet,  but  we 
have  to  recognise  that  a  patient  may  suffer  from  chronic  diarrhoea 
for  weeks,  months,  or  even  years,  and  that  his  diet  must  be  so 
arranged  that  it  will  supply  all  the  needs  of  his  body  and  enable 
him  to  perform  his  daily  duties  as  far  as  possible.  Such  a  diet 
will  exclude  all  superfluous  and  indigestible  articles,  and  those  that 
are  mainly  useful  as  affording  bulk,  e.g.,  vegetables  containing 
cellulose.  This  substance  is  of  great  value  in  promoting  intestinal 
peristalsis,  and  its  absence  is  regarded  by  many  as  responsible  for  the 
constipation  which  is  the  common  affection  of  civilised  peoples ;  but 
in  the  condition  we  are  considering  there  is  no  need  to  stimulate 
peristalsis,  so  that  cellulose  must  be  carefully  excluded.  The 
vegetables  which  contain  it  most  abundantly  are  :  green  vegetables, 
leeks,  radishes,  carrots,  turnips,  parsnips,  celery  and  kidney  beans ; 
it  is  also  present  in  nuts  and  in  most  fruits.  The  vegetables  that 
contain  least  cellulose  are  cauliflowers,  young  spinach,  cucumber, 
vegetable  marrow,  potato,  artichoke,  onion,  green  peas.  Of  fruits 
grapes  and  apples  may  be  mentioned.  The  permitted  vegetables 
should  be  given  in  the  form  of  purees,  that  is,  strained  to  remove  all  but 
a  fine  semi-liquid  paste.  Apples  may  be  eaten  reduced  to  a  pulp  in 
the  form  usually  served  as  apple  sauce ;  boiled  rice  may  often  take 
the  place  of  a  vegetable,  as  it  is  free  from  cellulose.  All  articles 
containing  bran,  such  as  brown  bread  and  oatmeal,  must  be  for- 
bidden ;  all  starchy  food  must  be  well  cooked,  a  condition  which 
excludes  pastry.  Meats  must  be  finely  divided  and  their  fibre 
should  be  easily  digestible,  so  that  we  must  prohibit  smoked  and 
salted  meats  and  fish,  pork  and  veal,  duck  and  goose,  salmon, 
mackerel  and  eel,  lobster  and  crab. 

It  is  best  to  prescribe  a  stringent  diet  at  first  in  order  to  get 
the  disease  under  control ;  this  may  be  exclusively  milk  or 
milk  thickened  with  flour,  a  tablespoonful  to  a  pint,  or  under- 
done minced  or  scraped  meat,  three  meals  a  day  each  of  4  oz., 
the  meat  being  freed  from  fat,  cooked  lightly  and  eaten  with- 
out condiments,  bread  or  vegetables,  each  meal  to  be  followed  two 
hours  later  by  £  pint  of  hot  water.  But  on  this  diet  the  amount  of 
nourishment  given  is  so  small  that  the  patient  should  be  kept  as 
much  as  possible  at  rest.  When  the  tongue  is  clean  and  the  stools 
are  better  formed  the  diet  should  be  modified.  The  change  should  be 
gradual,  at  first  involving  only  one  meal  and  one  article  of  food,  so  that 
if  the  result  is  unfavourable  the  cause  may  be  detected  and  it  is  easy 
to  retrace  our  steps.  In  making  changes  it  should  be  remembered 

S.T.— VOL.  II.  31 


482     Enteritis  (Acute  and  Chronic)  in  Adults. 

that  food  is  likely  to  be  well  borne  in  something  like  the  following 
order  :  Animal  food,  including  milk,  eggs  and  meat ;  starchy  food, 
including  the  pure  starches,  fine  flours  and  sugar ;  lastly,  well- 
cooked  vegetables  or  fruits.  The  last  should  be  selected  from  those 
which  contain  the  minimum  of  cellulose.  It  is  generally  necessary 
to  give  patients  positive  dietaries  as  well  as  lists  of  articles  of  food 
to  be  avoided.  Sour  milk  made  with  the  lactic  acid  bacillus  is 
valuable  in  some  cases  of  chronic  diarrhoea  ;  about  a  pint  should  be 
taken  daily.  It  may  be  started  with  the  well-known  cultures  and 
then  inseminated  from  day  to  day  with  a  spoonful  of  that  which  has 
been  made,  being  kept  at  a  suitable  temperature  in  a  thermos  flask. 
The  most  useful  drugs  are  opium  and  its  alkaloids,  arsenic,  the 
biniodide  and  bichloride  of  mercury,  bismuth,  vegetable  astringents 
containing  tannin  and  carminatives  such  as  the  essential  oils  :  1^ . 
Bismuthi  Garb.,  Sodii  Bicarb.,  aa  gr.  10;  Tr.  Catechu,  5  ss. ;  Muc. 
Tragacanth.,  ir[10;  Aq.  Cinnamomi,  ad  §j  [U.S.P.  J^.  Bismuthi 
Carb.,  Sodii  Bicarb.,  aa  gr.  10 ;  Tr.  Gambir.  Co.  5ij ;  Muc.  Traga- 
canth.,ii|  2;  Aq.  Cinnamomi,  ad  £j].  Sig.:  Two  tablespoonfuls  before 
each  meal.  This  mixture  may  be  strengthened  by  adding  10  min.  of 
tincture  of  opium  or  Collis  Browne's  chlorodyne  to  each  dose,  and 
after  the  diarrhoea  has  been  checked  this  can  be  left  out  and  the 
original  mixture  continued  as  long  as  necessary  :  1^.  Liq.  Hydrarg. 
Bichlor.,  5  ss. ;  Liq.  Arsenicalis,  iTj.5 ;  Pot.  lodidi,  gr.  2  ss.  ;  Inf. 
Gent.  Co.,  ad  §j  [U.S.P.  I£.  Hydrarg.  Chlor.  Corrosiv.,  gr.  g1^  ;  Liq. 
Potass.  Arsenitis,  iri5  ;  Pot.  lodidi,  gr.  2  ss.  ;  Inf.  Gent.  Co.,  ad  33']. 
Sig.  :  Two  tablespoonfuls  three  times  a  day  after  meals. 

ROBERT  SAUNDBY. 


FISTUIJE  OF  THE  INTESTINES. 

FISTULA  of  the  intestine  may  be  external  or  internal ;  the  former 
open  upon  the  surface  of  the  skin,  whilst  the  latter  are  bi-mucous 
and  open  into  another  abdominal  viscus.  Further,  the  external 
fistulae  are  of  two  degrees  of  completeness  ;  in  one,  the  simple  fistula, 
the  main  channel  of  the  gut  is  not  diverted  by  the  fistula,  but  there 
is  a  mere  leakage  of  faecal  material  through  it  ;  in  the  other  the 
faecal  stream  pours  out  at  the  fistula  itself,  and  the  latter  is  known 
as  an  artificial  anus.  One  of  two  conditions  must  be  present  in 
order  to  divert  the  faeces  through  an  abnormal  opening  in  the 
intestinal  wall,  either  the  presence  of  a  spur  of  bowel  dividing  the 
orifice  of  the  fistula  into  afferent  and  efferent  channels,  or  else  the 
existence  of  obstruction  of  the  bowel  beyond  the  fistula.  This 
distinction  between  fistulae  which  are  mere  faecal  leaks  and  those 
which  are  functionating  as  an  anus  is  of  cardinal  importance  in 
treatment,  because  in  the  latter  case  the  condition  cannot  be  cured 
until  the  gut  below  is  quite  patent  and  functional. 

SIMPLE  EXTERNAL  FISTULA. 

These  may  be  caused  by  many  different  factors,  inflammation, 
trauma  and  congenital  defects  being  the  chief.  (1)  Inflammation : 
(a)  Simple  :  Appendicitis,  pericolitis,  peritonitis,  hernia ;  (b)  Specific  : 
tuberculosis,  actinomycosis,  cancer;  (2)  trauma,  injury,  opera- 
tions, extrusion  of  foreign  bodies ;  (3)  congenital  (see  Affections 
of  the  Umbilicus ).  Of  these  appendicitis  and  tuberculosis  account 
for  the  great  majority. 

In  some  cases  the  bowel  is  attached  directly  to  the  skin  or 
parietes  and  the  fistula  is  direct.  This  is  the  case  in  the  majority 
of  operative  or  traumatic  origin.  In  others  a  more  or  less  extensive 
and  complicated  abscess  cavity  intervenes  between  the  bowel  and 
the  surface  and  the  fistula  is  indirect. 

The  urgency  of  these  conditions  for  treatment  depends  upon  their 
size,  position  in  the  intestine,  and  the  amount  of  suppuration  occur- 
ring in  an  accompanying  abscess.  A  widely  open  fistula  of  the  small 
intestine  or  caecum,  such  as  is  left  after  operations  done  for  the 
relief  of  urgent  obstruction,  will  constantly  discharge  large  quantities 
of  irritating  faeces  so  that  the  patient's  life  becomes  an  intolerable 
burden  ;  whereas  a  fistula  of  the  appendix  or  colon  may  merely 

31  —  2 


484  Fistulae  of  the  Intestines. 

cause  discomfort  by  its  intermittent  leaking.  If  any  doubt  exists 
as  to  the  part  of  bowel  with  which  the  fistula  communicates,  there 
are  several  methods  at  our  disposal  of  determining  this  point,  for  it 
must  be  borne  in  mind  that  the  situation  of  the  external  opening 
of  the  fistula  may  be  widely  distant  from  the  intestinal.  For 
example,  cscal  fistulae  of  appendical  origin  may  open  behind  the 
right  loin,  at  the  umbilicus  or  at  the  left  inguinal  region.  The 
faecal  discharge  from  the  small  intestine  is  usually  copious,  fluid 
and  continuous,  and  it  has  little  or  no  odour,  whereas  that  from 
the  caecum  or  appendix  has  a  characteristic  odour  and  that  from 
the  colon  is  less  fluid  and  more  intermittent.  If  carmine  is  given 
by  mouth  in  the  form  of  a  5-gr.  pill,  the  time  of  its  first 
appearance  in  the  fistulous  discharge  will  be  some  indication  of  the 
position  of  the  intestinal  lesion.  Thus,  its  discharge  from  the 
caecum  will  be  within  about  four  hours,  and  a  less  period  than  this 
will  indicate  a  small  bowel  leak,  whilst  the  longer  period  denotes  a 
colic  fistula.  Further,  a  supplementary  investigation  may  be  made 
by  injecting  colouring  matter  by  the  anus,  after  the  lower  bowel  has 
been  well  cleared  out  by  enemata.  If  a  rectal  injection  leaks 
readily  from  the  fistula  it  is  probably  in  the  large  intestine,  but  in 
some  cases  there  is  no  doubt  that  the  fluid  may  pass  the  ileo-caecal 
valve  and  escape  through  a  fistula  of  the  ileum. 

Non-operative  Treatment. — This  will  be  suitable  for  those 
cases  of  merely  leaking  fistulae,  such  as  are  so  often  left  after  opera- 
tions for  acute  appendicitis.  The  patient  is  kept  in  bed  on  a  light 
fluid  diet.  The  fistula  is  washed  out  with  solutions  of  peroxide  of 
hydrogen  and  lightly  packed  with  iodoform  gauze.  When  there  is 
much  pus  and  but  little  fasces  coming  from  the  fistula  the  use  of 
Biers'  cupping  glass  will  be  most  helpful,  and  indeed  this  device  if 
used  early  enough  will  often  prevent  the  formation  of  a  chronic 
fistula.  A  glass  cup,  about  2  inches  in  diameter,  with  a  good  rubber 
ball  attached,  is  applied  over  the  wound  after  smearing  its  rim  with 
sterile  liquid  vaseline  and  squeezing  the  ball.  Every  five  minutes 
the  suction  is  released  for  one  minute  and  an  intelligent  patient 
will  readily  carry  this  out  for  himself.  The  application  should  be 
for  about  one  hour  night  and  morning.  If  healing  does  not  take 
place  within  a  few  weeks  the  fistula  should  be  touched  with  the 
actual  cautery  after  packing  it  with  gauze  soaked  in  cocaine  solution 
(10  per  cent.).  This  should  of  course  be  done  with  due  regard  to 
the  length  and  relations  of  the  fistula.  I  have  found  that  in  some 
cases  a  small  Kelly's  tube  (illuminated  at  the  distal  end,  as  made 
by  the  American  Electro- Surgical  Instrument  Co.)  is  very  useful  in 
this  connection.  The  fistula  is  dried  as  much  as  possible  and  the 


Fistulae  of  the  Intestines.  485 

tube  then  passed.  In  favourable  cases  it  is  possible  to  see  the 
opening  into  the  intestine,  which  often  has  everted  edges  of  mucous 
membrane.  These  can  then  be  accurately  destroyed  by  the  electro- 
cautery. 

Another  non-operative  plan  which  is  of  great  value  consists 
in  immersing  the  patient  in  a  bath.  The  best  plan,  which  is 
specially  suited  to  emaciated  patients  with  a  copious  thin  fsecal 
discharge,  is  to  allow  the  patient  to  remain  altogether  in  the  bath, 
the  water  of  which  is  constantly  circulating  at  a  temperature  of 
about  100°  F.  In  addition  to  the  cleansing  and  healing  action  of 
the  water,  the  fact  that  the  patient's  weight  when  immersed  up  to 
the  neck  in  water  is  reduced  to  a  few  pounds  greatly  relieves  the 
back  from  pressure.  But  in  ordinary  cases  where  this  arrangement 
cannot  be  made,  the  patient  is  immersed  one  or  two  hours  daily 
and  then  rubbed  down  and  given  a  hot  meal.  The  procedure  is  a 
very  comfortable  one  and  will  often  greatly  expedite  the  spontaneous 
cure  of  a  fsecal  fistula. 

Probably  about  70  to  80  per  cent,  of  fistulae,  apart  from  those  due  to 
specific  diseases,  such  as  tuberculosis,  actinornycosis  or  cancer,  will 
close  in  response  to  these  non-operative  procedures,  though  in  some 
cases  this  result  may  take  several  months  for  its  accomplishment. 

Operations  for  Abscesses  connected  with  Fistulse. — When  the 
fistula  is  an  indirect  one,  opening  into  a  large  and  irregular  abscess 
cavity,  the  treatment  must  be  primarily  directed  to  the  cure  of 
the  abscess.  Such  conditions  may  be  found  in  connection  with 
appendicitis  where  an  abscess  has  spontaneous^  burst  or  been 
opened  without  removal  of  the  appendix,  also  with  subphrenic 
abscesses  connected  with  the  duodenum  or  tuberculous  abscesses 
anywhere  in  the  abdomen.  The  amount  of  pus  in  these  cases  is 
out  of  proportion  to  that  of  the  faeces  discharged  from  the  fistula, 
and  a  probe  can  be  made  to  enter  a  large  irregular  cavity  in 
various  directions.  Such  a  condition  will,  if  not  soon  cured,  lead 
to  septic  absorption  or  an  extension  of  the  peritoneal  inflammation. 

The  opening  in  the  parietes  must  be  enlarged  as  freely  as 
possible,  multiple  orifices  being  thrown  into  one  and  the  abscess 
cavity  exposed  in  all  its  recesses.  In  cases  of  some  standing  this  is 
by  no  means  an  easy  proceeding  or  one  devoid  of  risk,  because 
various  sinuous  tracks  which  invite  exploration  may  be  surrounded 
by  very  friable  adherent  intestine.  This  is  notably  the  case  with 
fistulae  of  tuberculous  origin  and  the  attempt  to  close  one 
fistula  may  lead  to  the  creation  of  many  more.  Therefore  an 
enlargement  of  the  external  orifice  with  a  very  gentle  swabbing  of 
the  main  abscess  cavity,  followed  by  careful  packing,  should  be  all 


486  Fistulae  of  the  Intestines. 

that  is  done  in  the  majority  of  cases.  When  the  condition  has 
resulted  from  appendicitis  and  there  is  any  doubt  as  to  the  appendix 
having  been  completely  removed,  it  should  be  searched  for  and 
removed.  The  tip  of  the  finger  is  sufficient  to  separate  the  adhesions 
round  the  end  of  the  caecum  and  the  root  of  the  appendix  is  sought 
for  at  the  point  where  the  colic  taenia  meet.  Sometimes  the 
appendix  lies  completely  separated  from  the  caecum.  It  is  only  in 
exceptional  cases  that  the  intestinal  leak  can  be  so  freely  exposed 
as  to  admit  of  satisfactory  suture.  If,  however,  the  abscess  cavity 
has  been  freely  opened  and  drained,  the  probability  is  that  the 
fistula  will  undergo  spontaneous  cure. 

Plastic  Operations  for  the  Cure  of  Fistulae. — Theoretically,  this 

is  the  ideal  method  of  dealing  with  fistulae,  but  practically,  it  is  very 

difficult  of  successful  execution ;  in  fact,  it  is  only  in  the  case  of 

the  direct  fistula  left  as  the  result  of  enterostomy  that  it  can  be 

regarded  as  at  all  satisfactory.     The  reason  for  this  is  that  in  all 

other  cases  the  fistula  is  surrounded  by  adherent  coils  of  intestine 

which  make  it  impossible  to  excise  it  adequately.     The  closure  of 

enterostomy  or  colotomy  fistulas  will  be  described  in  the  section  on 

artificial  anus,  and  the  present  paragraph  will  deal  only  with  the 

more  difficult  cases  of  the  more  indirect  fistulas  where  between  the 

bowel  and  parietes  there  intervenes  a  channel  formed  of  scar  tissue 

lined  by  granulations  and  surrounded  by  adhesions.     It  is  to  be 

presumed  that  this  has  refused  to  heal  in  response  to  the  non- 

operative  treatment,  including  the  use  of  the  actual  cautery  detailed 

above.     This  will  be  due  to  one  of  two  conditions,  either  the  specific 

infection  of  the  track  by  tubercle,  actinornycosis  or  cancer,  or  to 

the  bowel  opening  being  large  and  held  open  by  the  adhesions.     In 

the  case  of  a  specific   infection    any   plastic   operation   is   utterly 

useless  and  will  probably  make  matters  worse.      In   other  cases 

plastic  repair  may  succeed.     An  incision  is  made  round  the  mouth 

of  the  fistula  through  the  skin  and  the  matted  layers  of  the  parietes. 

This  is  most  conveniently  done  in  the  shape   of   two   converging 

crescentic  lines.     When  the  peritoneum  is   reached  this  is  found 

adherent  to  underlying  coils  of  bowel.     By  means  of  the  finger  and 

cautious  blunt  dissection  the  adhesions  are  broken  down  round  the 

fistula  and  the  latter  is  isolated  as  a  sort  of  test  tube  of  fibrous 

tissue.     If  this  can  be  carried  out  right  down  to  the  bowel  with 

which    it   communicates,   it   is   then   cut    off  about   ^    inch  from 

the  gut  and  its  edges  inverted  or  sewn  together  after  destruction 

of  its  lining  by  the  actual  cautery.     The  wound  is  closed  after 

inserting  a  small  rubber  drain.     If  in  the  course  of  the  operation 

it  is  found  that  the  tough  scar  tissue  of  the  fistula  is  so  densely 


Fistulae  of  the  Intestines.  487 

adherent  to  the  surrounding  coils  of  bowel  that  it  cannot  safely  be 
separated  from  them,  it  is  necessary  to  desist  from  further  efforts 
in  this  direction  and  be  content  with  a  thorough  cauterisation  of 
the  fistula. 

Anastomosis  Operations. — In  those  fistulae  which  refuse  to 
close  by  the  non-operative  methods  it  is  in  reality  a  far  safer  and 
more  satisfactory  proceeding  to  short-circuit  the  piece  of  gut 
involved  by  the  fistula  than  to  attempt  plastic  operations.  It  is 
necessary  of  course  to  know  exactly  where  the  intestinal  lesion  is 
situated  and  to  be  able  to  get  at  the  bowel  above  and  below  it.  In 
fistulae  communicating  with  the  ileo-caecal  region  the  operation  of 
ileo-sigmoidostomy  is  very  satisfactory. 

An  incision  is  made  in  the  mid-line  between  the  umbilicus  and 
pubes.     The  terminal  part  of  the  ileum  is  identified  by  its  relation 
to  the  mesentery,  and  it  is  completely  divided  by  the  actual  cautery 
between  clamps  as  near  as  convenient  to  the  adherent  mass  in  the 
caecal  region.     Both  ends  are  closed  by  double  purse-string  sutures. 
A  lateral  anastomosis  is  then  made  between  the  proximal  portion 
of  the  ileum  and  the  highest  convenient  piece  of  the  iliac  or  pelvic 
colon.     When  the  patient  has  recovered  from  this  operation  the 
fistula  will  either  close  spontaneously  or  be  amenable  (in  the  case 
of  direct  fistulae)  to  plastic  repair.     I  have  described  a  very  typical 
case   of    this   treatment   successfully   performed    after    numerous 
failures  of  direct  primary  operations  1  and  shown  how  perfectly  the 
nutrition  is  carried  out  after  this  unilateral  exclusion  of  the  greater 
part  of  the  colon.     The  details  of  this  operative  procedure  may  be 
varied  in  many  ways,  e.g.,  the  ileum  may  be  implanted  into  the 
transverse  colon,  an  end-to-side  anastomosis  may  be  made  instead 
of  a  side-to-side,  and  so  on,  but  the  principle  is  applicable  to  the 
majority  of  fistulae  which  occur  in   the  end  of  the  small  or  begin- 
ning of  the  large  gut.     It  is  essential,  however,  that  the  ileum 
be   divided  completely,  otherwise   faecal  material  will  continue  to 
be  passed  by  the   fistula.     In  the  case   of  an   intractable   fistula 
of  the  small  intestine,  the  exact  relations  of  which  are  not  known, 
anastomotie  operations  will  be  seldom  required.    If  such  fistulas  are 
of  traumatic  origin  (e.g.,  after  a  strangulated  hernia)  they  usually 
heal  spontaneously,  and  if  they  do  not  they  are  best  treated  by 
excision  of  the  involved  part  of  the  bowel.     If  they  are  associated 
with  an  inflammatory  condition  which  mats  together  many  coils 
of   bowel,  any  anastomotie   operation    will    be    fraught    with    the 
greatest  difficulty.     It  is  difficult  to  get  near  enough  to  the  affected 
coil  to  short-circuit  its  two  ends,  and  it  is  still  more  difficult  to 
identify  the  afferent  and  efferent  loops  which  are  connected  with 


Fistulae  of  the  Intestines. 

the  whole  mass.  Such  fistulae  are  usually  of  tuberculous  origin, 
and  these  are  particularly  unsuitable  for  operative  manipulations, 
because  the  adhesions  are  so  dense  and  the  bowel  so  friable. 

ARTIFICIAL  ANUS. 

The  existence  of  an  artificial  anus  nearly  always  implies  that  a 
previous  condition  of  intestinal  obstruction  has  been  relieved  either 
by  an  operation  or  by  the  bursting  of  a  faecal  abscess  ;  therefore 
the  first  condition  necessary  before  the  closure  of  such  an  artificial 
anus  can  be  contemplated  is  that  the  obstruction  below  the  anus 
should  be  permanently  cured. 

If  it  is  the  small  intestine  which  is  involved,  the  condition  is  one 
of  some  urgency,  because  not  only  does  the  constant  stream  of 
fluid  faeces  cause  great  discomfort  and  excoriation,  but  serious 
failure  of  nutrition  will  rapidly  result.  This  may  be  temporarily 
mitigated  by  the  injection  of  saline  solution  by  rectum  or  into  the 
distal  limb  of  the  bowel  at  the  artificial  anus.  Mr.  Bruce  Clarke 
has  described  a  most  interesting  case  where  the  jejunum  was 
involved  and  in  which  life  was  sustained  by  collecting  the  material 
which  escaped  from  the  proximal  end  of  the  gut  and  injecting  it 
into  the  distal.  But  such  expedients  can  only  be  for  a  matter  of 
days  or  a  week  or  two  at  most,  and  the  continuity  of  the  bowel 
must  then  be  restored.  If  the  stoma  involves  only  the  lateral 
wall  of  the  gut,  it  will  be  best  to  separate  it  from  the  skin  and 
then  sew  it  together  temporarily  in  order  to  avoid  soiling  the 
wound.  The  peritoneal  cavity  is  then  cautiously  opened  by  enlarging 
the  incision  which  encircles  the  artificial  anus,  and  the  continuity  of 
the  bowel  is  restored  by  infolding  the  stoma  in  a  direction  trans- 
verse to  the  lumen  of  the  bowel,  or  if  this  is  not  possible  without 
much  kinking,  the  affected  segment  is  cut  out  and  a  fresh  anasto- 
mosis made.  This  latter  procedure  will  also  be  necessary  if  the 
bowel  has  originally  been  cut  right  across  in  the  formation  of  the 
artificial  anus.  In  cases  where  the  obstruction  of  the  bowel  is 
irremediable  (e.g.,  an  inoperable  cancer  of  the  caecum),  and  where 
the  patient  has  recovered  well  from  the  acute  obstruction  for  which 
the  enterostomy  was  performed,  the  only  procedure  available  will 
be  an  ileo-colotomy,  the  incision  for  which  can  be  made  through  a 
clean  area  of  skin. 

If  the  case  is  one  of  colotomy  in  which  there  is  no  spur,  the 
opening  will  usually  close  spontaneously  if  it  affects  the  gut  at  or 
below  the  transverse  colon,  provided  that  the  cause  of  the  original 
obstruction  has  been  quite  removed.  But  this  closure  may  be 
so  tedious  that  an  operation  is  required  for  its  expedition.  This 


Fistulae  of  the  Intestines. 


489 


will  consist  in  the  following  procedure.  The  bowel  having  been 
thoroughly  emptied  by  purgatives  and  injections,  the  mucous  edges 
of  the  stoma  are  separated  from  the  skin  and  the  external  muscle 
aponeurosis.  The  edges  of  the  bowel  wall  are  then  brought 
together  by  two  rows  of  interrupted  Lembert  sutures  placed  in 
close  sequence.  The  muscle  and  skin  are  separately  sewn  up  with 


iSc 


FIG.  1. — Dupuytren's  enterotome. 

catgut  sutures.  It  is  almost  invariable  for  a  little  faecal  leaking  to 
occur  after  this  operation,  but  this  very  quickly  heals.  The  essential 
characteristic  of  this  operation  is  that  the  peritoneal  cavity  is  not 
opened. 

If  the  colotomy  is  provided  with  a  good  spur  which  separates 
the  proximal  from  the  distal  loop  of  gut,  its  spontaneous  closure 
will  be  very  unlikely  to  take  place.  There  are  two  alternative  ways 
of  treating  this  condition.  The  older  and  perhaps  the  safer  way  is 
to  destroy  the  spur  by  a  clamp  forceps.  The  original  instrument 
introduced  by  Dupuytren  and  figured  in  most  of  the  text-books  is 
quite  efficient,  but  several 
others  of  essentially  the  same 
principle,  but  of  somewhat 
lighter  construction,  have  been 
introduced.  That  of  Miculicz 
is  quite  good,  being  provided 
with  sharp  points  to  prevent 
it  slipping  out.  I  have  devised 

an  enterotome  which  is  worked       FIG.  2.— Hey  Groves'  enterotome  with  key. 

by  a  screw  and  key,  the  great 

advantage  of  which  is  the  avoidance  of  the  long  handles  projecting 
from  the  abdomen  and  dragging  upon  the  bowel.  Whichever  instru- 
ment is  used,  one  blade  is  introduced  into  the  proximal  and  the 
other  into  the  distal  limb  of  the  colon  and  then  screwed  up  as 
tightly  as  possible.  Every  day  the  screw  is  given  a  further  turn, 
and  usually  from  the  sixth  to  the  eighth  day  the  instrument  will 
come  away,  having  produced  a  pressure  necrosis  in  the  bowel  wall, 


490  Fistulae  of  the  Intestines. 

the  two  limbs  of  which  have  become  adherent.  After  this  the 
stoma  must  be  treated  as  described  above. 

The  more  modern  and  more  rapid  way  of  closing  this  type  of 
colotomy  is  by  opening  the  abdomen  and  excising  the  affected 
part  of  the  bowel,  restoring  its  continuity  by  some  method  of 
anastomosis.  As  a  preliminary  to  this  the  edges  of  the  colotomy 
are  tightly  sewn  together  and  touched  with  the  actual  cautery,  in 
order  to  prevent  peritoneal  infection. 

In  choosing  between  these  two  methods  various  facts  must  be 
taken  into  consideration.  The  enterotome  procedure  is  best  suited 
for  very  stout  patients  and  for  those  in  poor  general  condition.  If 
the  colon  is  known  to  be  loaded  with  fat,  its  accurate  anastomosis 
will  be  a  matter  of  some  difficulty.  And  in  cases  where  a  con- 
siderable length  of  gut  has  already  been  removed  (e.g.,  after  the 
excision  of  cancer  of  the  pelvic  colon)  there  may  not  be  enough 
bowel  to  allow  of  resection  and  anastomosis.  Where,  however, 
none  of  these  conditions  exist,  the  latter  operation  is  the  one  to  be 
chosen. 

BI-MUCOUS  OR  INTERNAL  FISTULA. 

Fistulous  communications  may  take  place  as  the  result  of  any 
inflammatory  process  between  various  parts  of  the  intestinal  canal 
and  other  hollow  viscera.  But  these  conditions  are  all  very  rare, 
even  as  pathological  events,  and  still  rarer  as  clinical  manifestations. 
They  have  been  recorded  in  connection  with  the  pleura,  the  gall- 
bladder, stomach,  kidney,  ureter,  urinary  bladder,  Fallopian  tube, 
uterus  and  vagina.  Of  these  the  majority  either  cause  no  symptoms 
or  else  are  only  a  part  of  some  extensive  disease  which  will  require 
special  treatment.  But  a  few  words  may  be  said  about  gastro- 
colic,  vesico-intestinal  and  vagino-intestinal  fistulse. 

Gastro-colic  Fistulae  usually  arise  from  the  extension  of  an 
ulcer,  either  simple  or  malignant,  from  the  stomach  into  the  trans- 
verse colon.  They  are  characterised  by  the  two  symptoms  of 
true  faecal  vomiting  and  lienteric  diarrhoaa.  The  fact  that  the 
whole  of  the  small  intestine  is  short-circuited  explains  the  rapid 
marasmus,  especially  if  there  is  also  any  pyloric  obstruction. 
Unless  the  condition  arises  as  a  complication  of  inoperable 
cancer  of  the  stomach,  it  will  require  operative  treatment  without 
delay.  The  diagnosis  may  be  confirmed  by  noting  that  carmine 
or  charcoal  given  by  mouth  appear  in  the  faeces  within  less  than  an 
hour,  that  air  can  be  injected  into  the  stomach  from  the  rectum, 
and  by  the  examination  by  means  of  radiography  after  bismuth 
feeding.  The  operation  will  consist  in  opening  the  abdomen  in  the 


Fistulae  of  the  Intestines.  491 

mid-line  and  excising  the  diseased  portions  of  both  stomach  and 
colon  with  appropriate  suture. 

Fistulae  between  the  Bladder  and  Intestine. — These  are  usually 

connected  with  the  rectum,  and  the  colon  comes  next  in  frequency. 

The  ileum  or  more  than  one  part  of    the  bowel  is    occasionally 

involved.     Gas  and  faecal  matter  are  passed  in  the  urine,  more  rarely 

urine  may  be  passed  in  the  faeces  and  septic  infection  of  the  kidneys 

soon  occurs.     The  recto-vesical  fistulae  may  result  from  the  injury 

produced  by  foreign  bodies,  from  tubercle,  cancer,  or  an  abscess 

bursting  into  both  viscera.     Unless  the  fistula  arises  in  the  course 

of  inoperable  malignant  disease,  it  must  be  treated  by  an  inguinal 

colotomy  at  once  before  irremediable  infection  of  the  urinary  tract 

has  taken  place.     The  operation  must  be  performed  with  a  good 

spur,  so  that  complete  diversion  of  the  faeces  is  effected,  and  the 

distal  limb  of  the  colon  is  then  used  for  copious  daily  irrigation  of 

the  rectum,  under  which  treatment  the  fistula  will  close  and  the 

colotomy    can    be  subsequently  dispensed  with.     The  vesico-colic 

fistulae  are  generally  due  to  some  inflammatory   affection  of   the 

colon,   which   js    often    of   the  nature  of  peri-diverticulitis.     Out 

of     63    cases    collected    by    Harrison    Cripps    45     were    due    to 

inflammatory    causes    and    only    9    to   malignant   disease.      The 

treatment   consists   in   laparotomy,    which  will  reveal  the   nature 

and  extent  of  the  disease  and  the  portion  of  bowel  affected.     Unless 

the  parts  are  densely  matted  together  by  adhesions,  the  affected 

portions  of  bladder  and  bowel  are  drawn  up  into  the  wound  and 

separated  and  then  sutured.     The  diseased  part  of  the  colon  will 

often  require  to  be  resected.     If  this  procedure  is  impossible  then 

a  colotomy  will  terminate  the  operation.     Faecal  fistulae  connected 

with  the  bladder  not  infrequently  arise  in  the  course  of  appendicitis. 

This  may  be  due  to  a  long  appendix  becoming  actually  adherent  to 

the  bladder  and  then  rupturing  into  it.     In  this  case  a  foreign  body, 

such  as  a  pin  or  worm,  may  be  passed  per  urethram.2     Much  more 

frequently,  however,  it  is  a   pelvic  abscess   which   communicates 

with  the  bowel  on  the  one  hand  and  the  bladder  on  the  other. 

Gas  and  faeces  may  be  passed  by  the  urethra  or,  if  the  case  has 

been  operated  upon,  urine  may  escape  by  the  wound.     These  cases 

usually   undergo   spontaneous   recovery   if   the  abscess  has  been 

freely  opened   and   drained.     It  will    very  seldom  be  possible  to 

subject  them  to   any  direct   operative   treatment.      Probably   an 

ileo-colotorny  would  be  the  safest  and  easiest  procedure  if  direct 

interference  is  demanded. 

Fistulae   between    the   Intestine    and    Female    Generative 
Organs. — These  may  involve  the  rectum,  pelvic  colon,   transverse 


492  Fistulae  of  the  Intestines. 

colon  or  ileuin  on  the  one  hand,  and  the  vagina,  uterus  or 
Fallopian  tube  on  the  other.  The  subject  of  recto-vaginal  fistulee 
is  dealt  with  in  another  section  of  this  work.  The  other  conditions 
which  usually  result  from  operations,  pelvic  peritonitis,  tuberculosis, 
or  cancer,  present  in  simple  cases  a  fair  prospect  of  spontaneous 
recovery  under  expectant  treatment  by  vaginal  douches,  which 
should  be  persevered  with  for  a  long  time.  If  this  fails  and  the 
case  is  not  due  to  tuberculosis  or  cancer,  the  abdomen  is  opened  and 
the  involved  part  of  the  intestine  separated  from  the  uterus  or 
vagina  and  sutured  or  excised. 

ERNEST  W.  HEY  GROVES. 


REFERENCES. 

1  Groves,   E.   W.   Hey,    Proc.    Boy.   Soc.    Med.,    1909,    II.    (Surg.    Sect.), 
pp.  121—133. 

2  Kelly  and  Hurdon,  "The  Vermiform  Appendix  and  its  Diseases,"  Philad. 
and  Lond.,  1905,  p.  319. 


493 


FOREIGN   BODIES    IN    THE    INTESTINES. 

FOKEIGN  BODIES  of  almost  every  conceivable  size  and  variety  may 
be  swallowed  or  passed  into  the  rectum,  particularly  in  the  case  of 
insane  patients.  Certain  concretions  may  be  formed  in  the  intes- 
tines or  gall-bladder  and  act  as  foreign  bodies  in  the  intestine. 
Very  rarely  they  may  be  introduced  through  the  abdominal  parietes, 
either  as  the  result  of  a  penetrating  wound  or  by  a  process  of 
ulceration  from  the  peritoneal  cavity,  where  they  have  been 
accidentally  left  (gauze  swabs,  drainage  tubes  or  forceps).  It 
would  be  quite  beyond  the  scope  of  this  article  to  discuss  any 
further  the  variety  of  the  foreign  bodies  which  thus  find  their  way 
into  the  intestinal  tract,  but  it  will  be  sufficient  for  the  purposes  of 
clinical  diagnosis  and  treatment  if  we  divide  all  these  cases  intp 
three  categories  according  to  the  predominating  character  of  the 
associated  symptoms,  viz. :  (1)  Those  with  no  symptoms ;  (2)  those 
with  inflammatory  symptoms ;  (3)  those  with  obstructive  sym- 
ptoms. A  few  preliminary  remarks  may  be  made  on  the  subject  of 
diagnosis. 

The  history  of  the  case  may  throw  some  light  upon  its  nature, 
but  it  is  perhaps  the  exception  for  this  to  happen.  Mothers  often 
bring  children  for  advice  who  are  stated  to  have  swallowed  various 
objects,  such  as  coins  and  whistles,  but  these  are  usually  the  cases 
which  require  no  treatment.  Hysterical  and  insane  persons  who 
devour  the  most  extraordinary  articles  usually  conceal  their  past 
acts.  A  history  of  previous  abdominal  attacks  of  pain  with  jaundice 
may  suggest  gallstones,  or  a  person  who  has  been  in  the  habit  of 
taking  large  quantities  of  medicine,  e.g.,  magnesia  or  bismuth,  may 
be  likely  to  have  developed  an  enterolith.  Kadiography  will  be  by 
far  the  most  valuable  aid  in  diagnosis,  for  in  the  case  of  all  metal, 
glass,  and  earthenware  articles  it  will  clearly  demonstrate  both 
their  presence  and  position.  Unfortunately,  however,  gallstones, 
the  commonest  foreign  bodies  to  cause  obstruction,  do  not  cast 
a  definite  shadow,  for  they  are  almost  as  transparent  to  the  X-rays 
as  the  soft  tissues  themselves. 

Cases  without  any  Definite  Symptoms. — Considering  that 
every  kind  of  solid  article  swallowed,  teeth-plates,  pins,  coins, 
clasp  knives,  etc.,  has  passed  by  the  anus  after  a  longer  or  shorter 
stay  in  the  alimentary  tract  and  that  the  majority  of  indigestible 


494          Foreign  Bodies  in  the  Intestines. 

articles  do  so  pass,  there  is  always  a  presumption  in  favour  of  this 
simple  ending  of  the  case.  When  the  article  is  round  and  small, 
e.g.,  a  coin  or  marble,  there  need  be  no  apprehension  about  it.  An 
anxious  parent  may  be  satisfied  by  the  frequent  examination  of  her 
child  by  means  of  a  fluorescent  screen,  which  shows  the  foreign 
body  in  a  different  position  on  each  examination  until  it  reaches 
the  pelvic  colon,  usually  within  twenty-four  hours,  and  then  is 
expelled.  Supposing,  however,  that  the  foreign  body  is  known  to 
be  of  a  sharp  or  angular  nature,  e.g.,  a  tooth  plate  or  shawl  pin, 
experience  teaches  that  if  such  a  body  has  negotiated  the  oaso- 
phagus  and  pylorus  successfully,  it  is  not  likely  to  cause  trouble  in 
the  intestine.  The  patient  should  be  kept  under  observation,  and 
if  any  signs  of  pain  or  local  tenderness  arise,  or  if  the  X-rays  show 
that  the  object  has  become  stationary  (in  either  case  this  will 
probably  be  near  the  ileo-caecal  region),  then  will  be  time  enough 
to  open  the  abdomen  and  remove  the  foreign  body.  No  drugs 
should  be  given  either  to  hasten  or  retard  the  intestinal  stream. 
Any  violent  or  unnatural  peristalsis  will  be  much  more  likely  to  do 
harm  than  good,  and  opiates  which  produce  stasis  will  merely 
postpone  the  natural  cure  of  the  case.  A  simple  enema  may 
be  useful  in  aiding  the  expulsion  of  a  foreign  body  which  has 
reached  the  pelvic  colon  and  in  helping  in  its  recognition  when 
it  is  passed.  The  diet  should  consist  of  food  which  leaves  a  bulky 
residue,  e.g.,  vegetables  and  fats.  Brown  bread,  porridge,  green 
vegetables  and  cream,  should  be  the  staple  food. 

Cases  Causing  Inflammatory  Symptoms. — The  cases  in  this 
group  are  usually  caused  by  small,  sharp,  irritating  objects,  e.g., 
pins,  pieces  of  straw,  or  fish-bones,  and  in  the  majority  of  them 
there  is  no  history  at  all  of  their  having  been  swallowed.  When 
we  think  of  the  great  variety  of  indigestible  things  which  are 
swallowed  by  most  people  every  day,  the  marvel  is  that  the  condi- 
tions we  are  considering  are  not  very  much  commoner  than  is 
the  case.  Pins,  which  are  sometimes  swallowed  in  large  numbers 
by  the  insane,  frequently  perforate  the  intestine  and  travel  to  the 
most  remote  parts  of  the  body  without  causing  any  symptoms  what- 
ever. An  angular  body  may  become  impacted  in  the  duodenum,  the 
ileo-caecal  region,  or  in  one  of  the  pouches  or  false  diverticula  of  the 
colon.  It  will  then  produce  ulceration  with  inflammatory  adhesions 
or  a  local  abscess,  or  general  peritonitis  from  perforation.  A 
certain  proportion  (probably  not  more  than  1  per  cent.)  of  cases  of 
acute  appendicitis  are  caused  in  this  way.  Pins,  bullets,  fish-bones, 
and  worms  are  found  extruding  through  an  inflamed  and  perforated 
appendix.  An  exactly  similar  train  of  events  may  happen  with 


Foreign   Bodies  in  the  Intestines.          495 

a  diverticulurn  of  the  pelvic  colon.  The  treatment  of  all  these 
inflammatory  manifestations  will  consist  in  opening  the  abdomen 
and  dealing  with  the  inflammatory  focus  by  drainage,  removal  of 
the  appendix,  or  diverticulum,  and  so  forth.  Very  frequently  it  is 
only  subsequent  examination  of  the  tissue  removed  that  reveals  its 
relation  to  a  foreign  body. 

Sometimes  ulceration  and  adhesion  may  result  in  fistula,  either 
external  or  internal.  Through  these  the  foreign  body  may  be 
extruded.  For  example,  a  spoon  has  escaped  from  a  fistula  of  the 
caecum  and  the  femur  of  a  rabbit  by  a  fistula  into  the  bladder. 
When  sharp  foreign  bodies,  such  as  fish-bones,  become  impacted 
just  above  the  anus  they  will  almost  certainly  cause  rectal  fistulas 
or  abscess.  They  should  therefore  be  most  carefully  removed 
under  an  anaesthetic,  with  the  aid  of  a  good  speculum,  immediately 
their  presence  is  ascertained. 

The  ulceration,  stenosis,  or  inflammatory  adhesions  left  by  the 
injuries  due  to  foreign  bodies  will,  of  course,  have  to  be  treated 
according  to  the  general  principles  applicable  to  these  several 
conditions. 

Cases  associated  with  Obstructive  Symptoms. — Foreign 
bodies  which  cause  blocking  of  the  intestinal  lumen  are  usually 
gallstones  which  have  ulcerated  their  way  into  the  duodenum  from 
the  gall-bladder,  or  the  condition  may  be  due  to  concretions  formed 
///  xitu,  either  of  medicinal  substances  (e.g.,  various  magnesia  salts), 
indigestible  residue  from  the  food,  or  veritable  stercoliths  formed 
by  a  deposit  of  mineral  salts  round  a  foreign  body.  And,  lastly, 
a  substance  swallowed  may  cause  obstruction,  but  this  is  extremely 
improbable,  because  the  lumen  of  the  gullet  is  less  than  that  of  the 
narrowest  part  of  the  intestine.  Swallowed  foreign  bodies  which 
give  rise  to  obstruction  generally  do  so  either  by  long-continued 
iinpaction  with  subsequent  ulceration,  adhesions  or  kinking,  or  by 
the  accumulation  of  large  quantities  of  small  articles. 

The  question  of  the  treatment  of  these  cases  of  obstruction  by 
gallstones  has  been  warmly  debated  in  the  past,  but  in  modern 
times,  provided  that  the  existence  of  obstruction  is  clear,  there 
ought  to  be  no  room  for  a  difference  of  opinion.  The  facts  which 
have  given  rise  to  discussion  are  :  (1)  That  in  a  fairly  large  propor- 
tion of  the  cases  (50  per  cent,  according  to  Naunyn)  the  stone  is 
passed  spontaneously  and  the  patient  recovers  without  operation ; 
(2)  that  the  mortality  of  operations  on  these  cases  has  been  very 
high.  Passage  of  the  stone  by  the  anus  has  been  recorded  at 
varying  intervals  of  four  to  twenty  days  from  the  beginning  of  the 
symptoms.  There  has  been  no  recorded  surgical  success  in  cases 


496          Foreign  Bodies  in  the  Intestines. 

operated  upon  as  late  as  the  seventh  day  of  illness.  But  no  modern 
surgeon  would  dream  of  allowing  any  case  of  intestinal  obstruction 
to  remain  untreated  for  a  whole  week,  and  we  may  confidently 
assume  that  if  these  cases  are  operated  upon  within  forty-eight  hours 
of  the  occurrence  of  obstructive  symptoms  the  mortality  will  be  as 
low  or  much  lower  than  other  cases  of  acute  obstruction.  In  obstruc- 
tion by  gallstones  the  operation  is  a  simple  and  short  one  and  the 
intestine  is  rarely  seriously  injured.  There  is  blocking  of  the  lumen 
of  the  gut  but  no  strangulation  or  obstruction  of  the  circulation.  If 
the  patient  refuses  to  be  operated  upon,  the  expectant  treatment 
consists  in  withholding  food  by  mouth,  giving  nutrient  and  aperient 
enemas,  and  administering  small  doses  of  morphia  and  atropine  to 
diminish  the  spasm  of  the  intestine  round  the  foreign  body. 

Operation  will,  however,  be  the  method  of  choice  and  should 
be  performed  as  soon  as  possible.  The  stomach  is  thoroughly 
washed  out  to  prevent  regurgitant  vomiting  and  the  abdomen 
opened  in  the  mid-line.  Very  rarely  the  foreign  body  will  form 
a  palpable  tumour,  in  which  case  the  incision  may  be  placed 
over  it.  Otherwise  it  is  best  to  open  the  abdomen  below  the 
navel.  The  terminal  part  of  the  ileum  is  identified  by  its  connec- 
tion with  the  caecum  and  the  empty  gut  passed  rapidly  through  the 
ringers  until  the  obstructing  mass  is  reached.  If  this  is  in  a  part 
of  the  ileum  or  jejunum  the  coil  can  be  brought  outside  the 
abdomen  whilst  the  rest  of  the  intestine  is  replaced.  In  one  case 
it  was  found  possible  by  Glutton  to  push  the  stone  onwards  through 
the  ileo-caBcal  valve  into  the  large  gut,  from  which  it  was  passed 
naturally  a  few  days  later.  But  generally  it  will  be  unwise  to 
attempt  any  manipulation  of  the  stone,  as  this  is  much  more  likely 
to  damage  the  bowel  than  to  effect  any  good  purpose.  An  incision 
of  an  appropriate  length  is  made  into  the  bowel  above  the  foreign 
body  after  the  gut  has  been  clamped  on  either  side  of  it.  The  mass 
is  removed  and  the  incision  closed  by  a  double  row  of  continuous 
sutures.  If  the  operation  has  been  done  without  undue  delay  it 
will  be  rare  for  there  to  be  any  damage  of  the  bowel  requiring 
resection,  or  such  distension  of  the  intestines  as  will  need  drainage. 
But  in  those  cases  where  the  operation  is  late  both  these  procedures 
may  be  necessary.  If  the  patient's  general  condition  is  very  bad 
the  following  technique  will  be  the  best  to  follow.  The  damaged 
bowel  is  freely  resected  and  the  bleeding  vessels  tied.  The  two 
ends  of  gut  are  then  sewn  together  by  a  through  and  through  con- 
tinuous stitch  for  about  two-thirds  of  their  circumference,  including 
the  mesenteric  border.  There  is  still  left  an  open  gap,  and  into  this 
is  tied  a  Paul's  tube  with  long  rubber  attachment.  The  clamps 


Foreign  Bodies  in  the  Intestines.         497 

are  removed  and  the  parietes  closed,  leaving  the  sutured  area  of  gut 
in  the  wound.  This  permits  of  a  thorough  evacuation  of  the 
intestines  by  the  tube,  and  when  the  latter  comes  'away,  about  the 
third  day,  the  fistula  can  readily  be  sewn  up  or  dealt  with  at  a  later 
date.  A  hypodermic  injection  of  pituitary  gland  extract  is  of 
great  value  in  restoring  the  tone  to  the  distended  and  paralysed 
bowel  above  the  stricture  (see  also  Gallstones  and  Intestinal 
Obstruction). 

ERNEST  W.  HEY  GROVES. 


3.T. — VOL.  II.  32 


498 


HERNIA. 

GENERAL   CONSIDERATIONS. 

THE  treatment  of  hernia  will  vary  according  to  circumstances. 
It  depends  on  the  age  of  the  patient,  whether  an  infant  or  child, 
an  adult,  or  one  advanced  in  years  ;  it  depends  on  the  sex,  on  the 
general  health,  and  on  the  surroundings  of  the  patient,  whether  he 
is  in  easy  circumstances  or  not,  living  in  out-of-the-way  places  or  in 
the  haunts  of  civilisation.  It  will  vary  as  to  whether  the  hernia  is 
reducible,  irreducible,  or  partly  reducible,  whether  it  is  obstructed  or 
strangulated;  whether  it  is  an  enterocele,  all  intestine;  an  epiplocele, 
all  omenturn ;  or  an  entero-epiplocele,  both  intestine  and  omentum  ; 
and  whether  the  sac  contains  such  rare  contents  as  the  urinary 
bladder,  ovary,  Fallopian  tube,  or  appendix  vermiformis ;  whether, 
too,  the  testis  is  descended  or  undescended,  and  when  the  latter, 
whether  it  is  properly  or  ill  developed. 

Treatment  may  be  palliative  by  trusses,  radical  by  operation,  and 
to  a  certain  extent  preventive. 

Palliative  Treatment  (by  Trusses)  was  in  the  past  almost  the 
only  method,  and  had  to  be  employed  even  after  successful  operations 
for  strangulation.  Nowadays,  at  the  best  a  makeshift,  it  should 
be  the  exception  rather  than  the  rule.  About  this  in  the  young 
and  vigorous  there  can  be  no  doubt,  but  even  in  the  old  and 
comparatively  feeble,  modern  surgery  has  made  much  that  in  the 
past  was  impracticable  and  impossible,  possible,  advisable  and  even 
urgent.  To  condemn  a  ruptured  person  to  truss  life,  with  its 
inconveniences,  difficulties  and  dangers,  is  more  risky  than  for  him 
to  undergo  an  efficient  operation  performed  by  a  skilled  surgeon. 

Operative  Treatment. — In  the  early  days  of  so-called  'radical 
cures  many  of  the  operations  were  inefficient,  many  of  the  operators 
unskilled  and  inexperienced,  many  of  the  results  lamentable.  To- 
day the  mortality  is  practically  nil,  and  the  operations  that  have 
survived  the  test  of  time  give  exceptionally  good  results  with 
an  exceedingly  small  percentage  of  recurrence.  Even  secondary 
operations  after  recurrence  hold  out  more  than  a  hope  of  a  permanent 
cure.  In  the  writer's  experience  it  is  more  common  if  a  second 
hernia  appears  after  operation  for  it  to  show  itself  on  the  opposite 
side  of  the  body,  or  in  some  part  away  from  that  first  operated 
on.  This  is  not  to  be  wondered  at  when  the  general  lack 
of  development,  patency  of  rings,  and  laxity  of  tissues  of  the 


Hernia.  499 

ruptured  are  taken  into  consideration.  The  operative  treatment  of 
hernia  sliould  not  as  a  rule  require  to  be  followed  l>y  the  wearing  of 
a  truss.  It  says  little  for  the  operator's  confidence  in  his  so-called 
radical  cure  if  he  thinks  this  necessary,  save  in  exceptional  cases. 
It  may,  however,  in  certain  large  herniae,  be  a  physical  impossibility 
to  perform  an  ideal  operation,  and  all  the  surgeon  can  hope  for 
may  be  to  enable  by  operation  his  patient  to  wear  a  truss  and 
subsequently  to  lead  a  careful  life,  avoiding  any  undue  strain  or 
over-exertion. 

Femoral  and  perhaps  umbilical  hernias  will  require  mechanical 
support  after  operation  much  more  often  than  will  inguinal  hernias. 
The  operation  for  femoral  hernia  is  less  adequate  and  complete  tha,n 
that  for  the  inguinal  variety.  That  for  an  umbilical  hernia  is  often 
complicated  both  by  the  size  of  the  rupture  and  the  size  of  the 
patient. 

Preventive  Treatment. — The  preventive  treatment  of  hernia 
resolves  itself  into  removing,  as  far  as  possible,  the  exciting  causes 
in  those  congenitally  predisposed  to  this  condition,  e.g.,  to  cir- 
cumcise the  phimosed  child  when  the  phimosis  is  a  bar  to  proper 
micturition,  to  treat  early  and  efficiently  all  causes  of  undue 
straining,  such  as  stricture  of  the  urethra,  stone  in  the  bladder, 
enlargement  of  the  prostate,  constipation,  or  stricture  of  the  rectum, 
to  allay  the  cough  of  chronic  bronchitis,  to  deprecate  the  wearing  of 
tight  belts  which  throw  excessive  strain  on  the  lower  abdomen, 
especially  during  gymnastics  or  athletic  exercises,  to  caution  those 
with  weak  abdomen  and  patent  rings  against  the  danger  of  rupture, 
to  let  them  wear  a  truss  as  a  precautionary  measure,  and  to  impress 
on  them  the  necessity  of  early  and  efficient  treatment  if  their 
potential  hernia  should  ever  become  actual. 

The  treatment  of  hernia  will  to  a  certain  extent  vary  according 
to  the  age  of  the  patient.  In  very  young  children  palliative  truss 
treatment  is  usually  indicated  until  they  are  older,  easier  to  operate 
upon,  and  better  able  to  stand  operation.  Yet  even  here  if  the 
hernia  is  unmanageable,  rapidly  increasing  in  size,  practically 
impossible  to  reduce  and  to  keep  reduced,  an  operation  may  be 
safely  undertaken. 

The  very  old  and  feeble  or  those  with  visceral  disease  must  be 
treated  with  caution  and  discretion.  That  which  is  imperative  for 
the  working  man  may  only  be  desirable  for  one  of  the  leisured 
classes.  That  which  is  advisable  and  urgent  for  a  man  with  years 
of  active  life  before  him  is  not  advisable  for  an  old  man  of  sedentary 
and  inactive  habits.  The  latter  should  only  be  subjected  to 
operation  if  there  is  some  local  condition  of  the  hernia  in  itself 

32—2 


500  Inguinal  Hernia. 

a  danger  to  life,  e.g.,  irreducibility,  constantly  threatening 
obstruction,  or  even  strangulation.  The  question  of  operation  in 
the  old  often  resolves  itself  into  the  question  of  an  anaesthetic.  If  this 
can  be  safely  given,  if  there  is  no  chronic  lung  or  cardiac  trouble  to 
forbid  it,  operation  may  be  advised  with  confidence. 

The  old,  as  was  pointed  out  years  ago  by  Sir  George  Humphrey, 
heal  well,  though  they  are  bad  at  making  up  loss  of  blood,  and  the 
shock  of  the  operation  is  perhaps  less  felt  by  them  than  by  very 
young  children,  who,  however,  rapidly  make  good  the  ill-effects  of 
haemorrhage.  Kenal  inadequacy  and  disease,  although  to  be  taken 
into  due  consideration,  are  of  less  importance  than  in  former  days  ; 
l^it  little  stress  is  thrown  on  the  excretory  organs  after  an  aseptic 
operation,  the  wound  of  which  should  heal  by  first  intention. 

A  man  with  hernia  may  take  the  risk  of  truss  life  if  he  lives 
within  reach  of  adequate  surgical  assistance  in  case  of  need  ;  he 
certainly  should  not  do  so  if  his  life  has  to  be  spent  in  remote 
or  out-of-the-way  places. 

The  very  real  dangers  of  strangulation,  even  when  treated  in  a 
large  hospital  by  men  accustomed  to  operate  daily,  may  be  realised 
by  the  statistics  of  St.  George's  Hospital  for  thirteen  years  : 
Of  155  cases  of  strangulated  inguinal  hernia  24  died, 
„  125     „      „  „  femoral        „     20    „ 

„     25     ,,      ,,  „  umbilical      ,,      13    „ 

that  is  to  say,  15*5  per  cent,  of  strangulated  inguinal  hernias, 
16'7  per  cent,  of  strangulated  femoral  hernias,  and  52  per  cent,  of 
strangulated  umbilical  herniae  have  died  after  operation. 

Operative  treatment  will  be  first  considered,  afterwards  the 
palliative  treatment  of  those  unfit  for  the  radical  cure  of  their 
hernias.  Operation  should  be  the  ordinary,  the  truss  the  extra- 
ordinary, treatment  of  rupture. 

INGUINAL   HERNIA. 

Modification  of  Bassini's  Operation. — The  operation,  whether 
for  bubonocele  or  the  complete  variety,  the  direct  or  indirect,  is 
much  the  same.  In  very  large  hernias  it  may  be  necessary  in  making 
the  incision  to  trench  on  the  scrotal  tissues  (a  thing,  if  possible,  to 
be  avoided),  especially  if  there  is  any  adhesion  of  omentum  or 
other  sac  contents-to  its  lower  part. 

Preliminary  sterilisation  of  the  skin  and  shaving  of  the  pubes 
are,  of  course,  necessary.  Bassini's  operation  of  laying  open  the 
inguinal  canal,  removal  of  the  sac,  and  suture  of  the  conjoined  tendon 
to  Poupart's  ligament,  thus  obliterating  the  inguinal  canal,  is  the 
model  of  most  of  the  modern  successful  operations.  The  operation 


Inguinal  Hernia. 


FIG.  1. — Operation  for  inguinal 
hernia.  External  incision 
avoiding  the  scrotal  tissues. 


about  to  be  described  is  a  modification  of  Bassini's,  and  has  been 
employed  in  many  hundreds  of  cases  with  good  results.    The  incision 
is  made  more  or  less  parallel  with  Pou- 
part's  ligament  and  1   inch  or  1^   inch 
above  it,  commencing  at  the  inner  side 
of    the    external    abdominal    ring    and 
running  upwards  and  outwards  for  the 
required  extent. 

In  exposing  the  external  ring  and 
aponeurosis  of  the  external  oblique, 
some  small  cutaneous  vessels,  the  super- 
ficial epigastric,  will  be  divided,  and 
should  at  once  be  clipped  to  make  the 
operation  as  bloodless  as  possible,  a 
point  very  important  in  dealing  with 
children  or  where  the  sac  is  very  thin 
and  perhaps  difficult  to  find ;  again, 
too,  in  recurrences  where  the  anatomy  has  already  been  inter- 
fered with  in  some  unknown  way  by  another  operator,  it  is 
very  essential  not-to  have  the  parts  obscured  by  bleeding,  howsoever 

trifling.  The  external  ob- 
lique is  divided  by  a  small 
incision  about  1  inch  exter- 
nal to  the  external  abdo- 
minal ring;  the  edges  of 
this  puncture  are  clipped 
by  Spencer  Wells's  forceps, 
which  subsequently  are 
used  as  retractors.  A  direc- 
tor introduced  and  passed 
downwards  and  inwards 
allows  of  further  division 
of  the  external  oblique 
aponeurosis,  the  inter- 
columnar  fibres  and  ex- 
ternal spermatic  fascia. 
The  divided  aponeurosis  of 
the  external  oblique  is  next 
separated  from  the  con- 
joined tendon  above,  and 

from  the  cord  and  sac  covered  by  the  cremaster  muscle  below.  In  this 
way  Poupart's  ligament  is  defined  and  ready  for  subsequent  suturing. 
The  cremaster  muscle  and  fascia  are  then  divided  and  separated  from 


FIG.  2. — Division  of  aponeurosis  of  external 
oblique.  The  clips  to  be  used  subsequently 
as  retractors  are  placed  wider  apart  than  in 
illustration. 


502 


Inguinal   Hernia. 


FIG.  3. — Separation  of  external  oblique  apoaeu- 
rosis  from  the  conjoined  tendon  and  definition 
of  Poupart's  ligament. 


the  subjacent  cord  and 
sac.  If  any  vessel  bleeds 
it  should,  for  reasons 
already  given,  be  secured 
at  once.  In  separating 
the  cremasteric  fascia 
from  the  sac  and  cord, 
sponging  is  of  the  greatest 
assistance.  The  sac  in 
old  hernise  is  self-evident, 
but  in  bubonoceles  and 
in  the  so-called  con- 
genital variety  its  finding 
and  separation  may  be 
attended  with  some  diffi- 
culty. The  white  line  of 
its  edge  is  very  helpful 
in  its  separation  from 

the  vas  deferens  and  vessels  of  the  cord.  Some  loose  connective 
tissue  may  require  division  by  the  knife ;  such  division  should  be 
parellel  to  the  course  of  the  vas  spermatic  vessels  and  veins.  Even 
in  the  congenital  variety  the  peritoneal  covering  can  with  care  be 
separated  from  the  subjacent  cord.  Sometimes  there  is  a  marked 
protrusion  of  subperitoneal  fat,  which  might  at  first  sight  be  taken 
for  an  omental  hernia,  and 
in  some  rare  cases  the 
muscular  coat  of  a  pro- 
truding urinary  bladder 
might  be  mistaken  for 
some  portion  of  the 
cremaster  muscle.  The 
writer  has  met  two  such 
cases.  The  sac  and  sac 
alone  is  isolated  and 
separated  from  both  cord 
and  testis;  any  diverticula 
of  the  sac  are,  of  course, 
dissected  away  and  re- 
moved. The  testis  in 
these  manipulations  may 
accidentally  or  unavoid- 
ably be  pulled  up  from  FlG-  4.— Separation  of  sac  from  the  cord  and 

enveloping  tissues  up  to  the  internal  abdominal 

the  scrotum.    It  should  be         ring. 


Inguinal   Hernia. 


503 


FIG.  5. — The  sac  of  a  direct  inguinal  hernia. 
Note  pedunculated  process  of  subperitoneal  fat 
near  internal  abdominal  ring. 


handled  as  little  as  pos- 
sible, and  care  should  be 
taken  that  in  its  replace- 
ment there  is  no  torsion  of 
the  cord.  Much  has  been 
written  as  to  the  treat- 
ment of  the  sac,  whether 
it  should  be  twisted, 
whether  it  should  be 
entirely  removed  and 
whether  it  should  be  in- 
vaginated.  In  the  writer's 
opinion  the  only  necessary 
thing  is  to  pull  it  down 
as  far  as  possible  and  to 
remove  it,  and  in  ligature 
of  its  neck  to  take  care 
that  nothing  else  is  in- 
cluded. To  ensure  this  it  is  well  to  put  the  finger  in  the  empty 
sac,  and  to  tie  the  neck  on  the  finger  which  is  removed  as  the 
catgut  is  tightened.  In  a  large  number  of  cases  a  tight  white 
fibrous  ring  is  found  about  the  neck.  This  is  the  usual  seat  of 
strangulation.  The  sac  of  a  bubonocele  has  often  a  digital 
process  below  this  fibrous  ring  extending  right  to  the  bottom  of  the 
scrotum  down  which  no  hernia  has  yet  descended,  but  into  which 

some  sudden  strain  may 
cause  the  bowel  to  enter 
and  symptoms  of  strangu- 
lation to  supervene.  The 
emptying  of  the  sac  of 
its  contents  is  usually 
easy.  Omentum  when 
adherent  must  be  sepa- 
rated and  may  have  to 
be  removed.  Whenever 
possible,  all  of  it  should 
be  returned  into  the  abdo- 
men without  any  inter- 
ference, as  the  stump 
of  divided  or  removed 
ornentum  might  give  sub- 
sequently rise  to  intestinal 

FIG.  I). — Method  of  ligature  of  sac.     Taken  from  u  » 

actual  operation  on  a  direct  hernia.  obstruction. 


504 


Inguinal  Hernia. 


Adhesion  of  bowel  to  sac  is  luckily  rare.  If  very  firm  and  extensive, 
a  portion  of  the  adherent  peritoneum  may  be  cut  away  from  the  rest 
of  the  sac  and  returned  with  the  bowel  into  the  abdomen.  As  a 
rule  the  adhesion  of  sac  to  bowel,  or,  as  is  more  commonly  the 
case,  to  oinenturn,  is  easily  separated.  It  should  be  remembered 
that  these  adhesions  are  very  frequently  due  to  the  improper 
wearing  of  a  truss  over  a  descended  hernia.  In  certain  cases, 
although  there  are  no  adhesions,  it  is  very  difficult  to  reduce  the 
bowel.  In  very  large  herniae  so  much  of  the  abdominal  contents 

tf 

have  for  so  long  a  time  lain  outside  the  proper  abdominal  cavity 
that  the  capacity  of  the  latter  seems  seriously  diminished,  or,  again, 
the  parts  within  the  sac  may  after  descent  have  become  swollen, 

congested  and  so  per- 
manently enlarged  that 
it  is  well  nigh  impossible 
to  return  them  through 
the  opening  down  which 
they  originally  travelled. 
This  is  especially  the  case 
when  the  large  intestine 
is  in  question.  The  sac 
having  been  emptied,  liga- 
tured and  removed,  suture 
of  the  conjoined  tendon 
to  Poupart's  ligament  is 
next  proceeded  with.  This 
maybe  done  either  behind 
or,  as  the  writer  prefers, 
in  front  of  the  cord.  There 
is  less  handling  of  the 
latter  if  the  suturing  is  in  front  of  it.  Poupart's  ligament  should 
be  picked  up  by  a  slightly  curved  needle  on  a  handle  armed  with 
silkworm-gut  or  kangaroo  tendon,  first  of  all  where  it  is  connected 
with  the  os  pubis ;  care  should  be  taken  that  the  end  of  the  suture 
subsequently  to  be  passed  through  the  conjoined  tendon  is  easily 
recognised.  Both  ends  of  the  suture  may  be  clipped  by  Spencer 
Wells's  forceps  with  the  one  subsequently  required  near  the 
handles.  Three,  four,  or  more  sutures  are  passed  through 
Poupart's  ligament  and  clipped  in  this  distinguishing  way. 
Traction  on  the  one  passed  last  will  readily  bring  up  the  ligament 
from  the  subjacent  structures  for  the  next  suture.  To  avoid  any 
splitting  of  the  aponeurosis  a  different  thickness  should  be  taken 
by  each  suture.  This  is  especially  necessary  in  very  young  children 


FIG.  7.— Method  of  suture  of  conjoined  tendon  to 
Poupart's  ligament. 


Inguinal   Hernia. 


505 


where  the  aponeurosis  has  a  great  tendency  to  split  obliquely  in 
the  direction  of  its  fibres.  The  conjoined  tendon,  which  varies  very 
considerably  in  its  muscularity,  is  now  perforated  by  a  McEwen's 
needle  and  thus  picked  up  in  two  places;  the  needle  eye  is  threaded 
by  the  kangaroo  tendon  or  a  piece  of  silkworm-gut  already  passed 
through  Poupart's  ligament,  and  the  needle  withdrawn  to  allow  the 
subsequent  approximation  of  the  two  structures.  When  these 
deep  stitches,  some  three  or  four  in  number,  are  tied  and  completed 
the  cut  aponeurosis  of  the  external  oblique  is  sutured  by  a  con- 
tinuous catgut  suture,  and  the  edges  of  the  superficial  skin  wound 
brought  together  by  silk.  No  drainage  tube  is  required.  The 
question  as  to  the  best  ma- 
terial for  these  deep  sutures 
is  still  unsettled.  Silk  in 
the  writer's  opinion  is  not 
good,  wire  is  distinctly  bad. 
Kangaroo  tendon,  silkworm 
gut,  and  chromic  catgut 
have  been  much  used.  It 
is  contended  by  some  that 
non-absorbable  sutures  can- 
not hold  living  structures 
together  for  any  length  of 
time.  The  points  to  re- 
member in  performing  tliis 
operation  are  that  the 
scrotal  tissues  as  far  as 

possible   are  to  be  avoided,         Fl«-    S.-Suture    of    conjoined    tendon    to- 

Poupart  s  ligament  completed.     The  knots 
all  superficial  blood-vessels  are  not  sufficiently  shown. 

are  to  be  secured,  and  the 

operation  throughout  conducted  as  bloodlessly  as  possible.  The 
external  abdominal  ring  and  the  external  oblique  aponeurosis 
is  to  be  freely  divided  as  high  as  the  position  of  the  internal 
abdominal  ring,  the  sac  to  be  carefully  defined  and  separated,  sac 
and  sac  alone,  from  the  cord ;  to  ensure  during  its  removal  and 
ligature  that  no  abdominal  contents  are  in  danger  it  should  be 
ligatured  upon  the  finger,  the  suture  of  the  conjoined  tendon  to 
Poupart's  ligament  should  be  complete  and  firm  ;  such  suture  is 
perhaps  best  anterior  to  the  cord.  The  cord  itself  should  be  handled 
as  little  as  possible  ;  if  there  is  a  varicocele  the  superfluous  veins 
should  be  removed,  otherwise  it  is  undesirable  to  interfere  with 
them.  The  stitching  up  of  the  external  oblique  should  include  a 
definite  amount  of  that  membrane,  especially  if  it  is  thin  and 


5o6 


Inguinal  Hernia. 


weak,  so  that  its  last  state  shall  be  stronger,  not  weaker  than  its 
first. 

If  any  hydroccle  of  the  tunica  vaginalis  is  present  it  should  be 
dealt  with  at  the  same  time  as  the  hernia  by  free  removal  of  the 
parietal  layer.  Cysts  along  the  course  of  the  cord  or  near  the 
testis  should  also,  when  present,  be  removed. 

It  matters  little  whether  a  hernia  is  of  the  congenital,  infantile  or 
adult  variety  if  all  the  sac  is  removed  right  up  to  the  internal  ring. 
The  congenital  variety  is  the  most  difficult  to  deal  with,  but  with 
care  the  serous  covering  can  be  separated  from  the  cord  and  vas, 

and  the  communication 
with  the  abdomen  closed 
either  by  a  catgut  ligature 
or  a  purse-string  suture. 

When  an  undescended 
testis  is  present,  if  it  is  in 
the  way,  ill-developed,  and 
if  the  patient  is  an  adult, 
it  is  best  removed.  In  the 
child  when  separated  from 
the  hernial  sac  it  may  be 
brought  down  into  and 
stitched,  to  the  scrotum.  It 
has  been  recommended  to 
separate  the  globus  minor 
and  body  of  the  epididyiais 
from  the  testis  proper  to 
effect  this.  The  writer  is 
not  in  favour  of  this  proceeding,  but  prefers  to  return  the  testis 
into  the  abdomen  when  the  cord  is  too  short  to  allow  of  scrotal 
stitching.'  The  argument  that  this  abdominal  position  is  dangerous 
in  the  event  of  orchitis  or  malignant  disease  in  later  life  may 
perhaps  be  disregarded. 

In  women  the  sac  of  an  inguinal  hernia  is  not  so  pyriform 
as  in  men,  the  neck  of  it  not  so  narrow,  and  accompanying 
the  hernia  there  may  be  some  anatomical  irregularities.  Cysts  in 
connection  with  the  round  ligament  are  not  uncommon,  and  when 
present  should  be  removed. 

The  dressings  may  be  varied  to  suit  the  taste  of  the  operator.  In 
children,  in  whom  there  is  greater  danger  of  soiling  by  urine,  gauze 
and  collodion  may  be  indicated,  and  protection  may  be  afforded  by 
jaconet  or  thin  mackintosh.  The  after-treatment  is  simple  :  rest  in 
the  horizontal  position  for  some  three  weeks  in  adults,  somewhat 


FIG.  9. — Continuous  catgut  suture   of    aponeu- 
rosis  of  external  oblique. 


Inguinal  Hernia.  507 

longer  in  children  who  cannot  be  trusted  to  avoid  any  over-exertion 
or  strain  on  first  going  back  to  normal  life.  For  at  least  six 
months  after  operation  no  great  strain  should  be  thrown  on  the 
lower  abdomen. 

Operations  Other  than  Modifications  of  Bassini's  Method. — 
In  his  early  operations  Kocher,  after  torsion  of  the  sac,  passed  it  by 
imagination  through  the  external  oblique  and  fixed  it  by  suture. 
Sloughing  of  this  displaced  sac  was  not  unusual,  so  that  after  lateral 
transposition  it  has  been  found  better  to  remove  it.  It  is  claimed 
for  this  that  "  the  peritoneum  is  stretched  in  a  lateral  direction, 
and  any  descent  of  the  sac  in  the  direction  of  the  cord  rendered 
impossible."  His  last  operation  is  transposition  of  the  unopened  sac 
by  invagination  into  the  abdominal  cavity.  It  is  then  made  to  pro- 
ject external  to  the  internal  abdominal  ring  and  an  incision  is  made 
through  the  abdominal  muscles  and  through  the  parietal  peritoneum 
on  to  it.  The  sac  is  pulled  out  and  the  base  crushed  with  pressure 
forceps.  It  is  then  transfixed  with  silk,  tied,  and  cut  off  and 
the  stump  pushed  back.  A  row  of  deep  sutures,  including  the 
external  oblique  aponeurosis  and  the  internal  oblique,  is  inserted 
to  strengthen  the  inguinal  canal  in  its  whole  length. 

In  McE wen's  operation  the  sac  is  thoroughly  separated  and 
reduced  into  the  abdominal  cavity,  forming  a  bulwark  pad  "  to 
shed  the  intestinal  waves  away,"  it  being  contended  that  if  the 
sac  is  merely  tied  there  remains  a  funnel-shaped  puckering  on  the 
peritoneal  aspect.  The  operation  consists  in  exposing  the  external 
ring.  The  sac  is  then  separated  from  the  cord  in  the  inguinal  canal 
and  for  half  an  inch  round  the  abdominal  aspect  of  the  internal 
abdominal  ring,  folded  on  itself  and  perforated  by  a  stitching  which 
is  made  to  penetrate  the  abdominal  wall  1  inch  above  the  internal 
abdominal  ring.  The  skin  during  this  manoeuvre  is  pulled  up 
and  is  not  included  in  the  suture.  The  inguinal  canal  is  closed 
by  stitching  the  conjoined  tendon  to  Poupart's  ligament,  and  the 
pillars  of  the  external  abdominal  ring  are  brought  together.  In 
congenital  hernia  the  sac  is  divided  transversely  and  the  upper 
part  dealt  with  in  the  manner  above  described. 

In  Halsted's  operation  the  spermatic  veins  are  tied  as  high  as 
possible  above  and  below  the  external  ring ;  the  intervening  mass  is 
excised.  Care  is  taken  not  to  touch  or  move  the  vas  lest  throm- 
bosis of  its  veins  occur.  The  neck  of  the  sac  is  transfixed  and 
tied.  The  ends  of  the  ligature  are  threaded  into  long  curved 
needles,  passed  deep  to  the  internal  oblique  and  transversalis 
above  and  outside  the  internal  abdominal  ring  and  tied,  displac- 
ing the  neck  of  the  sac  outwards.  The  lower  flap  of  the  divided 


508  Inguinal  Hernia. 

cremasteric  fascia  is  drawn  up  deep  to  the  conjoined  tendon  and 
sutured.  The  internal  oblique  and  conjoined  tendon  are  joined 
to  the  top  surface  of  Poupart's  ligament  by  interrupted  sutures. 
The  rectus  sheath  is  incised  vertically  if  the  conjoined  tendon  is 
narrow  or  atrophied.  A  flap  of  it  may  thus  be  sutured  to  the  top 
surface  of  Poupart's  ligament,  or  the  sheath  slit  up  and  the  rectus 
itself  sutured  to  that  structure. 

Professor  Nicoll,  if  Poupart's  ligament  is  weak  and  movable, 
sutures  the  conjoined  tendon  to  the  horizontal  ramus  of  the  pubes 
in  the  same  manner  as  in  his  operation  for  femoral  hernia. 

Direct  Inguinal  Hernia. — The  operative  treatment  of  direct 
inguinal  hernia  is  much  the  same  as  has  been  already  described. 
Variations  in  the  anatomy  of  the  conjoined  tendon  and  of  the 
sac  have  to  be  dealt  with  on  ordinary  surgical  principles,  and  the 
altered  relation  of  the  epigastric  artery  remembered.  The  neck  of 
the  sac  is  often  broad  and  not  well  defined,  and  the  conjoined 
tendon  may  be  pushed  aside  or  penetrated  by  the  hernia,  requiring 
sutures  after  its  reduction. 

Other  structures  than  bowel  or  omentum  may  be  found  within 
the  sac,  e.g.,  the  urinary  bladder,  or  the  latter  itself  may  be  mis- 
taken for  a  direct  hernial  sac  and  inadvertently  opened.  Suture  of 
such  accidental  wound  should  not  include  the  mucous  membrane. 
In  two  such  cases  which  have  come  under  the  writer's  cognisance 
no  harm  resulted  from  this  accident. 

The  appendix  vermiformis,  if  in  the  sac,  had  better  be  removed  ; 
so,  too,  an  ill-developed  ovary  or  Fallopian  tube. 

Interstitial  Hernia  occurs  in  front  of  or  behind  the  external 
oblique,  or  in  front  of  the  peritoneum  behind  the  abdominal  muscles. 
The  latter  variety  does  not  lend  itself  to  operation,  is  often  un- 
recognised, or  is  only  discovered  when  "  reduction  en  masse  "  has 
been  effected. 

The  interstitial  diverticulum  running  either  behind  or  in  front  of 
the  external  oblique,  if  not  of  excessive  size,  should  be  dissected  out, 
together  with  any  scrotal  or  labial  sac,  the  abdominal  aperture 
closed,  and  the  undescended  testis,  if  present,  treated  according  to 
its  position  and  development. 

In  some  of  the  larger  varieties  complete  operation  may  be  impos- 
sible ;  and  in  cases  of  strangulation  the  internal  opening  and  the 
seat  of  strangulation  may  be  exceedingly  difficult  to  find. 

If  "reduction  en  masse"  has  taken  place,  the  strangulated  reduced 
intestine  must  be  followed  up  and  relieved  by  appropriate  incision  ; 
the  treatment  of  the  bowel  will  have  to  be  varied  according  to  its 
condition,  as  is  described  under  the  heading  of  Strangulated  Hernia. 


Femoral  Hernia.  509 

In  the  varieties  of  reducible  interstitial  hernia  where  no  operation 
is  performed,  the  patient  will  have  to  wear  an  interstitial  pad  as  a 
truss. 

FEMORAL  HERNIA. 

The  treatment  of  this  variety  by  operation  is  attended  with  diffi- 
culty, and  the  results  are  not  nearly  so  good  as  those  that  follow 
operations  on  inguinal  hernia.  After  the  sac  has  been  removed, 
the  parts  to  be  brought  together  are  more  or  less  unyielding,  abso- 
lutely fixed  to  the  pubic  bone  and  in  the  immediate  neighbourhood 
of  a  large  vein  (the  femoral),  any  pressure  on  which  cannot  for 
obvious  reasons  be  allowed.  The  operation  usually  includes  the 
dissection  of  part  of  the  fascia  from  the  surface  of  the  pectineus 
muscle  and  its  suture  above  to  the  margins  of  the  femoral  ring, 
which  is  closed  by  kangaroo  tendon,  silk,  catgut  or  fishing  gut. 
This  pectineal  fascia  varies  in  thickness,  but  is  usually  thin  and 
but  poor  stuff  for  the  purpose. 

Operation. — The  superficial  incision  should  be  over  the  hernia, 
and  may  either  be  transverse  or  vertical,  according  to  the  operator's 
taste ;  the  vertical,  perhaps,  is  the  better.  Any  superficial  blood- 
vessels, such  as  the  superficial  external  pudic,  should  be  clipped  or 
tied,  and  the  internal  saphenous  vein  must  be  respected.  The 
femoral  sac,  with  its  coverings,  very  often  resembles  an  onion,  and 
in  dissecting  through  its  concentric  layers  it  is  occasionally  with 
difficulty  that  the  sac  itself  is  recognised.  Arborescent  vessels,  as 
a  guide  to  finding  it,  are  not  to  be  depended  upon.  When,  how- 
ever, it  has  been  unmistakably  defined,  it  should  be  separated  right 
up  to  the  opening  of  the  femoral  canal,  and  its  contents  reduced,  if 
possible,  into  the  abdominal  cavity.  To  effect  this,  and  to  remove 
the  sac  thoroughly,  the  external  oblique  aponeurosis  should  be 
divided  above  Poupart's  ligament,  so  that  the  femoral  ring  may  be 
accessible. 

Adherent  omentum  is  common,  adherent  bowel  rare  ;  such  adhe- 
sions, when  they  do  exist,  are  usually  due  to  the  previous  wearing 
of  a  truss  over  a  descended  hernia. 

Adherent  omentum  must  be  dealt  with  by  ligation  and  removal, 
and  in  ligaturing  it  the  usual  precautions  must  be  taken  against 
subsequent  intra-abdominal  haemorrhage ;  in  other  words,  the  liga- 
tures must  be  made  to  interlock,  and  must  be  firmly  tied.  Stout 
catgut  or  sterilised  silk  are  required  for  this.  In  ligaturing  the 
neck  of  the  sac,  care  must  be  taken  that  it  is  completely  empty ; 
and  the  suggestion  of  ligaturing  on  a  finger,  in  this  case  the  little 
one,  given  in  the  description  of  the  operation  for  inguinal  hernia, 


Femoral  Hernia. 


may  here  also  be  usefully  followed ;  in  many  cases  the  neck  of  the 
sac  is  too  small  to  admit  of  this  manoeuvre. 

Other  methods  of  treating  the  sac  are  as  follows : 

It  may  be  invaginated,  passed  through  a  small  opening  of  the 
abdominal  wall  above  Poupart's  ligament,  and  there  fixed  by  suture. 

It  may  be  transfixed,  tied  and  invaginated. 

It  may  be  ligatured,  the  body  of  the  sac  cut  away,  and  the  ligature 

ends  left  long  passed 
through  the  external 
oblique  aponeurosis  and 
tied. 

The  best  method  of 
getting  at  the  sac, 
and  dealing  with  it 
thoroughly,  is  to  make 
an  incision  through  the 
external  oblique,  to  pull 
it  upwards  through  the 
femoral  canal,  and  so 
tie  it  in  this  way  high 
up.  Some  surgeons  re- 
commend the  disloca- 
tion of  the  sac  and  fixing 
it  as  a  pad  above  the 
femoral  ring. 

When  the  sac  has  been 
dealt  with,  the  opening 
of  the  ring  has  to  be 


FIG.  10. — Operation  for  femoral  hernia.  Diagram  of 
parts  concerned.  The  front  of  the.femoral  sheath 
has  been  removed  to  show  the  relation  of  the 
vessels  to  the  femoral  canal.  1,  Flap  of  pectineal 
fascia  which  is  dissected  up  and  stitched  to  mar- 
gins of  femoral  canal.  The  saphenous  vein  dis- 
placed outwards.  2,  Incision  through  external 
oblique  aponeurosis  to  allow  of  invagination  and 
thorough  removal  of  sac  ;  also,  if  necessary ,  suture 
of  conjoined  tendon  to  parts  below. 


closed  by  sutures  (three 
in  number),  which  pass 
through  Poupart's 
ligament  down  into 
Cowper's  ligament 

below,  taking  up  and  including  a  flap  of  the  fascia  from  the  surface 
of  the  pectineus  muscle.  In  some  cases  this  will  be  the  only 
structure  that  the  surgeon  can  suture  to  the  upper  margin  of  the 
ring.  The  operator  must  constantly  bear  in  mind  the  propinquity 
of  the  femoral  vein,  and  on  no  account  do  anything  likely  to 
endanger  its  safety. 

To  close  the  femoral  canal  Bassini  passes  three  ligatures  through 
Poupart's  ligament  and  the  pectineal  fascia,  which  are  left  untied 
until  three  or  more  uniting  the  falciform  ligament  to  the  pectineal 
fascia  are  passed  and  tied.  Some  surgeons  recommend  a 


Umbilical  Hernia.  511 

purse-string  suture  of  kangaroo  tendon  which  takes  up  the  edge  of 
Poupart's  ligament,  the  pectineal  fascia  and  muscle,  the  fibrous 
septum  covering  the  inner  side  of  the  femoral  vein,  and  then 
Poupart's  ligament  again.  This  is  a  quick  method,  and  may  be 
done  in  cases  of  strangulation. 

Lotheissen's  operation  is  a  complete  and  thorough  one.  An 
incision  is  made  above  and  parallel  to  the  inner  half  of  Poupart's 
ligament,  the  edges  retracted,  the  neck  of  the  femoral  sac  exposed 
and  isolated  below  the  conjoined  tendon,  above  the  femoral  ring. 
The  sac  is  drawn  upwards.  If  this  is  not  possible  it  is  dealt 
with  from  the  femoral  aspect.  Closure  of  upper  end  of  femoral 
canal  is  effected  by  suture  of  the  conjoined  tendon  to  Cowper's 
ligament  by  means  of  sutures  on  very  curved  needles ;  the  opening 
in  the  aponeurosis  of  the  external  oblique  is  then  closed. 

Professor  Nieoll's  operation  is  ingenious,  but  difficult  to  perform 
and  requires  special  instruments.  The  sac  is  bisected  longitudinally, 
one-half  is  pierced  and  the  other  half  drawn  through  the  opening  so 
made,  so  that  the  neck  of  the  sac  is  closed  without  ligature.  It  is 
then  pushed  up  to  the  abdominal  aspect  of  the  femoral  ring.  The 
pectineus  muscle  and  fascia  is  joined  to  Poupart's  ligament  by 
interrupted  catgut  sutures.  The  horizontal  ramus  of  the  pubes 
is  exposed  and  drilled.  Catgut  sutures  passed  by  the  aid  of  a 
special  probe  through  the  drill  holes  in  the  bone  are  then  made  to 
take  up  Poupart's  ligament,  and  so  tie  it  down  to  the  pubes. 

Eoux  drives  a  metal  staple  through  Poupart's  ligament  and  the 
femoral  canal  into  the  horizontal  ramus  of  the  pubes. 

Superficial  inguinal  glands  may  have  to  be  removed  before  the 
sac  of  the  hernia  can  be  properly  defined,  and,  as  a  consequence,  a 
cavity  may  be  left  on  which  it  is  well  to  make  firm  pressure  by 
dressing  after  the  operation,  or  even,  if  need  be,  to  drain  for  forty- 
eight  hours.  The  superficial  wound  can  be  united  by  any  of  the 
usual  sutures.  The  patient  should  rest  in  bed  for  some  three  weeks, 
and  perhaps  it  is  as  well  if  a  truss  is  subsequently  worn. 

UMBILICAL   HERNIA. 

Small  herniae  in  adults  in  the  neighbourhood  of  the  umbilicus  in 
the  linea  alba  are  protrusions  of  subperitoneal  fat,  but  occasionally 
possess  a  definite  peritoneal  sac  and  even  bowel.  As  a  rule, 
they  are  above  the  umbilicus  and  are  easily  dealt  with  by  operation. 
They  attain  but  small  size  and  may  exist  for  some  time  without 
being  recognised,  and  rarely  give  rise  to  any  symptoms  other  than 
those  usually  attributed  to  indigestion. 

Operation  for  umbilical  hernia  is  rarely  necessary  in  children. 


512  Umbilical  Hernia. 

In  adults  these  herniae  often  attain  a  large  size,  and  frequently  a 
large  portion  of  their  contents  is  irreducible.  The  omentum  in 
them  commonly  forms  a  definite  lining  sac,  containing  loculi  in 
which  intestine  is  often  adherent.  The  patients,  as  a  rule,  are  fat 
elderly  women  with  fatty  hearts  and  often  chronic .  bronchitis, 
making  them  bad  subjects  even  for  a  necessary  operation.  If  the 
hernia  becomes  obstructed  or  threatens  strangulation,  in  spite  of 
the  attendant  risks  operation  must  be  undertaken.  If  the 
hernia  is  reducible  and  small,  the  operation  is  easy,  the  risk 
slight.  In  most  cases  the  condition  of  the  patient  is  so  unbearable, 
her  danger  from  the  hernia  so  great,  that  the  safest  thing  is  to 
operate.  Careful  preparation  and  the  treatment  of  any  intertrigo, 
excoriation  or  ulceration  of  the  skin  that  may  be  present,  is 
imperative. 

Operation. — The  incision  may  be  transverse  or  a  straight  vertical 
one,  long  enough  to  give  plenty  of  room.  "Where  the  integuments, 
as  is  so  frequently  the  case,  are  thin  and  perhaps  ulcerated  on  the 
surface,  an  excision  of  an  elliptical  portion  of  skin  may  be  the  best 
procedure.  The  latter  should  also  be  practised  when  there  is 
any  great  redundancy  of  skin,  apart  from  any  thinness  that  may  be 
present.  When  the  sac  is  opened,  the  adherent  omentum,  if  the 
adhesion  is  small  in  quantity,  should  be  separated ;  if,  however, 
this  adhesion  is  extensive,  it  is  better,  quicker  and  safer  to  remove 
sac  and  omentum  together.  To  do  this  it  is  necessary  to  get  at  the 
omentum  as  it  comes  through  the  umbilical  aperture  and  to  see 
that  there  is  no  portion  of  intestine  imbedded  or  mixed  up  with  the 
part  to  be  removed.  Small  intestine  can  usually  be  easily  reduced ; 
it  is  the  large  which  more  often  gives  trouble  by  its  omental 
adhesions.  The  ligature  and  removal  of  the  omentum  demands  all 
the  cautions  given  already  in  the  description  of  the  operation  for 
Inguinal  Hernia.  Sometimes  not  only  is  it  adherent  to  the  interior 
of  the  sac,  but  all  round  the  abdominal  aspect  of  the  umbilical 
aperture.  The  sac  being  cleared  of  its  contents  is  removed  by 
careful  dissection  right  down  to  the  abdominal  aponeurosis  ;  its  neck 
should  then  be  closed,  if  the  aperture  is  large,  by  definite  catgut 
suture,  if  small  by  ligature.  The  aponeurotic  margins  of  the  opening 
into  the  abdomen  must  now  be  dealt  with,  and  it  is  held  by  some  sur- 
geons that  a  better  result  is  given  by  teasing  out  the  rectus  muscle  on 
each  side,  cutting  through  the  edge  of  the  aponeurosis  horizontally  to 
effect  this.  This  is  not  nearly  so  easy  a  proceeding  as  it  sounds. 
If,  however,  it  is  possible  to  do  it  and  to  suture  the  two  layers  of  the 
aponeurosis  and  the  muscle  between  them  in  three  separate  layers, 
or  by  overlapping  layers,  a  better  and  more  permanent  closure  will 


Umbilical  Hernia.  513 

be  effected  than  by  simply  bringing  together  the  aponeurotic  edges 
of  the  opening.  If  the  latter  is  very  small  it  maybe  closed  by  silkworm 
gut.  In  using  this  suture  it  is  necessary  to  cut  the  knots  short, 
to  leave  as  far  as  possible  no  projecting  ends,  and  not  at  any  time 
to  use  it  as  a  subcutaneous  suture.  The  skin  wound,  any  redun- 
dancy bej[ng  removed,  can  be  united  in  the  ordinary  way  and  the 
ordinary  dressings  applied. 

The  operation,  when  there  is  any  adherent  bowel  or  adherent 
omentum,  is  often  difficult  and  may  be  dangerous.  The  separation 
of  such  adherent  bowel  may  take  time  and  cause  shock  in  subjects 
who  can  ill  bear  it.  When  the  hernia  is  strangulated,  and  when,  in 
consequence,  the  condition  of  the  bowel  is  seriously  modified  for  the 
worse,  when,  too,  there  may  be  septic  discharges  in  the  sac,  the  opera- 
tion becomes  one  of  the  most  dangerous  in  surgery.  It  requires  in 
the  separation  of  bowel  the  utmost  gentleness,  and  may  well  test 
the  experience  and  skill  of  the  operator  in  forming  a  correct  judg- 
ment as  to  how  a  damaged  bowel  is  to  be  most  efficiently  and  safely 
treated. 

Mayo's  operation  is  one  of  the  best  and  most  complete.  A  trans- 
verse elliptical  incision  exposes  the  aponeurosis  for  2  or  3  inches 
around  the  hernial  aperture.  The  fibrous  and  peritoneal  coverings 
are  divided  all  round  the  neck  of  the  rupture.  The  contents  of  the 
sac  are  examined,  any  adherent  intestine  dealt  with,  and  omentum 
ligatured  at  the  hernial  orifice.  The  sac,  adherent  coverings  and 
omental  contents  are  removed  in  one  mass.  The  margins  of  the 
hernial  orifice  are  easily  approximated  by  traction  above'and  below 
on  its  edges.  The  aponeurosis  ring  may  be  widened  by  two  incisions 
1  inch  or  more  outwards  from  the  lateral  poles.  The  peritoneum 
being  separated  from  the  deep  surface  of  upper  flap,  the  lower  flap  is 
drawn  up  behind  and  secured  by  mattress  sutures,  and  at  the  edges 
also.  The  peritoneum  itself  is  closed  by  continuous  suture. 

The  implantation  of  silver  wire  netting  or  filigree  may,  from  its 
presence  as  a  foreign  body,  involve  suppuration,  sinus  formation, 
and  perhaps  a  further  weakening  of  an  already  weak  abdominal 
wall. 

In  the  after-treatment,  looking  to  the  class  of  patient  usually 
affected,  the  sitting  posture  is  to  be  recommended.  Anything  like 
abdominal  distension  must,  as  far  as  possible,  be  combated,  as  such 
distension  adds  seriously  and  mechanically  to  heart  and  lung 
trouble  already  existing.  Shock  must  be  treated  by  warmth, 
stimulants,  strychnine  and  the  subcutaneous  or  intra-rectal  injec- 
tion of  saline  solution  ;  flatulence" by  the  rectal  tube  and  turpentine 
enemata. 

S.T.  — VOL.  II.  33 


514  Rare  Forms  of  Hernia. 

After  a  successful  operation  it  is  well  that  the  patient  should,  as 
a  precaution  against  recurrence,  wear  an  umbilical  or  abdominal 
belt. 

THE  RARER  FORMS  OF  HERNIA. 

Obturator  Hernia. — The  operation  for  this  variety^  is  more 
often  one  for  intestinal  obstruction  by  an  abdominal  incision  than 
a  deliberate  operation  on  the  thigh.  Both  of  the  cases  the  writer 
has  had  to  deal  with  were  regarded  as  intra-abdominal  obstruction, 
and  were  relieved  by  pulling  the  involved  bowel  out  of  the  obturator 
foramen  from  the  abdominal  surface.  It  may,  however,  happen 
that  an  obturator  hernia  can  be  definitely  diagnosed  as  forming  a 
swelling  in  the  upper  part  of  the  thigh,  and  can  be  felt  close  to  the 
origin  of  the  adductor  longus  muscle.  Direct  operation  would  mean 
the  exposure  of  the  sac  passing  out  to  the  inner  side,  as  a  rule,  of 
the  obturator  vessels  and  nerve  under  the  pectineus  and  superficial 
to  the  obturator  externus.  The  hernia  reduced,  the  sac  should  be 
invaginated,  removed,  and  the  ring  closed.  If  strangulation  should 
be  present,  the  incision  to  relieve  this  should  avoid  the  vessels  and 
nerve,  and  should  be  made  downwards  and  inwards  rather  than 
outwards.  Some  form  of  truss  would  be  indicated  after  such  an 
operation. 

Gluteal  and  Sciatic  Herniae. — These  present  in  the  buttock 
passing  out  of  the  pelvis  either  above  or  below  the  pyriformis 
muscle,  sometimes  attaining  a  large  size  with  the  ordinary  symptoms 
of  hernia.  The  operation  to  attempt  cure  would  involve  cutting 
down  over  the  upper  part  of  the  swelling,  reduction  of  its  contents, 
removal  of  the  sac,  ligature  of  its  neck,  and  the  suturing  of  the 
aperture  out  of  which  it  had  passed,  taking,  it  is  needless  to  say, 
care  not  to  interfere  with  the  sciatic  nerves  or  any  of  the  important 
vascular  or  nervous  structures  in  the  neighbourhood. 

If  small  and  strangulated,  the  condition,  as  in  strangulated 
obturator  hernia,  might  easily  be  overlooked,  and  only  revealed  by 
a  laparotomy  for  intestinal  obstruction. 

Ventral  Hernia. — This  variety  when  acquired  usually  follows 
operations  on  the  abdominal  walls,  and  should  be  guarded  against 
by  the  surgeon,  suturing  peritoneum  to  peritoneum,  aponeurosis  to 
aponeurosis,  and  skin  to  skin.  If  this  form  of  suture  is  used, 
hernia  will  be  less  frequent  than  when  all  the  layers  are  included  in 
one  suture.  When  ventral  hernia  is  spontaneous  it  is  found  at  the 
points  of  junction  and  splitting  of  the  aponeurosis,  the  lineaalba, 
or  much  more  rarely  the  linea  semilunaris. 

Some   modification   of   Mayo's   operation,  described   under   the 


Obstructed  Hernia.  515 

heading  of  Umbilical  Hernia,  is  indicated  when  the  hernia  gives  real 
trouble  and  annoyance,  the  less  severe  varieties  may  be  disregarded, 
or  require  truss  or  belt  treatment. 

The  exposure  and  removal  of  the  protruding  peritoneum  may  be 
a  difficult  matter,  and  not  devoid  of  danger,  if  there  is  not  only 
protrusion,  but  also  adhesion  of  the  bowel.  The  bringing  together 
and  union  of  the  aponeurotic  edges  of  the  hernial  opening  by  suture 
may  be  practically  impossible.  Such  cases  may  be  suitable  for  the 
implantation  of  silver  wire  netting  or  filigree. 

Lumbar  Hernia  very  rarely  requires  treatment,  and  whether 
traumatic,  i.e.,  occurring  at  an  operation  or  abscess  scar,  or  spon- 
taneous, i.e.,  occurring  at  Petit's  triangle,  will  demand  truss  or 
operation,  according  to  the  inconvenience  it  causes. 

Diaphragmatic  Hernia,  when  due  to  congenital  defect,  very 
rarely  calls  for  treatment,  as,  when  present,  its  existence  is  over- 
looked until  revealed  at  a  post-mortem  examination. 

When  acquired  and  strangulated,  if  diagnosed,  an  early 
laparotomy  might  save  the  patient. 

Perineal  Hernia,  due  to  protrusion  of  the  recto-vesical  pouch  of 
peritoneum,  may  show  itself  as  a  perineal  or  even  an  ischio-rectal 
swelling.  Reduction  of  the  hernial  contents  and  removal  of  the 
protruding  sac  may  be  tried  if  the  inconvenience  is  sufficient  to 
justify  operation. 

Vaginal  Hernia  is  probably  best  treated  by  the  wearing  of  a 
supporting  pessary. 

INFLAMED    HERNIA. 

The  condition  of  inflammation  of  a  hernia  is  nearly  always 
caused  by  an  ill-fitting  truss,  external  injury  or  forcible  taxis,  and 
requires,  as  a  rule,  little  more  than  warm  boracic  fomentations. 
If  later  there  should  be  signs  of  suppuration,  incision  is  indicated, 
and  it  may  be  necessary  in  rare  cases  to  open  the  sac,  to  evacuate  pus 
or  the  fluid  of  a  tense  "  hydrocele  of  the  sac."  Strangulation,  if 
neglected,  leads  to  inflammation  of  the  hernia,  requiring  prompt 
immediate  operation.  In  out-of-the-way  cases  it  may  happen  that 
tubercle  or  some  other  growth  causes  a  chronic  inflammation  of 
the  hernial  sac. 

Umbilical  and  femoral  herniae  are  more  often  inflamed  than 
inguinal. 

OBSTRUCTED    HERNIA. 

Differing  as  it  does  from  strangulation  in  causing  little  if  any 
collapse,  little  if  any  vomiting,  little  if  any  tenderness,  with  a 

33—2 


516  Strangulated  Hernia. 

constipation  that  may  not  be  complete,  the  hernia  still  possessing 
an  impulse  on  coughing  although  it  is  irreducible,  being  a  swelling 
larger  than  usual,  but  which  perhaps  lacks  the  tension  and  the 
suddenness  of  onset  of  strangulation,  obstructed  hernia  can  be 
dealt  with  more  vigorously  and  with  less  fear  than  a  strangulated 
one ;  in  other  words,  taxis  may  be  employed,  enemata  and  even 
purgatives  given,  and  operation,  although  in  the  writer's  opinion 
indicated,  is  not  of  such  urgent  necessity  as  in  the  more  grave 
conditions  when  the  vascular  circulation  through  the  bowel  is  also 
stopped.  In  cases,  then,  of  old  people,  perhaps  fat  with  fatty 
hearts,  bad  subjects  for  a  general  anaesthetic,  where  the  hernia  is 
umbilical,  it  may  be  advisable  to  delay,  and,  if  posssible,  put  off 
altogether  operation.  In  the  young,  healthy,  vigorous,  and  those 
desiring  to  lead  an  active  life,  obstruction-  should  be  met  by 
operation,  and  may  be  a  blessing  in  disguise  in  inducing  the  patient, 
who  otherwise  would  not  have  thought  of  it,  to  submit  to  radical  cure. 
The  amelioration  of  chronically  obstructed  inguinal  hernia  may 
occasionally  be  assisted  by  the  elevation  of  the  lower  part  of  the 
patient's  bed,  and  matutinal  purgation  with  gentian  and  magnesia 
mixture. 

STRANGULATED   HERNIA. 

The  treatment  of  a  strangulated  hernia  should  be  nearly  always 
by  immediate  operation.  The  only  other  treatment  is  by  taxis,  and 
taxis  is  sp  of  ten  dangerous,  so  often  unsuccessful,  that  its  employment 
should  be  reserved  for  selected  cases.  Much  injury  has  in  the  past 
been  done  by  indiscriminate  taxis.  The  bowel  may  be  bruised,  may 
be  lacerated,  may  be  burst,  the  mesentery  may  be  torn,  the 
superficial  coverings  of  the  hernia  may  be  bruised,  damaged  and 
become  inflamed;  the  whole  hernia  may  be  reduced  en  masse, 
the  septic  contents  of  the  hernia  sac  may  be  returned  into  a 
peritoneal  cavity  as  yet  uninflamed,  and  may  perhaps  produce  a 
general  septic  fatal  peritonitis.  Again,  too,  a  gangrenous  or 
permanently  damaged  bowel,  incapable  of  renewing  its  functions, 
may  by  taxis  be  most  unfortunately  reduced  into  the  abdomen. 

The  writer  has  never  met  with  such  a  case  when  actual  gangrene 
was  present,  and  is  of  opinion  that,  if  the  constriction  has  been  so 
severe  and  so  prolonged  as  to  have  caused  this  condition,  taxis  could 
hardly  procure  reduction  without  causing  a  rupture  of  the  friable 
gangrenous  intestine. 

The  return  of  a  seriously  damaged  bowel  not  yet  absolutely 
gangrenous  is  a  very  dangerous  thing,  and  is  said  to  account  for 
more  than  half  the  deaths  after  herniotomy. 


Strangulated  Hernia.  517 

Operation   by  opening   the    sac,    which  in  the  writer's  opinion 
should  always  be  done,  enables  the  exact  condition  of  the  strangu- 
lated parts  to  be  observed,  the  nipped  portion  of   the   bowel  or 
omentuni  to  be  investigated,  the  septic  contents  of  the  sac  to  be 
got  rid  of,  the  constricting  bands  to  be  divided,  and   usually  a 
radical   cure   of    the   hernia   to   be   effected.     Against   immediate 
operation  it  may  be  urged  that  the  dangers  of  a  general  anaesthetic 
are  sometimes  real  to  a  patient  collapsed,  aged  or  perhaps  organically 
diseased ;  that  the  division  of  the  constriction  (e.g.,  femoral  hernia 
where  Gimbernat's  ligament  is  divided)  may  leave  the  patient,  if  he 
recovers,  a  much  larger  aperture  of  exit  from  the  abdomen  outwards. 
Local  anaesthesia  may  in  certain  rare  cases  be  advisable ;  modern 
surgery,  by  the  use  of  intra-spinal  injection  of  stovaine  or  eucaine 
locally,  can  do  much  in  this  way  that  formerly  was  impossible. 
The  dangers  of   sepsis  and  subsequent  septic  implication  of   the 
peritoneum  have  again,  too,  been  urged  against  operation ;  but,  on 
the   whole,   looking   at   the   undoubted   dangers   of    taxis,  of  the 
frequency  when  it  is  inadmissible,  it  is  far  better  to  make  it  a  rule 
to  operate  on  strangulated  hernia  than  to  treat  it  in  any  other  way. 
Taxis  is  inadmissible  when  the  bowel  has  been  strangulated  for  any 
length  of  time,  and  when  consequently  its  resisting  power  is  uncer- 
tain, when  it  may  be  gangrenous  or  ulcerated  at  the  seat  of  stricture, 
or  when  there  already  is  swelling,  redness,  oedema  or  other  signs  of 
local  inflammation  present.     If,  too,  the  collapse  of  the  patient  is 
great,  operation  should  be  performed  without  previous  taxis.     The 
method   of  applying  taxis  when  admissible,  or  if  the  patient  or  his 
friends  refuse  operation,  is  to  relax,  as  far  as  possible,  the  tension 
of  the  rings ;  in  inguinal  hernia  to  flex  the  leg  on  the  thigh,  the 
thigh  on  the  abdomen  and  to  rotate  the  limb  inwards,  and  then  to 
apply  pressure  in  the  proper  direction,  that  is  to  say,  towards  the 
internal  opening  of  the  hernial  canal.     The  extent  of  that  pressure 
and   the  method   of  applying  it   must   be  left  to  the  discretion, 
judgment  and  experience  of   the  surgeon.     If   the  hernia  should 
suddenly    disappear     under     such    pressure    without    the    usual 
characteristic  snap  or  gurgle  of  returning  bowel,  the  surgeon  must 
remember  the  possibility  of  reduction  en  masse,  or  even  of  rupture 
of    the   strangulated   bowel.      Either   of    these   unfortunate   and 
lamentable  accidents  would  imperatively  demand,  at  all  costs,  an 
immediate  operation.     There  is  no  doubt  in  the  writer's  opinion 
that  the  more  or  less  old-fashioned  treatment  of  strangulation  by 
the  local  application  of  an  ice-bag  does  most  undoubtedly  facilitate 
reduction  of  the  hernia.     Alternative  local  treatment  occasionally 
runs  to  the  other  extreme  of  hot  fomentations  with  those  who  hold 


518  Strangulated  Hernia. 

that  cold  is  likely  to  increase  still  further  the  chance  of  gangrene  in 
the  sorely  tried  howel. 

When  operation  is  decided  upon,  if  the  patient's  condition  allow 
of  it,  a  general  is  better  than  a  local  anaesthetic ;  all  the  usual 
precautions  against  shock  must  be  taken,  and  the  parts  to  be 
operated  on  properly  sterilised,  but  no  time  should  be  wasted, 
especially  when  the  hernia  is  a  femoral  one,  in  an  attempt  to  attain 
the  ideal  if  this  means  anything  like  serious  delay. 

The  superficial  incision  will  vary  according  to  the  site  of  the 
strangulation,  but  in  all  cases  it  should  be  free  and  of  such  size 
that  the  deeper  structures  can  subsequently  be  exposed  without 
difficulty.  The  sac  must  be  defined  and  in  all  cases  opened.  It 
frequently  will  contain  some  fluid,  and  this  more  than  colour  or 
arborescent  vessels  will  favour  its  recognition. 

This  fluid  in  the  sac  of  the  strangulated  hernia  may  be  serous, 
blood-stained,  more  or  less  purulent,  or  muddy  and  offensive  when 
gangrene  has  occurred.  Omentum  may  be  merely  inflamed, 
congested  or  gangrenous.  The  bowel  at  first  is  lustrous,  soon 
becomes  plum-coloured  from  congestion,  later  even  being  black 
from  extravasation  of  blood  in  its  coats,  yet  still  retaining  its 
lustre ;  when  passing  into  a  state  of  gangrene  the  lustre  is  lost, 
the  colour  is  either  an  ashen  grey  or  black.  The  best  treatment  of 
omentum,  inflamed,  congested  or  gangrenous,  is  removal,  ligaturing 
it  with  all  the  precautions  against  subsequent  infra-abdominal 
haemorrhage  previously  mentioned.  Should  any  bleeding  occur 
from  the  omentum  after  it  has  been  returned  into  the  abdomen,  it 
must  be  immediately  dealt  with  by  extension  upwards  of  the  hernia 
wound,  or  even  a  deliberate  laparotorny.  Fatal  bleeding  from  this 
cause  has  before  now  occurred.  The  bowel,  if  obviously  lustrous 
and  plum-coloured,  may  be  safely  returned ;  so,  too,  if  still 
lustrous,  its  colour  is  black  or  nearly  so,  when  this  is  due  only  to 
extravasated  blood.  There  are  cases  when  it  is  difficult  to  say 
whether  the  discoloration  of  the  imprisoned  bowel  is  due  to  blood 
or  to  commencing  mortification ;  perhaps  it  is  well  to  give  it  the 
benefit  of  the  doubt  and  to  return  it  into  the  abdomen,  leaving  it 
with  a  drainage  tube  which  will,  if  necessary,  carry  away  any 
subsequent  extravasation  of  bowel  contents. 

When  the  lustre  is  lost  and  the  bowel  obviously  gangrenous, 
several  courses  are  open  to  the  surgeon.  He  may  open  the  bowel 
and  leave  it  in  situ  ;  this  is  easy  to  do,  but  not  always  an  efficient 
way  of  treating  a  bowel  paralysed  and  unable  by  its  own  peristaltic 
movements  to  pass  its  contents  out  of  the  artificial  anus  or  faecal 
fistula  so  made.  Another  method  is  removal  of  the  gangrenous 


Strangulated  Hernia.  519 

portion  and  suture  of  the  bowel  to  the  wound,  the  deliberate 
making  of  an  artificial  anus.  This,  if  the  patient  recovers,  may 
well  be  found  very  difficult  to  close.  The  best,  but  at  the  same 
time  a  proceeding  attended  with  some  considerable  risk  to  a 
collapsed  patient  the  subject  of  gangrene,  is  to  excise  the  gangre- 
nous parts  and  suture  the  ends  of  the  bowel  together.  This 
anastomosis  is  difficult  to  perform,  the  bowel  coats  in  the  neighbour- 
hood being  inflamed  and  soft,  and  the  ends  of  the  gut  perhaps  of 
unequal  size.  A  comparatively  large  portion  of  bowel  may  require 
excision  before  healthy  ends  can  be  approximated.  In  some  cases 
as  much  as  6  feet  have  been  excised.  Some  surgeons  recommend 
an  end-to-end,  some  a  lateral,  anastomosis  ;  some  are  for  doing  this 
operation  in  the  hernial  wound,  others  would  do  a  deliberate 
laparotomy  to  effect  their  purpose. 

If  the  patch  of  gangrene  is  but  small,  it  may  possibly  be  invagi- 
nated  by  a  Lembert  suture  of  the  neighbouring  walls  over  the  spot 
of  mortification. 

In  all  cases  of  strangulated  hernia  it  is  as  well  to  see  the  seat  of 
constriction,  otherwise  a  minute  perforation  may  be  overlooked, 
and  a  bowel  so  damaged  passed  back  to  infect  the  peritoneal 
cavity.  Dragging  down  the  intestine  for  the  purpose  of  this 
inspection  must  be  performed  with  extreme  care  and  gentleness, 
so  that  impending  rupture  or  perforation  shall  not  be  completed 
by  the  surgeon. 

Another  essential  after  reduction  is  to  pass  the  finger  along  the 
hernial  canal  into  the  abdomen  to  make  sure  that  everything  has 
been  returned.  This  might  also  enable  the  operator  to  detect  some 
hitherto  undiscovered  seat  of  obstruction  apart  and  away  from  the 
hernial  sac.  In  a  case  of  strangulated  umbilical  hernia  under  the 
writer's  care,  a  piece  of  intra-abdominal  gangrenous  intestine, 
strangulated  by  an  omental  band,  was  in  this  way  detected. 

After-treatment. — The  after-treatment  of  cases  of  strangulated 
hernia  should  be  directed  to  the  avoidance  and  treatment  of  shock. 
Warm 'clothing,  a  warm  operating  table,  and  a  warm  bed  are  here 
obviously  indicated.  The  bed  should  be  previously  warmed  by  hot- 
water  bottles,  and  care  must  be  taken  that  the  unconscious  patient 
is  not  accidentally  burned  by  having  them  put  too  close.  It  is  well, 
in  fact,  not  to  use  them  after  he  is  once  back  in  bed.  Strychnine 
subcutaneously,  stimulants,  saline  rectal  injections  may  be  required, 
or  even  the  subcutaneous  injection  of  saline  in  the  tissues  of  the 
thorax  or  other  appropriate  place.  Warm  subcutaneous  saline 
injection  may  be  given  continuously.  Opium,  the  pre-operation 
curse,  may,  in  rare  cases,  when  there  is  nothing  to  contradict  it, 


520  Strangulated  Hernia. 

be  the  post-operation  blessing,  but  usually  is  not  indicated.  The 
bowels  should  be  left  religiously  alone  even  for  four  or  five  days 
or  longer  ;  nature  should  be  given  time  to  effect  the  restoration  of 
function  of  the  damaged  intestine.  In  some  cases,  which  may  have 
gone  on  to  the  so-called  f feculent  vomiting,  it  is  well,  while  the 
patient  is  still  on  the  operating-table,  to  wash  out  the  foul  contents 
of  the  stomach.  Vomiting  of  this  material  while  the  patient  is 
under  the  anaesthetic  is  dangerous,  and  before  now  has  led  to 
death  on  the  table  from  the  vomit  having  entered  the  air  passages. 

A  semi-recumbent  or  sitting  posture  will  often  allow  an  old 
person  with  a  tendency  to  bronchitis,  or  with  laboured  action  of 
the  heart  from  flatulent  distension,  to  overcome  these  very  real 
obstacles  to  recovery.  Food  may  have  to  be  administered  at  first 
by  means  of  nutrient  enemata,  but  as  soon  as  possible  the  feeding 
should  be  in  small  quantities  by  the  mouth.  The  amount  of  sick- 
ness will  determine  to  a  large  extent  the  method  by  which  nutri- 
ment can  be  given.  The  vomiting  that  follows  an  anaesthetic  must 
not  be  confused  with  the  persistence  of  vomiting  due  to  the  effects 
of  the  strangulation.  The  bowel,  although  released  from  its 
imprisonment,  may  still  by  its  paralysis  offer  a  mechanical  obstacle 
to  the  flow  of  intestinal  contents ;  time  alone  can  here  do  good. 

Vomiting,  too,  may  continue  from  some  other  source  of  intestinal 
obstruction,  or  even  from  such  an  accidental  or  overlooked  cause, 
such  as  pregnancy. 

It  should  be  definitely  ascertained  that  there  is  no  second  obstruc- 
tion; if  there  is  it  must  at  once  be  suitably  dealt  with  by  operation. 
The  possibility  of  re- strangulation  should  not  be  overlooked. 

The  causes  of  Strangulated  Hernia  not  doing  well  after 
operation  are  many.  Apart  from  collapse  immediately  afterwards, 
death  may  occur  from  sepsis,  peritonitis,  or  lung  complications,  such 
as  bronchitis  or  pneumonia.  The  damaged  bowel  itself  may  be 
acutely  inflamed  (enteritis),  may  be  paralysed  or  become  the  seat 
of  stricture.  Adhesions  may  form  in  its  neighbourhood,  giving 
rise  to  internal  strangulation  by  kinking  of  the  bowel  or  «by  an 
omental  band. 

The  bowel  may  be  reduced  en  masse,  and  this,  whether  the 
sac  is  multilocular  or  not. 

Treatment  of  the  condition  of  persisting  intestinal  obstruction, 
which  must  not  be  confused  with  the  somewhat  similar  symptoms 
of  simple  peritonitis,  is  to  find  out  its  cause  and  locality,  and  not  to 
hesitate  to  perform  a  necessary  laparotomy  when  thorough  examina- 
tion of  all  the  rings  show  them  to  be  patent  and  the  seat  of  the 
trouble  to  be  elsewhere. 


Strangulated   Hernia.  521 

Strangulated  Inguinal  Hernia. — The  operation  for  this  condi- 
tion in  the  initial  steps  is  exactly  the  same  as  in  the  operation  for 
radical  cure.  The  sac  is  exposed  and  opened.  The  constricting 
point  is  usually  found  to  be  a  circular  fibrous  ring  in  the  neck  of  the 
sac,  sometimes  a  .structure  outside  it.  In  its  division  upwards  the 
relation  of  the  epigastric  artery  should  be  remembered ;  but  the 
danger  of  wounding  this  in  an  open  operation  when  the  external 
oblique  is  slit  up,  all  structures  divided  down  to  the  sac,  and  the  sac 
alone  is  being  dealt  with,  is  infinitesimal. 

The  reduction  of  the  intestine  may  present  some  mechanical  diffi- 
culty in  large  herniae,  especially  if  the  coils  are  distended  with  flatus, 
and  part  of  it  before  strangulation  has  been  irreducible.  Adhesions 
of  omentum  and  bowel  to  sac  or-to  each  other  must  be  separated, 
and  the  sac  during  reduction  of  its  contents  must  be  kept  tense  and 
not  allowed  to  fall  into  folds.  The  surgeon  should  first  reduce  the 
part  nearest  to  the  ring,  unravelling  the  coils  of  intestine  and 
passing  it  back  bit  by  bit.  If  one  end  of  the  bowel  cannot  be 
made  to  move,  attention  should  be  paid  to  the  other  end,  and  any 
redundant  blocking  omentum  should  be  removed.  To  facilitate 
reduction  the  rings  should  be  relaxed  by  flexing  the  thigh  on  pelvis 
and  rotating  it  inwards.  The  exposed  intestine  should  be  kept 
warm  and  covered  by  gauze  or  warm  sterile  sponges.  Excessive 
flatulent  distension  may  require  puncture  of  the  bowel  with  a  very 
fine  trocar  ;  after  the  relief  thus  afforded,  a  Lembert  stitch  or  two 
should  be  inserted  to  close  safely  the  minute  opening  thus  made  into 
the  gut.  Extreme  care  must  be  taken  that  nothing  exuding  from 
the  puncture  is  allo\ved  to  soil  the  sac  or  its  contents. 

The  different  varieties  of  inguinal  hernia,  except  the  interstitial, 
the  different  shapes  of  the  sac,  e.g.,  hour-glass,  present  no  diffi- 
culty if  only  the  parts  are  thoroughly  exposed.  Small  incisions,  not 
involving  the  external  oblique,  and  deep  divings  with  hernia  knives  to 
divide  tense  constricting  bands  of  doubtful  structure  in  interesting 
anatomical  neighbourhoods  are  as  dangerous  now  as  they  were  in 
the  past. 

A  deliberate  open  operation  as  for  radical  cure  with  the  inguinal 
canal  fully  exposed  right  up  to  the  internal  abdominal  ring  leaves 
nothing  of  doubt  and  very  little  of  difficulty. 

After  the  strangulation  has  been  rectified  the  radical  cure  is 
proceeded  with.  The  whole  operation  for  strangulation  in  an 
ordinary  case  takes  very  little  longer  than  an  ordinary  radical  cure, 
but  grave  conditions  of  the  bowel,  such  as  gangrene  involving 
excision  or  other  radical  treatment,  may  very  materially  prolong  the 
duration  of  the  operation  and  be  accompanied  by  shock  and  collapse. 


522  Strangulated   Hernia. 

The  bowel  in  strangulated  inguinal  hernia  is  not,  however,  usually  so 
severely  nipped  as  in  the  femoral  variety  where  it  is  pressed  against 
the  sharp  edge  of  Gimbernat's  ligament. 

Strangulated  Femoral  Hernia. — A  strangulated  femoral  hernia, 
if  neglected,  is  a  very  serious  matter,  as  the  parts  are  tightly  nipped 
at  Gimbernat's  ligament.  The  bowel  is  soon  seriously  damaged, 
gangrene  or  ulceration  at  the  seat  of  stricture  not  uncommon, 
the  mesentery,  too,  may  become  thrombosed,  with  no  pulsation  of 
its  arteries.  A  loop  of  bowel  with  a  thrombosed  mesentery  must 
not  be  returned  into  the  abdominal  cavity,  but  resected  as  if  it 
were  already  gangrenous.  There  has  been  much  discussion  as  to 
whether  it  is  safe  or  useful  to  divide  the  constriction  if  the  intestine 
is  unfit  to  return ;  some  advocate  the  opening  of  the  injured  bowel 
and  the  passing  of  a  drainage  tube  into  the  interior  of  the  distended 
bowel  above  the  constriction.  Recovery  after  this  method  of  treat- 
ment has  occurred  in  only  10  per  cent.,  so,  perhaps,  resection, 
even  when  it  is  to  be  extensive,  i.e.,  some  feet,  is  to  be  preferred. 

The  sac  of  a  strangulated  femoral  hernia  is  often  difficult  to 
define.  Concentric  layers  of  fat  and  tissues  containing  oedematous 
fluid  add  to  the  difficulty.  The  sac  itself,  when  bowel  is  the  sole 
occupant,  may  be  adherent  to  its  contents  and  its  opening  a  matter 
of  difficulty  and  danger.  If  the  intestine  should  be  accidentally 
wounded,  the  opening  should  be  closed  by  a  Lembert's  suture,  if 
the  general  condition  of  the  gut  allows  of  this ;  if  not,  re-section  or 
the  making  of  an  artificial  anus  may  be  indicated. 

The  constriction  at  the  femoral  ring  must  be  divided  inwards,  or 
upwards  and  inwards,  cutting  into  Gimbernat's  ligament.  This 
must  be  done  on  a  director  by  a  hernia  knife,  and  care  must  be 
taken  to  see  that  there  is  no  overlapping  of  the  bowel  while  it  is 
done.  The  nick  should  not  be  excessive,  but  it  is  no  good  attempt- 
ing to  reduce  a  damaged  bowel  through  an  opening  insufficiently 
enlarged.  A  too-careful,  inexperienced  operator,  fearful  of  an 
abnormal  obturator  artery,  may  easily  waste  valuable  time  in 
attempts  at  a  reduction  of  bowel  which  is  mechanically  impossible. 
Too  free  a  division  of  Gimbernat's  ligament  may  favour  recurrence 
of  the  hernia ;  but  if  the  operation  for  strangulation  is  followed  by 
one  of  the  methods  of  radical  cure,  as  it  should  be,  this  is  much  less 
likely  than  formerly.  If  by  any  unfortunate  chance  the  obturator 
artery  is  in  the  way  and  is  wounded,  the  immediate  haemorrhage 
may  be  checked  by  pressure  or  clip  pressure,  the  parts  then  freely 
exposed  and  the  divided  vessel  duly  ligatured.  If  the  haemorrhage 
should,  as  sometimes  happens,  not  immediately  follow  the  injury, 
the  treatment  when  it  does  occur  must  be  on  the  same  lines. 


Palliative  Treatment  of  Hernia.  523 

It  is  quite  possible  that  a  fairly  free  division  of  the  abdominal 
aponeurosis  may  be  required  to  allow  of  the  ligature  of  the  bleeding 
vessel. 

It  was  suggested  years  ago  that  strangulated  hernia  should  be 
treated  by  laparotomy,  and  the  strangulated  parts  pulled  back  into 
the  abdominal  cavity.  This  would  not  allow  of  a  radical  cure  being 
performed,  future  hernia  would  not  be  prevented,  adhesions  of  sac 
contents  to  sac  might  make  the  proceeding  impossible,  and  any 
seriously  damaged  intestine  might  readily  give  way  when  pulled  upon. 

Strangulated  Umbilical  Hernia. — It  is  sometimes  difficult  in 
an  old  irreducible  umbilical  hernia  to  say  whether  it  is  strangulated 
or  merely  obstructed.  The  urgency  and  gravity  of  the  symptoms, 
both  local  and  general,  will  have  to  determine  this  question,  so 
important  both  to  surgeon  and  patient.  The  un suitability  of  the 
latter  for  a  grave  operation  may  well  make  the  former  unwilling  to 
undertake  it  when  there  is  any  doubt  as  to  its  absolute  necessity. 

The  seat  of  strangulation,  so  often  within  a  sac,  with  many 
recesses,  by-paths,  and  cul-de-sacs  made  up  of  omental  and  bowel 
adhesions,  may  be  difficult  to  find,  and  its  rectification- involves  much 
handling  and  separation  of  adherent  inflamed  intestine. 

In  cases  where  the  strangulation  is  one  of  recently  descended 
bowel  only,  no  such  difficulties  may  be  encountered,  but  when  a 
small  knuckle  of  strangulated  intestine  is  tucked  away  in  some 
remote  corner  t>f  a  complicated  sac  containing  old  adherent  intestine 
and  old  sacculated  ornentum  its  relief  may  be  no  easy  matter.  It 

•/  «/ 

should  be  a  rule  of  the  operating  surgeon  to  expose  freely  the  parts, 
so  that  he  can  see  exactly  what  he  is  doing  and  how  to  do  it.  He 
must  take  the  ordinary  precautions  to  prevent  chill  of  exposed  intes- 
tine and  avoid  pulling  and  tearing  at  adhesions  as  much  as  possible. 
If  the  condition  of  the  patient  allow  of  it,  and  all  the  hernial 
contents  can  be  reduced,  a  radical  cure  should  be  performed,  but  in 
any  bad  case  this  may  be  impossible. 

PALLIATIVE    TREATMENT    OF    HERNIA. 

Palliative  treatment  is  treatment  by  trusses  and  belts.  A  truss 
is  a  belt  containing  a  stout  spring  encircling  the  body,  fitted  with  a 
pad  by  means  of  which  the  force  of  the  spring  is  applied  over  the 
internal  ring  and  hernial  canal.  The  pad  is  usually  made  of  cork  and 
covered  with  chamois  leather,  and  the  spiral  spring  is  also  covered 
with  leather  or  some  other  suitable  material.  It  may  be  necessary 
to  measure  for  a  truss.  In  doing  so  the  measuring  tape  passing 
over  the  base  of  the  sacrum  should  be  brought  midway  between  the 
upper  border  of  the  great  trochanter  and  the  crest  of  the  ilium 


524  Palliative  Treatment  of  Hernia. 

round  to  the  middle  line  above  the  symphysis  pubis.  The  size  of 
the  truss  is  measured  by  the  number  of  inches  thus  traversed.  In 
fat  people  allowance  must  be  made  for  their  obesity  in  fitting  the 
pad  of  the  truss,  which  must  not  rest  on  the  pubic  bone  ;  neither 
must  it  press  too  lightly  or  too  heavily.  It  is  supposed  by  some 
that  atrophy  of  the  abdominal  wall  or  even  enlargement  of  the 
hernial  ring  may  be  caused  by  excessive  pressure. 

The  double  truss  is  easier  to  apply  and  keep  applied  than  is  the 
single  one.  Looking  to  the  natural  weakness  of  both  sides,  even 
when  hernia  has  actually  shown  itself  only  on  the  one,  a  good 
many  surgeons  recommend  a  double  truss  as  being  more  efficient 
than  a  unilateral  one,  especially  as  it  can  often  be  worn  without 
under  straps. 

When  fitted,  the  truss  pressure  and  support  should  be  present  in 
all  positions  and  movements  of  the  body. 

Certain  forms  of  trusses  are  used  for  protection  rather  than 
repression  of  irreducible  hernial  contents,  and  are  called  bag 
trusses.  Occasionally  it  may  be  necessary  to  prolong  the  pad 
downwards  in  what  is  known  as  a  rat-tail  truss.  Abdominal  belts 
are  required  for  ventral  and  umbilical  hernias ;  they  may  when 
necessary  be  combined  with  stays.  Vulcanite  or  other  waterproof 
material  may  be  used  for  trusses  worn  whilst  bathing,  or  in  children 
or  old  people  likely  to  soil  them  with  urine. 

Trusses  of  the  spiral  spring  variety  usually  encircle  the  body  on 
the  same  side  as  the  hernia,  but  in  some  varieties  an  opposite  side 
truss  will  give  a  better  result. 

A  femoral  truss  is  more  irksome  than  is  an  inguinal  one,  and 
in  some  cases  of  difficulty  the  pad  may  have  to  be  incorporated  in 
a  belt  going  round  the  upper  part  of  the  thigh. 

It  should  be  remembered  that  the  wearing  of  a  truss  is  not  only 
often  a  matter  of  inconvenience,  but  in  the  uneducated  and  ignorant 
classes  sometimes  a  positive  danger,  insomuch  as  they  are 
frequently  put  on  over  a  descended  hernia.  It  has  already  been 
pointed  out  that  this  is  frequently  the  cause  of  adhesions,  and  may 
even  induce  obstruction  or  aggravate  strangulation.  It  should  be 
a  rule  that  a  truss  is  put  on  when  the  patient  is  in  the  recumbent 
position,  and  should  be  taken  off  after  the  patient  is  lying  down  in 
bed  at  night.  If  any  of  the  hernia  is  down  it  should  not  be  worn. 
If  there  is  any  redness,  inflammation  or  excoriation  of  the  skin, 
this  must  be  treated  before  any  further  truss  pressure  is  allowed. 
If  a  gland  should  enlarge  and  threaten  suppuration,  truss  wearing 
must  be  at  once  discontinued  and  rigid  rest  in  bed  be  enforced.  If 
truss  abscess  should  unhappily  occur,  the  truss  must  not  be  again 


Palliative  Treatment  of  Hernia.  525 

worn  until  the  parts  after  operation  are  thoroughly  healed.  The 
skin  under  the  truss  should  be  prepared  for  pressure  by  the  local 
application  of  spirit  lotions  to  harden  it,  and  in  warm  weather  by 
powders,  such  as  starch,  boracic  acid,  and  oxide  of  zinc  in  equal 
parts,  to  obviate  the  effects  of  perspiration. 

The  skin  should  be  protected  from  direct  pressure  of  the  truss-pad 
by  a  piece  of  silk ;  a  portion  of  an  old  silk-handkerchief  does  very 
well  for  this.  The  efficiency  of  the  truss  when  it  is  on  should  be 
tested  by  making  the  patient  forcibly  cough  while  the  rings  are 
relaxed  by  a  bent  position  of  the  knees,  hips  and  body.  If  there  is 
no  descent  of  the  hernia  under  these  conditions,  the  truss  is  probably 
efficient.  The  pressure  should  not  be  so  hard  as  to  be  painful  in 
any  way,  nor  so  little  as  to  allow  any  protrusion.  The  truss-pad 
itself  should  be  accurately  applied  over  the  internal  ring,  and  if 
there  is  any  great  difficulty  in  fitting  the  patient  a  plaster  cast  of 
the  parts  may  be  taken  and  a  truss  "built  "  to  fit  them  accurately. 
The  direction  of  the  pressure  naturally  varies  according  to  the 
existing  hernia. 

In  very  young  children  femoral  hernia  is  rarely  seen,  and 
consequently  femoral  trusses  are  not  required  except  for  adults. 
Some  yielding  at  the  umbilicus  or  definite  small  umbilical  hernia  is 
common  in  infants,  and  requires  a  pad  larger  than  the  aperture 
and  pressure  made  either  by  a  truss  or  strapping.  As  the  child 
grows  the  umbilical  aperture  is  relatively  smaller,  and  slight  degrees 
of  hernia  undergo  spontaneous  cure  or  leave  but  "  a  windy  navel." 

A  carefully  applied  spica  bandage  with  a  pad  over  the  inguinal 
canal  may  be  sufficient  support  for  some  children's  hernia.  The 
latter  should  never  be  allowed  to  descend,  especial  care  being  taken 
when  the  child  is  washed  to  keep  good  firm  pressure  with  the  finger 
or  vulcanite  or  indiarubber  truss  on  the  weak  abdominal  wall.  An 
intelligent  mother  or  nurse  can  do  much  in  this  way.  A  good 
digestion  leading  to  a  placid  temperament  and  absence  of  crying  or 
screaming  will  be  valuable  aids.  Such  good  digestion  and  placidity 
is  more  often  seen  in  breast-fed  infants  than  in  others  less  naturally 
reared.  No  truss  will  cure  a  child  when  causes  of  straining,  such  as 
constipation  or  phimosis  hindering  proper  micturition,  are  left 
unattended  to. 

A  certain  number  of  children  treated  by  trusses  appear  to  "grow 
out  "  of  the  inguinal  hernia  of  infancy.  It  may  be  that  in  some 
the  truss  pressure  and  irritation  causes  peritoneal  adhesion  and 
closure  of  the  processal  vaginalis  at  a  later  period  than  the  normal, 
but  a  large  number  remain,  even  if  not  the  subjects  of  actual 
hernia,  potential  sufferers  from  the  malady  in  after  life. 


526 


Palliative   Treatment  of  Hernia. 


"  Rupture,"  which  suggests  the  breaking  of  something,  is  a  most 
misleading  term.  When  an  adult  becomes  "  ruptured  "  it  is  nearly 
always  (if  not  always)  because,  being  the  subject  of  a  developmental 
defect,  his  hernia  has  come  down  on  some  slight  provocation  or 
strain  into  a  previously  existing  but  unused  sac.  A  lack  of  muscular 
and  aponeurotic  development  in  the  groins  and  about  the  recti  and  a 
protrusion  of  the  median  abdomen  are  frequent  concomitants  or 
forerunners  of  actual  hernia.  The  latter  should  be  guarded  against 
by  a  belt  or  preventive  bi-lateral  truss.  Thishernial  predisposition, 
almost  diathesis*  cannot  be  cured,  but  may  in  this  manner  be 
obviated.  Protective  bag  trusses  are  but  poor  things,  and  do  little 
in  the  way  of  protection ;  when  a  hernia  requires  a  rat-tail  truss,  it  is 
a  difficult  one  to  treat  efficiently  save  by  operation. 

The  pads  of  some  trusses  are  made  of  horseshoe  shape  to  avoid 
pressure  on  such  a  structure  as  an  undescended  testis.  They  may 
be  difficult  to  put  and  keep  on  properly,  and  cases  where  they  are 
used  cry  aloud  for  operation. 

A  truss  may  be  recommended  for  very  young  children  both  for 
inguinal  or  umbilical  hernia  until  such  time  as  either  the  hernia  has 
been  cured  or  the  child  is  ripe  for  operation ;  also  for  old  people 
not  fit  subjects  for  operation,  on  account  of  cardiac  or  lung  com- 
plications, or  other  visceral  disease,  and  after  operation  in  certain 
cases,  especially  bad  cases  of  femoral  or  umbilical  hernia ;  the 
latter  usually  requires  an  abdominal  belt.  A  truss  should  rarely  be 
wanted  after  operation  for  inguinal  hernia,  except  in  very  voluminous 
ones  where  the  chief  object  of  the  operation  has  been  to  enable  a 
truss  to  be  worn  rather  than  a  real  radical  cure,  or  in  cases  of 
interstitial  hernia  not  fit  for  operation.  A  large  interstitial  pad 
is  then  required. 

After  operations  for  recurrence  a  truss  may  be  advisable,  but  it 
will  depend  much  on  how  the  first  operation  has  been  performed 
and  what  was  the  cause  of  the  recurrence. 


Single  truss  for  inguinal  hernia. 


Single  truss  for  femoral  hernia. 


Palliative  Treatment  of  Hernia. 


527 


Child's  double  truss  for 
inguinal  hernia. 


^^"^^^r 

Child's   umbilical  belt. 


Umbilical  truss. 


Salmon  and  Ody's  truss  for 
inguinal  hernia. 


Abdominal  belt  for 
umbilical  hernia. 


Truss  for  irreducible  hernia. 


G.  R.  TURNER. 


528 


INTESTINAL  OBSTRUCTION. 

THERE  is  no  need,  for  the  purpose  of  this  article,  to  enter  with 
any  minuteness  into  the  pathology  of  the  various  causes  that  lead 
to  acute  intestinal  obstruction.  For  the  most  part  they  are  due 
to  an  antecedent,  and  usually  to  a  localised,  peritonitis.  Bands  of 
lymph  glue  adjacent  coils  of  intestines  together,  or  anchor  them  to 
the  abdominal  wall  or  the  viscera.  With  the  movement  of  the  in- 
testine these  bands  may  stretch  and  form  string-like  bands,  leading 
to  constriction  by  pressure,  kinks,  internal  hernias,  twists  or  other 
causes  of  obstruction.  If  left  alone  the  patient  usually  dies  in  about 
a  week  or  ten  days.  Successful  treatment  depends  essentially  on 
early  recognition  and  early  operation.  The  cases  are  really  simple 
for  the  trouble  is  purely  mechanical  in  its  inception,  and  it  must 
therefore  be  relieved  by  mechanical  means.  It  is  necessary  to  re-' 
state  even  so  bald  a  surgical  truism.  Far  too  often  early  recognition 
is  not  immediately  followed  by  operative  treatment.  The  patient 
dies,  simply  because  the  medical  man  has  not  the  courage  of  his 
opinions.  To  wait  for  the  text-book  symptoms  is  to  wait  until  there 
may  be  no  doubt ;  but  little  hope  either.  To  postpone  operation,  for 
instance,  until  faecal  vomiting  has  commenced  is  to  procrastinate 
until  the  effects  of  a  general  anaesthetic  are  ill-borne,  until  operative 
difficulties  are  immensely  increased,  and  until  secondary  com- 
plications, such  as  distension,  paralysis  or  even  gangrene  of  the 
intestine  and  toxaemia  have  set  in  and  the  prospects  of  recovery 
have  melted  away  owing  to  pusillanimous  indecision.  It  is  a  sound 
maxim  that  faecal  vomiting  is  a  symptom  which  ought  never  to  be 
seen  at  all ;  it  is  little  less  disastrous  to  wait  until  visible  peristalsis 
is  evident  and  distension  has  commenced. 

A  patient  with  a  strangulated  external  hernia  is  usually  submitted 
to  operation  promptly  enough,  while  a  patient  with  an  internal  hernia 
or  practically  similar  obstruction  is  too  frequently  left  unrelieved 
until  his  case  is  hopeless.  Yet  the  operation  for  an  internal  hernia 
is  almost  as  simple  a  proceeding  in  the  early  stages,  while  the  effects 
of  neglecting  to  deal  with  it  are  far  more  disastrous.  In  dealing 
with  an  external  hernia,  the  sac  and  its  cellular  tissue  investments, 
loaded  with  toxic  products,  can  be  cut  away.  This  is,  of  course, 
impossible  with  an  internal  hernia,  save,  occasionally,  when  omentum 
is  involved.  Poisoning  is  localised  in  the  one  case  and  not  in  the 


Intestinal    Obstruction.  529 

other,  and  yet  the  graver  ease  is  the  one  that  is  often  more  tardily 
dealt  with.  The  fact  that  there  is  no  palpable  visible  tumour  in  the 
one  instance  while  it  is  present  in  the  other  ought  to  make  no 
difference.  A  patient  who  gives  a  history  of  a  previous  attack  of 
appendicitis  or  perimetritis,  and  is  sei/ed  with  a  sudden  severe 
abdominal  pain,  perhaps  recurring  three  or  four  times  with  regular 
intermission  during  the  first  few  hours,  and  then  subsiding  into 
a  condition  of  comparative  comfort,  is  just  the  person  whose 
condition  imperatively  cries  out  for  operation.  This  quiescent 
interval,  more  or  less  well  defined,  almost  invariably  occurs,  just  as 
happens  in  the  case  of  a  perforated  gastric  or  duodenal  ulcer.  Often 
the  patient  vomits  but  once  or  twice  only  before  the  quiet  stage  sets 
in.  Unless  the  diagnosis  is  wholly  at  fault,  the  symptoms  are 
absolutely  certain  to  recur.  And  when  they  do  recur  the  patient's 
chance,  in  any  case  doubtful,  has  been  reduced  by  more  than 
50  per  cent.  It  is  during  this  period  of  calm  that  the  surgeon  of 
any  experience  sees  his  best  opportunity.  He  acts  and  wins,  hold- 
ing, if  he  is  weak  enough  to  take  the  point  into  account,  that  he 
risks  his  reputation  less  by  action  than  by  delay.  The  inex- 
perienced or  timid  man,  buoyed  up  by  a  hope  he  does  not  really 
feel,  waits,  and  loses ;  his  failure  conceivably  mitigated  by  the  tragic 
irony  of  a  newspaper  paragraph  to  the  effect  that  "  a  successful 
operation  was  performed,  but  the  patient  died  a  few  hours  later." 
When  symptoms  of  the  kind  have  occurred  and  the  patient  is  seen 
within  the  first  twenty-four  hours,  the  prospect  of  recovery  is  good, 
and  the  operation  if  undertaken  at  once  is  easy  and  short.  Even  if 
the  diagnosis  is  wholly  wrong  and  the  operation  results  merely  in  a 
profitless  exploration,  every  surgeon  of  experience  will  agree  that, 
when  there  is  any  such  history  as  described  above,  operative 
measures  are  not  only  justifiable  but  imperative. 

Broadly  speaking,  in  the  absence  of  any  positive  indication  as  to 
the  site  of  the  obstruction,  the  best  point  to  make  for  is  over  the  line 
of  the  right  sacro-iliac  joint.  Local  pain  and  tenderness  are  often 
misleading  symptoms.  The  vertical  interval  between  two  horizontal 
lines,  drawn  across  the  abdomen  at  the  level  of  the  highest  point  of 
the  crests  of  the  ilium  and  the  anterior  superior  spines  respectively, 
indicates  roughly  the  extent  of  this  joint ;  a  line  drawn  directly 
upwards  through  the  middle  of  Poupart's  ligament  corresponds  to  the 
distance  at  which  the  joint  lies  from  the  middle  line.  The  best  incision 
is  through  the  right  rectus  muscle,  an  inch  from  the  middle  line. 
Incision  through  the  semi-lunar  line  allows  less  ready  access  to  the 
other  side  of  the  abdominal  cavity,  and  if  at  all  extensive  the  nerves 
supplying  the  muscle  are  necessarily  divided.  The  various  forms  of 

S.T.  — VOL.  ii.  34 


530  Intestinal  Obstruction. 

mechanical  ileus  occur  more  frequently  on  the  right  side,  owing,  no 
doubt,  to  their  being  so  frequently  the  result  of  appendicitis.  The 
incision  can  be  prolonged  readily  up  towards  the  gall-bladder,  or  down 
so  as  to  give  access  to  the  pelvis,  with  the  least  damage  to  the  abdominal 
wall  or  risk  of  subsequent  ventral  hernia.  In  cutting  through  the 
abdominal  wall  notice  should  be  taken  of  the  condition  of  the 
cellular  tissue  in  the  inter-muscular  spaces ;  if  there  is  any 
oedema  there  is  likely  to  be  pus  within  the  abdominal  cavity.  The 
wound  will  be  more  satisfactorily  closed  subsequently,  if  in  the 
lower  half  of  the  abdomen,  if  the  transversalis  fascia  and  the 
peritoneum  are  divided  together.  When  the  intestine  is  at  all 
distended  it  lies  in  very  close  apposition  to  the  peritoneum,  and  in  the 
case  of  children  it  must  be  remembered  that  the  peritoneum  is  so 
thin  that  it  may  be  opened  before  it  is  recognised.  The  peritoneal 
cavity  being  open,  search  for  the  obstruction  must  be  carried  out 
on  methodical  lines.  Rapidity  is  of  the  first  importance,  and  a 
prolonged  search  conducted  in  a  haphazard  way  is  very  prejudicial. 
As  soon  as  the  abdomen  is  open  the  finger  is  passed  in  towards  the 
right  sacro-iliac  joint.  Whatever  the  form  of  obstruction,  it  will 
probably  be  recognisable  by  the  fact  that  something  abnormally 
hard  can  be  felt.  The  twist  of  a  volvulus  seems  hard.  An 
internal  hernia  seems  hard;  just  as  a  large  impacted  gall-stone 
or  other  foreign  body,  or  a  malignant  growth,  or  a  twisted  ovarian 
cyst,  would  seem  harder  than  natural.  It  may  be  mentioned  here 
that  a  twisted  ovarian  cyst  will  give  rise  to  symptoms  which 
closely  resemble  those  of  acute  intestinal  obstruction.  If  nothing 
definite  can  be  felt,  the  omentum,  if  it  presents,  should  be  pushed 
upwards  and  to  the  left.  Distended  intestines  should  be  ignored 
and  gently  kept  back  while  search  is  made  for  a  collapsed 
portion  of  the  gut.  This  can  be  often  felt  with  great  ease  without 
allowing  any  of  the  abdominal  contents  to  extrude.  The  moment 
that  a  portion  of  collapsed  gut  is  found  it  should  be  traced  methodi- 
cally upwards  to  the  site  of  the  obstruction.  If  the  obstruction 
involves  the  small  intestine  high  up,  a  considerable  length  may  have 
to  be  drawn  out  before  the  exact  site  of  the  trouble  is  discovered  ; 
but  there  is  no  difficulty  in  replacing  collapsed  gut,  and  if  the  oblique 
attachment  of  the  mesentery  is  remembered,  the  operator  will  not 
fall  into  the  error  of  tracing  the  intestine  in  the  wrong  direction. 
As  the  collapsed  gut  is  passed  through  the  fingers  it  should  be 
replaced  within  the  abdominal  cavity.  On  arriving  near  the  actual 
site  of  the  obstruction  great  gentleness  must  be  used,  particularly  if 
symptoms  have  been  present  for  some  time.  If  possible,  the  portions 
of  the  gut  actually  involved  in  the  obstruction  should  be  drawn 


Intestinal  Obstruction.  531 

outside  the  abdominal  cavity,  and  there  dealt  with.  Frequently, 
however,  this  is  impossible.  It  is  best  to  have  a  fairly  long  in- 
cision when  the  obstruction  is  deeply  situated,  in  order  to  secure 
free  and  rapid  access  to  the  seat  of  trouble.  When  this  is  once 
exposed  any  portion  of  the  wTound  that  is  really  not  required  is 
packed  off. 

Even  when  the  administration  of  the  anaesthetic,  if  general,  is  in 
the  most  skilled  hands,  the  patient  is  apt  to  strain  violently  at  some 
period  of  the  operation.  If  this  complication  comes  about  it  is  best 
to  wait  for  a  little,  rather  than  run  any  risk  of  handling  intestine 
roughly.  When,  as  is  usually  the  case,  the  intestines  are  dis- 
tended, difficulties  begin  as  soon  as  the  peritoneum  has  been  divided. 
The  coils  of  inflated  gut  tend  to  protrude  at  once  ;  as  the  relief  to 
the  embarrassed  breathing  allows  the  diaphragm  to  act  with  more 
freedom  and  power  loop  after  loop  may  be  forced  out,  particularly 
in  children.  When  the  small  intestine  is  involved,  puncture 
at  this  stage  of  the  operation  is  undesirable,  for  .it  will  relieve 
the  distension  over  only  a  short  length ;  the  process  of 
unloading  the  contents,  gaseous  or  other,  is  a  slow  one.  Still, 
in  extreme  cases,  puncture  may  have  to  be  performed.  A  stout, 
double  silk  thread  may  be  passed  through  all  the  layers  of 
the  abdominal  wall  on  either  side  of  the  wound.  This  allows  of 
great  control.  The  abdominal  wall  can  be  drawn  forwards  or  the 
edges  of  the  wound  approximated  with  ease.  The  intestines  cannot 
be  efficiently  kept  back  by  packing  in  rolls  of  gauze.  The  rolls  ball 
at  once.  Thin  flat  pads  of  gauze  to  which  tapes  are  attached  serve 
better.  Flat  marine  sponges  answer  best  of  all.  At  no  stage  of 
the  operation  is  the  value  of  skilled  assistance  more  pronounced. 
In  extreme  cases  all  the  distended  gut  has  been  allowed  to  extrude, 
protected  by  warm  sterile  cloths  soaked  in  saline  solution.  The 
temporary  convenience  is  dearly  secured.  The  site  of  obstruction 
may  be  exposed,  but  will  often  be  still  within  the  belly.  The  shock, 
always  considerable,  is  likely  to  be  formidable.  The  abdominal  con- 
tents are  chilled :  paralysis  of  the  gut  is  likely  to  supervene  for  a 
time  while  the  difficulty  of  replacing  the  coils  leads  to  undue  hand- 
ling, and  often  to  bruising  or  even  tearing  of  the  distended  gut.  Dry 
intestine  is  much  more  easily  damaged  than  moist,  and  if  there  is 
much  difficulty  in  keeping  back  the  abdominal  contents,  irrigation 
from  time  to  time  with  saline  solution  will  be  advantageous.  The 
serous  coat  is  less  likely  to  be  split,  the  gut  will  absorb  some  of  the 
fluid,  and  such  manipulation  as  is  absolutely  necessary  becomes 
more  easy  and  safe.  Rubber  gloves,  if  at  all  dry,  will  damage  the 
gut  more  than  the  uncovered  hands.  When  the  distension  is 

34—2 


532  Intestinal  Obstruction. 

more  or  less  limited  to  the  large  intestine,  the  difficulty  is  not  so 
great  nor  are  the  effects  of  exposure  so  serious. 

The  site  of  obstruction  being  revealed,  prompt  decision  must  be 
taken  as  to  the  best  method  of  dealing  with  it.  Obvious  bands  may 
be  divided  between  two  ligatures.  It  is  safer  to  ligature  bands 
rather  than  to  clamp  them  between  two  clip  forceps  before  dividing, 
for  not  infrequently  the  involved  intestine,  directly  the  drag  is 
relieved,  disappears  altogether  out  of  sight,  carrying  the  clamp  with 
it,  and  this  involves  drawing  it  back  again  before  ligating.  Long 
stretched  out  bands  are  almost  avascular,  but  it  frequently  happens 
that  what  appears  to  be  a  simple  strand  of  lymph  is  really  a  drawn 
out  funnel  of  intestine.  Consequently  the  division  of  what  appears 
to  be  a  band  really  wounds  the  gut.  If  the  small  opening  is  not 
dealt  with  at  once,  leakage  may  take  place  after  release.  "When 
the  small  intestine  is  adherent  to  the  abdominal  wall,  fixed 
and  acutely  flexed  or  kinked,  this  kind  of  slender,  diverticulum-like 
process  of  the  intestine  is  particularly  likely  to  be  formed.  It 
is  quite  safe  in  these  cases  to  ligature  the  drawn  out  process  of 
intestine.  It  is  seldom  necessary  to  formally  suture.  Care  must 
be  taken,  when  the  band  is  relieved,  that  the  occluded  portion  of 
intestine  does  not  recede  out  of  sight,  for  its  condition  must  be 
carefully  investigated. 

If  there  has  been  much  pressure  the  damage  to  the  constricted 
portion  of  the  intestine  has  to  be  dealt  with  exactly  as  in  the 
case  of  an  external  hernia.  It  must  be  remembered  that 
when  a  portion  of  the  intestine  is  tightly  constricted,  the  destruc- 
tive changes  begin  first  in  the  mucosa  and  sub-mucosa,  and  next 
in  the  muscular  coat,  while  the  serous  investment  holds  out 
longest.  A  piece  of  intestine  that  has  been  constricted  may  there- 
fore appear  to  be  comparatively  little  damaged  when  it  really, 
at  the  site  of  the  obstruction,  consists  of  little  more  than  a  tube 
composed  of  serous  membrane.  Subsequent  sloughing  is  certain  to 
occur.  The  state  of  the  gut  can  be  judged  by  its  translucency. 
If  the  constriction  has  only  been  moderately  tight,  if  the 
circulation  shows  signs  of  returning  at  the  constricted  part 
and  the  warmth  comes  back,  the  intestine  may  be  left  within  the 
belly  as  it  is.  But  for  a  time  there  will  be  paresis  of  the  gut,  and 
frequently  it  will  be  seen  that,  after  the  constriction  has  been 
relieved,  the  contrast  between  the  distended  and  collapsed  intestine 
is  as  marked  as  it  was  before  the  division  of  the  band.  Inasmuch 
as  paresis  of  the  intestine  is  one  of  the  most  serious  complications 
that  may  prevent  recovery  after  an  operation  otherwise  successful, 
it  is  essential  to  take  every  possible  measure  to  obviate  this  grave 


Intestinal  Obstruction.  533 

complication.  By  gently  stroking  the  distended  gut  so  as  to  press 
its  contents,  gaseous  and  fluid,  into  the  collapsed  portion,  much 
good  may  be  done.  Sometimes  a  feeble  movement  of  the  collapsed 
intestine  can  be  seen  to  occur  almost  at  once,  a  little  gas  passing 
on  in  the  proper  direction.  If  so  favourable  a  phenomenon  takes 
place  the  case  may  be  regarded  without  any  great  anxiety.  But 
where  the  obstruction  has  existed  for  a  considerable  time  it  is 
usually  disastrous  to  limit  the  operation  to  the  mere  relief  of  the 
obstruction.  A  loop  of  the  distended  intestine  above  the  con- 
striction may  be  drawn  out  and  a  small  Paul's  tube  inserted. 
As  a  rule  drainage  for  a  time  is  preferable  to  immediate  puncture 
and  closure  of  the  puncture  wound. 

It  must  be  remembered  in  dealing  with  obstruction  by  bands 
that  these  are  frequently  multiple.  At  the  same  time  no  undue 
prolonged  search  for  possible  multiple  sites  of  strangulation, should 
be  made.  The  risk  of  death  from  shock  is  very  great,  and  often 
has  to  outweigh  the  possible  risk  of  leaving  the  operative  measures 
incomplete. 

An  iutt'rnul  licrnia,  in  any  of  the  multifarious  forms  in  which 
it  may  occur,  such  as  through  a  hole  in  the  mesentery  or  omentum, 
or  in  connection  with  a  Meckel's  diverticulum,  can  be  dealt  with 
exactly  as  an  external  hernia,  though  greater  care  may  be  necessary 
in  dealing  with  the  constriction.  It  is  generally  safer  to  stretch 
gently  the  constricting  material  than  to  cut  it.  The  constricting 
ring  may  contain  large  blood-vessels,  and  these  being  exsanguine 
at  the  time  may  pass  unrecognised.  Here,  again,  the  line  at  which 
the  intestine  is  most  damaged  must  be  very  carefully  investigated, 
The  temperature  of  the  herniated  portion  of  the  gut  may  form 
a  guide  as  to  its  vitality.  Gangrenous  intestine  will  on  very  slight 
exposure  become  cold  and  remain  cold.  Short  loops  of  bowel  may 
become  herniated  into  any  of  the  small  peritoneal  fossae,  and  with 
such  cases  it  is  difficult  to  deal  satisfactorily,  owing  to  their  deep 
situation.  Very  extensive  internal  hernia  may  take  place  through 
the  foramen  of  Winslow,  and  here,  of  course,  the  utmost  care  must 
be  taken  in  dealing  with  the  cause  of  strangulation. 

Volvulus  usually  affects  the  large  intestine,  and  commonly  occurs 
about  the  sigmoid  colon.  The  condition  is  characterised  by  rapid 
and  marked  distension.  Strangulation  occurs  early.  The  occluded 
loop  is  likely  to  be  distended.  The  only  portion  of  the  gut  likely  to 
be  collapsed  is  the  pelvic  colon,  and  even  this  condition  need  not  be 
found.  The  distension,  however,  causes  the  involved  portion  of 
intestine  to  bulge  forwards,  and  the  altered  colour,  due  to  conges- 
tion, leads  easily  to  recognition  of  the  site  of  the  trouble.  The 


534  Intestinal  Obstruction. 

induration  at  the  actual  site  of  the  twist  can  be  easily  felt.  Puncture 
of  the  distended  and  occluded  loop  will  often  assist  materially  in 
rendering  the  condition  plain  and  the  operation  easy.  Care  must, 
of  course,  be  taken  that  the  affected  coil  is  not  mistaken  for  intestine 
distended  above  a  malignant  stricture  of  the  pelvic  colon  or  rectum. 
As  a  rule  the  loop  can  be  untwisted  and  replaced  in  position  with- 
out any  difficulty,  for  adhesions  are  unlikely  to  have  formed.  The 
chief  difficulty  is  to  decide  what  further  action  is  necessary  after 
relieving  the  twist.  Everything  depends  upon  the  degree  of  torsion 
and  the  condition  of  the  bowel.  Often,  in  cases  of  volvulus,  the 
condition  has  been  present  in  a  mild  degree  for  some  time,  and  the 
acute  symptoms  supervene  as  a  result  of  distension  or  a  little 
increase  of  the  twist.  It  is  stated  that  unless  torsion  is  through 
180  degrees  occlusion  is  not  likely  to  be  complete.  In  the  majority 
of  case*  the  safest  proceeding  after  relieving  the  twist  is  to  drain  the 
intestine  above  the  lesion.  Short-circuiting  or  other  similar  opera- 
tions are  formidable  proceedings  on  a  patient  in  a  state  of  toxaemia, 
and  if  practised  immediately  are  likely  to  lead  to  a  fatal  result. 
Resection  for  volvulus  would  usually  entail  excision  of  a  long  length 
of  large  inte.stine  and  will  not  often  be  necessary,  as  the  gut,  though 
it  revives  slowly,  has  remarkable  powers  of  recovery  when  it  is  once 
emptied.  Resection  is  not  likely  to  lead  to  any  better  result  than 
simple  drainage  and  the  formation  of  an  artificial  fistula.  The  fluid 
which  is  usually  found  in  the  peritoneal  cavity  should  be  carefully 
swabbed  out,  as  it  is  in  all  probability  highly  toxic.  Irrigation  is 
now  generally  considered  undesirable,  but  a  drainage  tube  can  be 
left  in  the  peritoneal  cavity. 

Volvulus  may  affect  any  part  of  the  large  intestine,  and  sometimes, 
though  rarely,  is  met  with  at  the  caecum.  Occasionally  it  occurs  in 
the  small  intestine.  In  such  cases  the  condition  is  likely  to  be  pro- 
duced by  peritoneal  adhesions.  In  rare  instances  practically  the 
the  whole  of  the  small  intestine  is  in  a  condition  of  volvulus,  being 
twisted  over,  as  a  rule,  towards  the  left  side.  This  again  is  com- 
monly associated  with  old  peritonitis,  and  not  very  infrequently 
follows  on  the  relief  by  operation  of  a  band  or  kink.  This  condition 
is  necessarily  fatal.  Delay  in  operation  is  perhaps  more  disastrous 
in  cases  of  volvulus  than  in  any  other  form  of  acute  intestinal 
obstruction,  owing  to  the  extensive  cutting  off  of  the  blood  supply 
and  the  rapidity  and  extent  of  the  distension.  Even  after  a 
mechanically  successful  operation  the  condition  is  apt  to  recur. 

If  the  operation  has  been  performed  at  a  sufficiently  early 
stage,  the  relief  of  the  mechanical  cause  of  an  acute  intestinal 
obstruction,  whether  single  or  multiple,  is  all  that  is  needed. 


Intestinal  Obstruction.  535 

But  too  often  the  operator  has  to  deal  with  cases  of  obstruction 
which  have  existed  so  long  that  grave  complications  have 
supervened.  Not  only  are  the  local  changes  grave,  but  the 
general  condition  of  the  patient,  owing  to  the  toxic  absorption, 
or  the  establishment  in  a  greater  or  less  degree  of  a  septic 
peritonitis,  is  infinitely  more  serious.  The  general  state  of  the 
patient  must  determine  how  much  or  how  little  has  to  be  done  ; 
whether  temporary  drainage  of  the  intestine  must  be  practised  or 
an  operation  for  short-circuiting  or  total  resection.  If  puncture 
and  drainage  is  the  proceeding  selected,  a  portion  of  distended 
intestine,  not  too  near  the  site  of  the  obstruction,  should  be  chosen. 
If  close  to  the  obstruction,  the  gut  is  less  healthy  and  more  likely  to 
be  drawn  back  through  the  wound  as  it  collapses.  Occasionally  any 
more  extensive  operation  can  be  safely  deferred,  provided  that  the 
involved  intestine  can  be  drawn  out  of  the  wound.  The  condition 
is  desperate,  but  sometimes  there  is  no  other  course  open.  Atten- 
tion should  be  centred  on  the  general  condition  of  the  patient  rather 
than  on  the  local  trouble.  When,  however,  any  portion  of  deeply 
fixed  strangulated  bowel  is  on  the  verge  of  sloughing,  actually 
gangrenous,  or  when  any  perforation,  however  minute,  exists,  simple 
drainage  must  be  disastrous.  Short-circuiting  operations  are  rarely 
called  for  when  the  small  intestine  is  involved,  though  they  may  be 
practised  with  advantage  when  an  acute  has  supervened  on  a 
chronic  obstruction,  as  so  often  happens  in  malignant  disease  of  the 
large  intestine.  Resection  of  the  gut  takes  a  little  longer  than  a 
short-circuiting  operation.  It  is  more  thorough  and  satisfactory 
and  on  the  whole  safer  to  the  patient. 

Operative  details  of  intestinal  surgery  are  described  elsewhere, 
and  it  suffices  here  to  allude  only  to  general  principles.  If  resection 
is  adopted  the  operator  need  not  hesitate  to  excise  a  considerable 
length  of  intestine.  The  all-important  point  is  to  cut  through 
healthy  intestine.  The  ends  may  be  united  either  by  an  end- 
to-end  or  a  lateral  anastomosis.  It  is  difficult  to  unite  satis- 
factorily a  distended  to  a  collapsed  piece  of  intestine  by  the  end-to- end 
method,  and  there  is  likely  to  be  a  weak  spot  just  at  the  attach- 
ment of  the  mesentery.  It  must  be  remembered  that,  normally, 
nearly  one-sixth  of  the  circumference  of  the  small  intestine  is 
uncovered  by  peritoneum.  Very  accurate  apposition,  therefore, 
of  the  ends  of  the  intestines  at  the  site  of  the  mesenteric  attach- 
ment is  all-important.  The  suture  should  be  passed  through 
both  layers  of  the  mesentery  on  each  piece  of  intestine,  so  as  to 
provide  a  good  serous  investment  for  the  portion  of  gut  that  is 
normally  uncovered  by  peritoneum.  Serous  surfaces  when 


536 


Intestinal  Obstruction. 


united  heal  strongly,  completely,  and  with  extraordinary  rapidity. 
There  is  no  need  to  prolong  the  process  of  suturing  by  using 
very  small  needles  and  the  finest  silk.  Continuous  sutures  are 
now  almost  universally  employed  in  place  of  the  numerous  inter- 
rupted sutures  formerly  advocated.  When  the  intestine  is  healthy 
a  second  row  of  sutures  is  unnecessary.  Lateral  anastomosis 
is,  on  the  whole,  a  better  proceeding,  and  though  more  suturing  is 
involved  the  operation  can  really  be  done  as  quickly.  Multiplica- 
tion of  sutures  is,  again,  quite  superfluous.  There  is  no  doubt  that 
even  the  comparatively  rough  suturing  of  two  portions  of  healthy 
gut  together  may  lead  to  perfect  union.  At  any  rate,  rapidity  should 
be  considered  more  than  elaboration.  The  cut  ends  of  intestine  are 

invaginated  and  sutured  rapidly  with 
a  continuous  suture.  The  csecal  ends 
atrophy  in  the  course  of  time,  and 
indeed  it  may  be  hard  ultimately  to 
recognise  whether  an  end-to-end  or 
a  lateral  anastomosis  has  been  per- 
formed. The  use  of  Murphy's  button 
is  now  generally  discarded.  The  sole 
advantage  of  this  contrivance  lay  in 
rapidity,  and  its  numerous  drawbacks 
are  more  than  neutralised  by  the  use 
of  continuous  sutures  and  general 
simplification  of  the  methods  of  anas- 
tomosing intestine.  The  sutures 
should  pass  down  to  the  sub-mucosa. 
If  some  of  them  go  deeper  still  and 
enter  the  lumen  of  the  bowel,  no  harm 
will  follow.  The  idea  that  needle 
punctures  and  the  presence  of  sutures  through  all  the  coats  might 
lead  to  leakage  has  now  been  shown  to  be  imaginary.  A  rapid 
method  of  end-to-end  anastomosis,  recently  suggested,  consists  in 
invaginating  an  inch  or  so  of  one  portion  of  the  gut  into  the  lumen 
of  the  other.  The  cut  edge  of  the  investing  portion  of  intestine 
is  then  folded  inwards  on  itself  for  a  short  distance  and  the 
doubled-back  termination  of  the  receiving  intestine  rapidly  sutured 
to  the  invaginated  portion.  Apparently  the  fear  that  an  intus- 
susception might  follow  is  groundless.  Theoretically,  the  establish- 
ment of  a  nodal  point  in  the  intestine,  such  as  is  involved  by  any 
form  of  end-to-end  union,  would  be  likely  to  form  the  starting  point 
of  an  intussusception,  but  it  never  actually  occurs.  The  free  end 
of  intestine  probably  shrinks  back  and  atrophies.  The  particular 


FIG.  l. 


Intestinal  Obstruction.  537 

method  with  which  the  surgeon  is  most  familiar  is  the  most  rapid 
in  his  hands,  and  it  is  unwise  to  adopt  any  novel  form  of  procedure 
without  preliminary  practice  on  the  cadaver. 

The  obstruction  may  not  be  of  any  of  the  forms  already  dealt 
with,  but  really  only  a  secondary  manifestation.  Thus  a  malignant 
growth  of  any  part  of  the  large  intestine  or  elsewhere  in  the 
abdominal  cavity  is  extremely  likely  to  lead  to  secondary 
adhesions,  any  one  of  which  may  produce  a  mechanical  obstruc- 
tion. Usually,  the  surgeon,  if  judicious,  has  to  be  content  with 
a  partial  procedure.  Elaborate  or  prolonged  operations  are 
commonly  fatal ;  the  main  thing  is  to  relieve  the  distended 
intestine.  If  in  the  large  gut,  the  best  place  for  puncture  and 
drainage  is  probably  the  caecum.  Malignant  disease  on  the  left 
side  of  the  abdomen  is  very  frequently  of  the  annular  form,  and  is 
particularly  prone  to  affect  deeply  situated  portions  of  the  gut ; 
the  hepatic  or  splenic  colon  is  liable  to  be  bound  down,  and  the 
actual  growth  is  sometimes  extremely  hard  to  discover.  Even  on 
the  post-mortem  table  elaborate  dissection  may  be  necessary  to 
reveal  the  precise  site  of  the  disease.  With  distended  gut  prolonged 
search  is  wholly  unjustifiable.  The  gut  may  give  way  and  per- 
forations form,  either  close  above  the  actual  site  of  obstruction  or,  as 
not  infrequently  happens,  at  the  caecum  itself.  When  drainage  has 
relieved  the  distension,  further  measures  may  be  much  more  safely 
and  easily  undertaken  if  the  patient  survives,  but  it  is  best  to  delay 
these  for  at  least  two  or  three  weeks.  Any  short-circuiting  operation 
or  attempts  at  excision  of  the  malignant  growth  practised  on  gut 
that  has  been  greatly  distended,  paralysed,  septic  and  loaded  with 
toxic  products,  is  sure  to  be  disastrous,  though  even  in  extreme 
cases  the  patient  will  often  survive  for  a  few  hours. 

When  a  distended  gut  has  to  be  drained,  it  is  best  to  draw  out  a 
fairly  long  loop.  As  the  distension  subsides  the  intestine  is  prone 
to  recede  into  the  abdominal  cavity.  Moreover,  if  a  large  loop  is 
drawn  out  it  can  be  clamped  and  secured  in  position  before  the 
Paul's  tube  is  introduced.  Then  on  releasing  the  clamp  the 
contents  escape  without  risk  of  soiling  the  wound  or  the  peritoneum. 
Even  when  the  drainage  tube  is  inserted  into  highly  distended 
gut  escape  of  the  contents  only  takes  place  at  first  to  a  limited 
extent.  Frequently  there  is  a  comparatively  small  escape  of  gas 
and  putrid  contents  ;  but  an  hour  or  two  afterwards,  as  the  gut 
recovers  power  and  the  effects  of  the  anaesthetic  pass  off,  an 
abundant  How  ensues.  The  gradual  emptying  of  a  greatly  distended 
intestine  like  the  gradual  emptying  of  any  other  overloaded 
viscus  is  less  exhausting  and  far  safer  for  the  patient  than  sudden 


538  Intestinal  Obstruction. 

evacuation.     In    extremely    bad    cases    preliminary    injection    of 
pituitary  extract  and  spinal  analgesia  are  to  be  recommended. 

The  closure  of  the  abdominal  incision  may  often,  in  cases  of 
intestinal  obstruction,  be  found  the  most  difficult  part  of  the  whole 
proceeding.  Any  endeavour  to  close  layer  by  layer  often  leads  to 
useless  expenditure  of  most  valuable  time.  If  the  wound  is  in  the 
upper  part  of  the  abdomen,  it  is  almost  impossible  to  suture  the 
peritoneum,  transversalis  fascia  and  aponeurosis  of  the  transversalis 
muscle  at  all  satisfactorily.  The  fibres  of  the  transversalis  muscle 
in  the  upper  part  of  the  abdomen  frequently  extend  up  to  the  middle 
line  and  the  retraction  of  this  layer  is,  consequently,  very  vigorous. 
Frequently  the  quickest  and  most  satisfactory  way  is  the  old- 
fashioned  method  of  passing  stout  silkworm-gut  sutures  through 
all  the  layers  of  the  abdominal  wall,  drawing  the  peritoneum 
towards  the  middle  line  as  far  as  possible.  Two  needles  are  needed 
on  each  suture,  and  these  are  passed  right  and  left  from  within 
outwards.  If  there  is  any  difficulty  in  bringing  the  wound  together 
owing  to  distension,  the  operator  should  not  hesitate  to  draw  out  a 
loop  of  intestine  and  drain  it. 

No  operation  can  be  considered  satisfactory  or  complete  that 
results  in  closing  an  abdomen  containing  much  distended  intestine, 
or,  rather,  in  dragging  together,  somehow  or  other,  the  surfaces  of 
the  incision.  Drainage  always  leaves  a  weak  spot  and  a  cicatrix 
liable  to  stretch ;  but  the  risks  of  subsequent  ventral  hernia  should 
not  be  considered  for  a  moment  when  the  life  of  the  patient  hangs 
in  the  balance. 

In  many  cases  the  performance  of  a  surgical  operation  is  but  the 
commencement  of  a  grave  responsibility,  and  this  is  constantly 
true  when  dealing  with  acute  obstruction.  After-treatment  is  here 
no  matter  of  routine,  nor  one  that  can  be  entrusted  to  an  assistant 
or  nurse,  however  watchful  and  experienced.  Incessant  and  close 
attention  is  essential ;  but  a  patient  can  be  over-nursed.  Most 
delicate  judgment  is  required  in  deciding  when  to  act  and  when 
simply  to  watch.  The  patient  should  be  removed  from  the 
operating  table  lying  on  his  side,  and  kept  in  that  position  with  the 
head  raised  as  much  as  the  general  condition  will  safely  allow. 
Skilful  and  gentle  action  in  moving  the  patient  and  placing  him  in 
bed  is  a  highly  important  detail  to  which  far  too  little  attention  is 
often  given.  Disturbance  of  a  patient  still  unconscious  from  the 
anaesthetic  is  sure  to  provoke  vomiting.  Frequently  the  best  plan 
is  to  leave  the  patient  on  the  table  for  an  hour  or  two. 

Of  the  treatment  of  initial  shock,  following  the  operation,  little 
need  be  said  here.  The  lines  to  be  followed  are  the  same  as  after 


Intestinal  Obstruction.  539 

other  grave  operations.  The  main  point  is  to  avoid  unduly  energetic 
measures.  Recovery  ensues  best  when  it  is  slow  at  first  but  still  pro- 
gressive, however  gradual.  Continuous  rectal  irrigation  is  not  ex- 
hausting, and  is  particularly  well  adapted  to  these  cases.  The  irriga- 
tion greatly  relieves  the  thirst,  which  is  so  distressing  a  symptom. 

It  is  usually  desirable,  if  there  has  been  vomiting,  to  wash  out 
the  stomach  before  the  anaesthetic,  whether  local  or  general,  has 
been  administered.  Unless  the  condition  is  desperate  the  stomach 
should  be  washed  out  again  at  the  conclusion,  and  often  the 
contents  will  be  found  abundant  and  very  foul.  Post-operative 
vomiting  is,  of  course,  a  symptom  of  grave  significance.  If  it  is 
borne  in  mind  that  vomiting  may  still,  after  an  operation  for  acute 
obstruction,  be  due  to  a  variety  of  causes,  the  treatment  is  more 
likely  to  be  rational.  Assuming  that  the  mechanical  cause  has 
been  wholly  relieved,  the  persistence  of  vomiting  may  be  regarded, 
broadly,  as  due  to  the  presence  of  foul  material  in  the  stomach, 
of  paresis  of  the  intestinal  tract,  of  peritonitis,  or  of  poisoning  of 
the  visceral  nerve  centres.  This  last  condition,  which  must  be 
present  in  some  degree,  had  best  be  regarded  as  the  pre- 
dominant feature.  Gastric  lavage,  though  rather  exhausting  and 
distressing  to  an  enfeebled  patient,  is  often  tolerated  owing  to  the 
relief  which  it  affords  for  a  time.  Little  reliance  can  be  placed  on 
drugs.  Infundibular  extract  has  been  recommended  for  post- 
operative as  for  other  pareses  of  the  intestines.  Bell  has  used 
it  in  a  limited  number  of  cases  and  states — rather  optimistically — 
that  he  has  never  known  it  to  fail.  The  drug  may  be  given  in 
doses  of  15  min.  intra-muscularly,  and  repeated  in  an  hour. 

Cocaine  (in  doses  of  ^  to  -£$  gr.)  is  one  of  the  best  purely 
sedative  remedies.  But  it  does  not  mend  the  toxic  state ;  nor 
can  gastric  lavage  benefit  the  general  accumulation  in  the  rest 
of  the  intestines.  Ice  should  be  absolutely  avoided.  The  patient's 
temperature  is  low  enough  as  it  is,  and  does  not  require  further 
beating  down. 

The  cardinal  indication  is  to  expel  the  decomposing  contents  of  the 
intestinal  tract.  Enemata  may  assist,  but  if  they  merely  wash  out 
the  lower  intestine  are  but  as  partial  remedies  as  gastric  lavage. 
It  may  be  noted  here  that  the  best  of  the  stimulating  enemata  is 
the  "  Enema  Eutae "  of  the  St.  George's  Hospital  Pharmacopeia. 
Not  only  does  this  remedy  give  great  relief  to  the  flatulence,  but  it 
constantly  leads  to  free  evacuation  of  the  bowels.  It  is  far  superior 
to  the  ordinary  turpentine  enema.  The  rectum  may  be  emptied 
and  the  stomach  washed  clean  ;  but  of  what  value  is  this  if  the  whole 
length  of  intestine  is  loaded  with  foetid  contents  ?  Procrastination 


540  Intestinal  Obstruction. 

may  be  fatal.  The  idea  that  the  injured  bowel  must  have  a  rest  is 
frequent  cause  of  disaster.  Constantly,  after  a  successful  operation, 
the  bowels  act  naturally  within  a  few  hours.  Why,  then,  hesitate  to 
profit  by  the  lesson  and  imitate  natural  processes  ?  Paralysis  or 
paresis  of  the  intestine  is  one  of  the  gravest  after-troubles.  "Why, 
then,  foster  so  undesirable  a  condition  ?  To  give  opium  or 
similar  drugs  after  operation  is  to  administer  a  potent  poison.  A 
paralysed  is  not  a  resting  intestine.  The  patient  tends  to  die  of  the 
toxaemia.  Wherefore,  get  rid  of  the  toxic  material  with  all  possible 
expedition,  for  it  is  poisonous  in  itself,  and,  further,  leads  inevitably 
to  distension  by  its  gas-producing  properties.  Irritant  purgatives 
are  contra-indicated,  but  mild  aperients  can  only  do  good.  It  is 
difficult  to  understand  why  the  obvious  indication  is  so  constantly 
neglected  until  it  is  too  late,  or  why  people  fail  to  recognise  that  the 
intestine,  like  the  heart,  is  never  resting  more  efficiently  than  when 
it  is  discharging  its  natural  functions  very  quietly.  Stagnation  of 
the  intestinal  contents  implies  gas-producing  decomposition  and 
increased  toxic  absorption.  Castor  oil,  if  it  does  not  make  the 
patient  sick,  is  the  safest  of  all  aperients.  The  relief  afforded  by 
an  action  of  the  bowels  is  enormous,  for  it  is  mental  as  well  as 
physical.  Sometimes,  in  fortunate  and  promptly  treated  cases  the 
patient  can,  in  the  course  of  a  few  minutes,  be  almost  seen  to  turn 
the  corner.  Not  infrequently,  when  this  favourable  turn  has  been 
taken,  and  at  a  later  stage  of  recovery,  the  patient  is  seized  with  a 
sudden  pain,  usually  pelvic,  and  in  a  few  minutes  becomes  greatly 
distended.  The  symptom  is  alarming,  but  not  unfavourable,  and  is 
due  to  the  impaction  of  a  mass  of  fsecal  matter,  commonly  in  the 
pelvic  colon.  An  enema  will  promptly  relieve  the  trouble,  which  is 
especially  apt  to  follow  obstruction  from  volvulus. 

Prolonged  rectal  feeding  is  usually  unnecessary,  and  suitable  food 
may  be  given  by  the  mouth  with  advantage  at  a  much  earlier  period 
than  is  generally  the  practice.  The  writer  has  for  some  years  been 
in  the  habit  of  giving  food  by  the  mouth  in  cases  such  as  gastro- 
jejunostomy,  or  suture  of  perforating  gastric  or  duodenal  ulcer 
within  a  few  hours  of  the  operation,  and  has  never  seen  anything 
but  benefit  result.  Here,  again,  the  stomach  if  quietly  doing  its 
natural  work  to  a  mild  extent  is  enjoying  the  best  form  of  rest  that 
can  be  secured.  A  fortiori,  after  the  intestinal  lesions  under  con- 
sideration, the  same  principles  may  be  observed. 

Secondary  operations  may  be  demanded,  but  the  condition  of  the 
patient  rarely  allows  of  any  such  proceeding.  Drainage  of  the 
intestine  is,  as  a  rule,  all  that  can  be  done. 

C.  T.  DENT. 


INTUSSUSCEPTION. 

ACUTE  INTUSSUSCEPTION  is  by  far  the  most  frequent  cause  of 
intestinal  obstruction  in  children.  It  is  most  commonly  met  with 
during  the  second  half  of  infancy,  and  at  this  period  of  life  it  is 
.the  most  important  surgical  emergency  with  which  the  practitioner 
has  to  deal.  Early  diagnosis,  followed  by  prompt  and  skilled 
surgical  treatment  within  twenty-four  hours  of  the  occurrence  of  the 
invagination,  will  result  in  from  80  to  90  per  cent,  of  cures.  With 
each  additional  twelve  hours  which  is  allowed  to  elapse  before  surgical 
aid  is  obtained,  the  mortality  rapidly  and  progressively  increases. 
If  operative  interference  is  delayed  until  forty-eight  hours  after 
the  first  symptom,  the  mortality  reaches  about  76  per  cent.  The 
time  required  for  an  acute  intussusception  to  become  irreducible 
varies  considerably;  in  exceptional  cases  this  complication  may 
occur  within  twelve  hours,  while  in  other  cases  three  days  may 
elapse  before  it  occurs.  In  only  six  cases  among  the  last  hundred 
operated  on  in  the  Koyal  Edinburgh  Hospital  for  Sick  Children 
was  reduction  with  recovery  obtained  after  forty-eight  hours. 

Fortunately  the  diagnosis  of  acute  intussusception  presents  no 
difficulty.  The  age  of  the  patient,  the  acute  onset  of  the  illness, 
ushered  in  by  severe  cramp-like  abdominal  pain,  the  repetition  of 
the  spasms  at  intervals,  the  vomiting,  the  slightly  collapsed  look  of 
the  child,  the  quick  feeble  pulse,  and  subnormal  temperature,  and 
the  absence  during  the  first  forty-eight  hours  of  acute  abdominal 
tenderness  and  distension  should  make  the  practitioner  think  at 
once  of  intussusception.  The  diagnosis  is  confirmed  by  the 
presence  of  a  tumour,  often,  though  not  always,  sausage-shaped. 
If  there  is  any  doubt  about  the  presence  of  a  tumour  an  anaesthetic 
should  be  administered.  One  or  two  normal  motions  are  often  passed 
soon  after  the  onset  of  the  illness ;  later,  blood-stained  mucus  takes 
the  place  of  faecal  matter.  This  symptom  may  occur  within  a  very 
few  hours  of  the  invagination,  while  in  other  cases  it  is  delayed 
from  twelve  to  twenty-four  hours.  If  advice  is  sought  early  enough, 
there  is  no  reason  why  the  diagnosis  should  not  be  made  before  the 
discharge  of  blood-stained  mucus.  The  practitioner  should  not 
wait  for  this  symptom  before  calling  in  the  surgeon.  It  cannot  be 
too  often  repeated  that,  as  in  strangulated  hernia  and  all  other 
forms  of  acute  obstruction,  so  in  acute  intussusception,  the  early 


542  Intussusception. 

diagnosis  is  the  all-important  factor  in  regard  to  prognosis.  The 
responsibility,  therefore,  for  the  issue  of  the  case  lies  entirely  with 
the  medical  attendant,  as  it  is  he  who  is  called  to  the  case  in  the 
first  instance.  If  he  can  obtain  skilled  surgical  assistance  within 
twenty- four  hours  of  the  occurrence  of  the  invagination,  the  chances 
are  ten  to  one  that  the  child's  life  will  be  saved  ;  if,  on  the  other 
hand,  the  diagnosis  has  not  been  made  until  the  invagination  has 
become  irreducible,  the  chances  are  a  hundred  to  one  the  infant 
will  die. 

Up  till  recent  years  physicians,  and  indeed  some  surgeons,  have 
advocated  that  an  attempt  be  made  to  reduce  the  invagination  by 
the  introduction  of  air,  water,  or  oil  into  the  bowel  before  proceeding 
to  operation.  During  the  twelve  years  the  writer  has  been  surgeon 
to  the  Royal  Edinburgh  Hospital  for  Sick  Children  he  has  never 
countenanced  this  procedure,  because  by  such  means  complete  reduc- 
tion is  only  very  rarely  effected,  and  it  is  precisely  in  these  cases  in 
which  it  is  likely  to  be  successful  that  laparotomy  and  manual  reduc- 
tion are,  in  experienced  hands,  practically  free  from  risk.  The 
strongest  argument  against  the  bloodless  method  is  that  it  is  often 
impossible  to  say  until  some  hours  later  if  the  apex  of  the  intussuscep- 
tion has  been  reduced  ;  if  not,  valuable  time  has  been  lost,  the  infant 
has  to  be  anaesthetised  a  second  time,  the  shock  is  augmented,  and 
it  may  be  that  the  invagination  has  become  irreducible,  which  is 
practically  equivalent  to  stating  that  the  delay  has  been  responsible 
for  the  loss  of  the  child's  life.  Another  objection,  although 
perhaps  a  less  forcible  one  if  due  care  is  exercised,  is  the  risk  of 
rupturing  the  bowel. 

Some  surgeons  still  advocate  inflation  or  injection  of  the  bowel 
as  a  preliminary  step  to  operative  treatment,  on  the  grounds  that  it 
can  nearly  always  be  counted  on  to  effect  at  any  rate  a  partial 
reduction,  and  that  in  this  way  the  size  of  the  tumour  may  be  so 
reduced  as  to  enable  it  to  be  delivered  out  of  the  wound  through  a 
small  incision,  and  without  having  to  pull  out  a  considerable 
amount  of  the  small  intestine.  In  cases  in  which  the  intussus- 
ception has  reached  the  pelvic  colon,  or  even  the  rectum,  there  is 
seldom  any  difficulty  in  effecting  a  partial  reduction  through  a 
comparatively  small  laparotomy  wound  without  any  evisceration. 
In  cases  of  unusual  difficulty  the  writer  never  hesitates  to  enlarge 
the  wound  and  pull  out  the  small  intestine.  If  this  is  done  rapidly, 
and  if  care  is  taken  to  surround  the  intestine  with  saline  cloths,  the 
additional  shock  will,  at  any  rate,  be  no  greater  than  that  induced 
by  the  prolongation  of  the  anaesthesia  attendant  upon  the  pre- 
liminary injection  of  the  bowel. 


Intussusception.  543 

Ouvry  reports  a  case  in  which  he  saved  the  infant's  life  by 
passing  a  Ne"laton's  soft  rubber  catheter  through  an  intussuscepturn 
which  had  reached  the  rectum.  A  quantity  of  fostid  liquid  material 
and  gas  escaped,  after  which  the  bowel  was  irrigated  with  saline. 
The  imagination  had  existed  for  four  days,  the  abdomen  was 
distended,  and  the  pulse  almost  imperceptible.  Thirty-six  hours 
later  spontaneous  reduction  took  place.  This  is  a  method  which 
should  be  tried  when  operative  assistance  is  not  available. 

The  Operation. — The  operating  room  should  be  of  a  tempera- 
ture at  or  a  little  above  70°  F.  The  operating  table  should  be 
provided  with  a  heating  apparatus,  the  most  convenient  being  a 
large  hot  water  bag,  care  being  taken  to  see  that  the  water  in  it  is 
not  too  hot,  as  infants  are  very  easily  burned.  The  chest  and 
limbs  should  be  swathed  in  cotton-wool  secured  by  bandages.  As 
the  infants  are  generally  robust,  there  is  no  objection  to  using 
chloroform  as  the  anaesthetic,  but  in  weakly  infants  ether  may  be 
given  by  the  open  method,  or  the  latter  may  be  substituted  after 
the  patient  has  been  put  under  with  chloroform,  or  a  mixture  of 
1  part  of  chloroform  and  2  of  ether  may  be  used. 

The  incision  should  almost  invariably  be  in  the  middle  line 
and  about  3  inches  in  length.  Whether  the  greater  part  of 
the  incision  be  above  or  below  the  umbilicus  will  depend  on  the 
position  of  the  tumour.  When  the  tumour  is  situated  in  the  right 
lower  region,  the  incision  may  be  placed  parallel  to  and  a  little  to 
the  inner  side  of  the  outer  edge  of  the  right  rectus.  When,  as  HO 
often  happens,  the  greater  part  of  the  tumour  is  situated  under  the 
left  rectus,  it  is  a  mistake  to  make  the  incision  to  the  left  of  the 
middle  line,  because  the  first  part  of  the  reduction  is  readily 
effected  from  the  middle  line,  whereas  the  ileo-caecal  region  (some- 
times the  lower  end  of  the  ileum)  which  is  the  last  and  most 
difficult  part  to  disinvaginate,  might  be  difficult  to  deliver  into  a 
wound  situated  to  the  left.  Moreover,  as  the  last  parts  to  be 
reduced  are  those  whose  circulation  is  most  interfered  with  it 
is  important  that  they  should  be  brought  well  into  view  so  that 
the  question  of  their  viability  may  be  settled.  Another  advantage 
of  the  middle-line  incision  is  that,  besides  giving  access  to 
the  intussusception  wherever  situated  and  at  all  stages  in  its 
reduction,  it  helps  to  reduce  the  duration  of  the  operation  to  a 
minimum. 

After  the  abdomen  has  been  opened,  search  should  at  once  be 
made  for  the  distal  end  of  the  intussusception.  If  it  can  be 
reached  and  delivered  out  of  the  wound  without  coils  of  the  small 
intestine  escaping  so  much  the  better,  but  if  not  valuable  time 


544  Intussusception. 

should  not  be  wasted  in  replacing  them  or  in  attempting  to  keep 
them  inside  the  abdomen  by  the  introduction  of  gauze  packs. 
Should  they  prolapse,  the  best  plan  is  to  let  them  do  so,  indeed  in 
many  cases  the  delivery  of  the  distal  end  of  the  tumour  can  only 
be  effected  after  the  greater  part  of  the  small  bowel  has  been 
withdrawn  from  the  abdomen.  As  before  stated,  when  the  intus- 
susception has  reached  the  pelvic  colon,  disinvagination  may  be 
effected  to  a  very  considerable  extent  with  the  tumour  still  within 
the  abdomen  by  compressing  the  distal  end  (apex)  of  the  intussus- 
ception in  an  upward  direction  between  the  thumb  and  two  fingers. 
If  there  is  any  difficulty  in  reaching  the  distal  end  there  should  be 
no  hesitation  in  enlarging  the  incision  so  as  to  admit  the  whole 
hand.  When  the  intussusception  has  reached  the  lower  part  of  the 
pelvic  colon  or  the  rectum,  it  is  sometimes  an  advantage  to  get  an 
assistant  to  push  upwards  the  intussusception  by  means  of  a  finger 
introduced  into  the  rectum. 

Having  so  far  reduced  the  invagination  as  to  enable  the  tumour 
to  be  delivered  out  of  the  wound,  further  disinvagination  is  effected 
by  grasping  the  distal  end  of  the  tumour  in  the  palm  of  the  hand 
in  such  a  way  as  to  compress  the  apex  in  the  proximal  direction,  the 
sheath  being  at  the  same  time  drawn  downwards,  that  is  to  say,  in 
the  distal  direction.  This  movement  is  repeated  at  a  higher  and 
higher  level  as  the  disinvagination  proceeds.  As  a  rule,  there  is 
no  difficulty  in  reducing  the  greater  part  of  the  invagination,  even 
if  the  intussusception  should  have  reached  the  rectum. 

In  cases  in  which  the  intussusception  has  lasted  for  less  than 
twenty-four  hours,  complete  disinvagination  can  generally  be 
effected  without  difficulty.  Owing,  however,  to  the  increased 
swelling  of  the  apical  portion  of  the  intussusception  (due  to  the 
great  venous  engorgement  and  oedema,  more  especially  of  its 
muscular  and  serous  coats),  there  is  often  considerable  difficulty  in 
disinvaginating  the  last  portion  of  the  intussusception.  The 
difficulty  may  be  increased  also  by  enlargement  of  the  lymphatic 
glands  at  the  ileo-csecal  angle.  Such  cases  call  for  the  exercise  of 
both  patience  and  perseverance.  The  compression  should  be  kept 
up  for  some  time  in  the  hope  of  reducing  the  diameter  of  the  intus- 
susception by  reducing  the  venous  engorgement.  The  attempt 
should  not  necessarily  be  abandoned  as  hopeless  because  the 
peritoneal  coat  of  the  sheath  commences  to  split.  If  this  should 
occur  ihe  operator  should  keep  up  steady  compression  before  again 
resorting  to  onward  compression.  Moreover,  he  should  realise 
that  if  reduction  is  not  accomplished,  the  result  is  almost  certain 
to  be  fatal.  After  pretty  considerable  tearing  of  the  peritoneum, 


Intussusception.  545 

the  operator  is  often  rewarded  for  his  perseverance  by  the  dis- 
invagination  of  the  appendix,  possibly  also  of  some  engorged 
lymphatic  glands,  and  finally  of  the  ileo-csecal  valve.  It  is  just  in 
these  "  touch-and-go  "  cases  that  one  is  not  only  justified,  but  often 
helped  in  effecting  the  final  reduction  by  making  steady  traction  on 
the  emptying  tube.  It  must  be  borne  in  mind,  however,  that  it  is 
not  only  useless  but  actually  harmful  to  do  this  at  the  outset ;  on 
the  other  hand,  in  critical  cases  it  is  occasionally  the  determinating 
factor  in  effecting  the  final  reduction.  After  the  appendix  and 
ileo-csecal  valve  have  been  reduced,  there  still  remains  a  deep 
infolding  of  the  outer  wall  of  the  caecum.  This,  which  is  the 
result  and  not  the  cause  of  the  ileo-ceecal  invagination,  is  easily 
reduced  by  a  little  manipulation.  After  reducing  the  ileo-csecal 
junction  it  not  infrequently  happens  that  a  primary  enteric 
intussusception,  involving  the  lower  few  inches  of  the  ileum,  is 
brought  into  view  ;  it  must  of  course  be  disinvaginated,  and  here 
more  especially  it  may  be  necessary  to  make  gentle  traction  on 
the  entering  tube. 

Having  completely  disinvaginated  the  intussusception,  the  next 
step  is  to  examine  the  bowel  and  adjacent  mesentery  so  as  to 
ascertain  how  far  it  has  been  damaged.  Many  cases  make  an 
uninterrupted  recovery  in  spite  of  considerable  tearing  of  the 
serous  coat.  While  the  edges  of  the  peritoneal  wounds  should  be 
brought  together  with  a  few  sutures,  it  is  quite  unnecessary  to 
waste  time  in  suturing  up  every  tear  completely.  It  is  surprising 
how  severely  the  bowel  may  appear  to  be  damaged  and  yet  recovery 
take  place.  In  doubtful  cases  it  is  wise  to  give  the  bowel  the 
benefit  of  the  doubt  and  return  it  into  the  abdomen,  as  it  is  more 
likely  to  recover  if  returned  to  its  natural  position.  Another  strong 
reason  for  returning  it  is  the  well-nigh  hopeless  prognosis  following 
resection.  If  the  operator  deems  the  bowel  too  much  damaged  to 
warrant  its  being  returned,  he  may  adopt  a  middle  course,  viz., 
that  of  short  circuiting  the  damaged  portion  by  performing  a 
lateral  anastomosis ;  he  must,  however,  consider  carefully  whether 
the  infant  is  likely  to  stand  such  a  prolongation  of  the  operation 
as  this  procedure  would  entail. 

Recurrence  of  the  intussusception  has  occurred  four  times  in  the 
last  hundred  cases  operated  on  in  the  Hospital  for  Sick  Children. 
It  is,  of  course,  more  likely  to  occur  in  cases  in  which  reduction 
has  been  effected  easily  and  in  which  the  bowel  has  not  been 
damaged.  As  a  precaution  against  recurrence,  especially  in  easily 
reduced  cases,  and  where  there  is  a  well-marked  mesentery  to  the 
ascending  colon,  it  is  advisable,  before  closing  the  abdomen,  either 

S.T. — VOL.  ii.  35 


546  Intussusception. 

to  reef  up  the  ileo-colie  portion  of  the  mesentery  with  one  or  two 
catgut  sutures,  or,  what  comes  to  much  the  same  thing,  to  suture 
the  lowest  part  of  the  ileum  to  the  inner  edge  of  the  ascending 
colon  in  such  a  way  that  the  former  is  made  to  descend  parallel  to 
the  ascending  colon  on  its  way  to  join  the  caecum. 

In  cases  which  are  being  operated  on  early  there  is  seldom  any 
difficulty  in  returning  prolapsed  intestine.  In  cases,  however,  in 
which  the  operation  has  been  delayed  the  small  intestine  is  often 
distended  and  some  difficulty  may  occur.  Eeposition  is  greatly 
facilitated  if  the  assistant  keeps  the  edges  of  the  wound  held  well 
up  with  suitable  grip  forceps.  When  the  intestine  is  still  more 
distended  and  -paretic,  it  must  be  emptied  as  far  as  possible  by 
puncturing  it  with  a  suitable  trocar  and  cannula  to  which  a  rubber 
tube  is  fixed  so  as  to  carry  the  contents  well  away  from  the  field  of 
operation.  The  puncture  is  closed  by  a  purse-string  sero-muscular 
suture,  which  should  be  introduced  before  the  puncture  is  made  ; 
by  tightening  up  the  suture  just  as  the  cannula  is  withdrawn  all 
danger  of  soiling  is  avoided. 

The  closure  of  the  abdominal  wound  is  a  matter  of  considerable 
importance  in  infants.  Several  cases  have  been  recorded  in  which 
the  wound  has  burst  open,  owing  either  to  faulty  suturing  or  to 
too  early  removal  of  the  sutures.  In  infants  through- and-through 
suturing  is  distinctly  preferable  to  suturing  in  layers,  especially 
when  a  median  incision  has  been  made.  The  saving  of  time  is 
a  very  important  matter.  On  no  account  should  the  sutures  be 
removed  before  the  tenth  day,  and  if  they  can  be  kept  in  until  the 
twelfth  or  fourteenth  day  so  much  the  better. 

The  best  material  to  use  is  silkworm  gut,  which  should  not  be 
too  thin.  To  prevent  the  sutures  cutting  through  the  delicate  skin 
into  the  subcutaneous  tissue  they  should  each  be  threaded  with  a 
piece  of  fine  rubber  tubing  (about  f  inch  long),  in  such  a  way  that 
when  the  suture  is  tied  the  part  of  the  loop  which  overlies  the  skin 
is  surrounded  by  the  tubing.  Without  this  small  but  important 
detail,  the  infant  may  suffer  much  discomfort,  and  an  anaesthetic 
may  be  required  before  the  stitches  can  be  removed.  The  intro- 
duction of  the  sutures  is  greatly  expedited  and  facilitated  by  using 
a  handled  needle,  such  as  Doyen's  (the  smallest  of  the  three  sizes). 

When  the  intussusception  is  irreducible  a  variety  of  pro- 
cedures is  open  to  the  surgeon,  but  unfortunately,  owing  to  the 
already  collapsed  and  toxaemic  condition  of  the  infant,  none  of  them 
can  be  expected  to  hold  out  more  than  the  remotest  chance  of 
success.  The  procedures  are  : 

(1)  To  relieve  the  obstruction  by  short-circuiting,  the  ileum  on 


Intussusception.  547 

the  proximal  side  of  the  intussusception  being  joined  by  lateral 
anastomosis  to  the  colon  on  its  distal  side.  The  intussusception  is 
returned  into  the  abdomen,  which  is  closed  without  drainage. 
Eutherford  and  Parry  have  each  reported  a  successful  case  by  this 
method.  Although  the  stools  were  carefully  watched  after  the 
operation  no  trace  of  sloughed  intestine  was  discovered,  and  what 
exactly  happened  to  the  intestine  itself  is  not  known. 

The  advantages  of  this  method  are  that  it  is  a  comparatively  rapid 
means  of  restoring  the  continuity  of  the  canal,  and  that  it  is 
attended  with  much  less  shock  than  resection.  Moreover,  the 
infant  can  be  properly  nourished  and  no  second  operation  is 
required  to  restore  the  continuity  of  the  canal. 

When  the  bowel  above  the  obstruction  is  distended  and  more  or 
less  paralysed,  and  when  every  intestinal  stitch  puncture  is  likely 
to  be  followed  by  a  septic  track,  Mr.  Henry  Eutherford,  of  Glasgow, 
points  out  the  importance  of  drainage  of  the  bowel  contents.  In 
making  an  artificial  anus  he  suggests  that  "  it  would  probably  be  the 
best  procedure  to  select  a  loop  low  down  and  take  it  out  to  the  extent 
of  4  or  5  inches  through  an  opening  in  the  flank,  tie  in  a  glass  tube, 
and  after  assisting  the  adjacent  coils  to  empty  themselves,  to  close 
the  wound  of  exploration,  which  is  presumably  in  the  middle  line. 

"  This,  of  course,  is  to  be  regarded  as  a  temporary  expedient. 
Supposing  the  child  to  have  recovered,  it  will,  I  believe,  be  best  to 
reopen  the  abdomen  in  the  middle  line  and  make  such  a  lateral 
anastomosis  as  may  be  practicable  between  the  ileum  above  the 
artificial  anus  and  the  colon  below  the  intussusception.  Such  an 
anastomosis  should  be  free ;  it  is  to  be  for  life,  and  a  large  stoma 
will  simplify  the  treatment  of  the  artificial  anus.  There  is  no 
question  of  restoring  the  continuity  of  the  bowel  at  this  point ;  the 
ends  will  simply  be  freed,  cut  short  down  to  their  intact  surfaces, 
inverted  and  dropped  into  the  abdomen." 

The  disadvantage  is  that  should  the  intussusception  be,  or 
become,  gangrenous,  the  chances  are  the  infant  will  succumb  to 
toxaemia  and  peritonitis.  However,  the  results  of  resection  with 
or  without  the  formation  of  an  artificial  anus  are  so  uniformly  bad 
that  to  leave  the  intestine  to  take  its  chance  is  perhaps  the  lesser 
of  the  two  evils.  Further  results  of  this  method  of  treatment  will 
be  awaited  with  interest. 

(2)  If  gangrene  has  already  set  in,  the  condition  is  indeed 
desperate.  Mr.  Barker  recommends  that  the  neck  of  the  intussus- 
ception be  stitched  to  the  entering  tube,  after  which  a  longitudinal 
incision,  about  2  inches  in  length,  is  made  through  the  sheath  close 
to  the  neck.  The  gangrenous  intussusception  is  then  amputated, 

35—2 


548  Intussusception. 

and  the  inner  and  middle  tubes,  which  form  the  stump,  are  united 
by  a  continuous  through-and-through  top  stitch  which  unites  the 
opposing  serous  surfaces  and  at  the  same  time  checks  the  bleeding. 
Care  must  be  taken  to  include  all  bleeding  vessels  of  the  divided 
mesentery.  The  operation  is  completed  by  closing  the  longitudinal 
opening  in  the  sheath  in  the  usual  way  by  a  through-and-through, 
followed  by  a  sero-muscular  uniting,  suture.  The  author  is  not 
aware  that  any  successful  case  has  been  reported  by  this  method. 
The  objections  to  it  are  that  it  is  almost  impossible  to  prevent 
soiling  of  the  peritoneum  by  such  a  method,  and  that  the  drainage 
through  the  inner  tube  is  liable  to  fail  owing  to  the  pressure 
exerted  on  it  by  the  thickening  and  engorgement  of  the  middle 
tube  and  mesentery. 

(8)  Another  method  is  to  resect  the  intussusception,  and  after 
ligaturing  the  vessels  of  the  mesentery,  to  establish  an  artificial  anus 
by  bringing  the  divided  ends  of  the  bowel  out  of  the  wound  and 
introducing  into  each  a  small  Paul's  tube.  Unfortunately  this 
method,  too,  has  not  been  successful.  Although  it  may  occasionally 
save  the  infant  from  obstruction  and  peritonitis,  it  is  difficult  with 
a  tube  in  the  small  intestine  to  maintain  its  nutrition  sufficiently 
to  enable  it  to  pull  through  the  subsequent  operation  for  the 
restoration  of  the  continuity  of  the  alimentary  canal. 

If,  after  removing  the  intussusception,  the  patient's  condition  is 
found  to  be  fairly  satisfactory,  an  attempt  should  be  made  to 
restore  at  once  the  continuity  of  the  canal.  The  operation  must 
be  done  as  rapidly  as  possible,  and  every  care  should  be  taken  to 
prevent  faecal  contamination.  The  steps  of  the  operation  are  as 
follows  : 

The  tumour  is  removed  by  dividing  the  bowel  above  and  below 
the  tumour  between  two  catgut  or  linen  thread  ligatures  placed 
about  an  inch  apart.  The  vessels  of  the  mesentery  are  clamped, 
divided  and  ligatured.  The  divided  ends  of  the  intestine  are 
trimmed,  disinfected,  and  the  stumps  invaginated  by  means  of  a 
purse-string  suture,  after  which  the  continuity  of  the  canal  is 
established  by  lateral  anastomosis,  care  being  taken  to  make  the 
opening  sufficiently  large  and  not  too  near  the  invaginated  stump. 
One  or  two  interrupted  sutures  are  placed  beyond  the  anastornotic 
opening  so  as  to  anchor  the  stumps  to  the  adjacent  bowel.  The 
gap  in  the  mesentery  is  closed  by  means  of  a  few  interrupted 
catgut  sutures,  care  being  taken  to  avoid  puncturing  the  vessels. 
If  there  has  been  no  faecal  contamination,  the  abdomen  is  closed 
without  drainage. 

The  operation  is  facilitated  and  rendered  cleaner  by  the  use  of 


Intussusception.  549 

clamps,  which  should  be  small  and  springy.  The  needles  and 
thread  .(or  silk)  should  be  as  fine  as  possible.  The  advantages 
of  the  lateral  anastomosis  over  end-to-end  union  are :  that 
the  operation  is  cleaner,  that  no  inconvenience  is  caused  by  the 
difference  in  the  size  of  the  lumina,  that  the  suturing  does  not 
involve  the  dangerous  meseuterie  area,  and  that  there  is  less  risk 
of  the  blocking  of  the  lumen  by  the  inverted  edges  of  the  gut. 

After-treatment. — Warmth  and  the  introduction  of  saline  per 
rectum  by  the  drop  method,  supplemented  by  saline  injections 
into  the  subcutaneous  tissues  of  the  infra-axillary  region,  are  the 
most  reliable  means  of  combating  shock.  Small  doses  of  alcohol 
may  be  given  if  necessary,  but  such  active  drugs  as  strophanthus, 
digitalis,  and  large  doses  of  strychnine  do  more  harm  than  good. 
A  few  minims  of  pituitary  extract  may  prove  of  value  in  critical 
cases  by  maintaining  the  blood  pressure  and  stimulating  the 
paralysed  intestine. 

In  simple  cases  the  infant  should  be  put  to  the  breast  as  soon  as 
it  begins  to  cry  vigorously  and  show  signs  of  hunger.  If  not  on 
the  breast,  albumen  water,  milk  and  water,  or  peptonised  milk  may 
be  given  in  small  quantities  at  first.  It  is  a  mistake  to  give  an 
opiate  after  the  operation.  If  the  bowels  have  not  been  moved 
within  twenty-four  hours  after  the  operation  small  doses  of  calomel 
may  be  administered.  If  vomiting  persists  after  the  operation  the 
stomach  should  be  repeatedly  washed  out  and  the  saline  must  be 
continued  until  feeding  by  the  mouth  can  be  commenced.  Paralytic 
distension  of  the  intestine  is  best  treated  by  repeated  small  doses  of 
calomel,  and  if  this  fails  to  move  the  bowels,  resort  must  be  had  to 
physostigmin  or  pituitary  extract. 

Of  the  fifty-two  cases  of  intussusception  admitted  into  the  Royal 
Edinburgh  Hospital  for  Sick  Children  during  the  four  years 
previous  to  July,  1910,  thirty-three  cases  were  operated  on  within 
twenty-four  hours  of  the  onset  of  the  invagination,  and  of  these 
twenty-eight  (85  per  cent.)  recovered  ;  of  the  seven  operated  on 
during  the  second  twenty-four  hours,  five(71'4  per  cent.)  recovered ; 
while  of  the  twelve  operated  on  after  forty-eight  hours,  only  three 
(25  per  cent.)  recovered.  All  the  irreducible  cases  (8  =  15' 4  per 
cent.)  died. 

HAROLD  J.  STILES. 


550 


PERFORATION   OF   THE  INTESTINE. 

THIS,  which  constitutes  one  of  the  most  urgent  conditions  of 
abdominal  cataclysm,  is  fortunately  of  rare  occurrence.  It  is  caused 
in  the  upper  part  of  the  bowel  by  chronic  peptic  ulcers  in  the  first 
part  of  the  duodenum  or  in  the  jejunum,  near  the  site  of  a  gastro- 
enterostomy  (usually  an  anterior  anastomosis);  in  the  ileum  by 
the  ulcers  of  typhoid  fever ;  and  in  the  colon  by  stercoral  ulcers, 
which  may  be  above  malignant  or  innocent  strictures,  or  by  the 
giving  way  of  false  diverticula.  Very  .rarely  a  foreign  body  may 
cause  intestinal  perforation,  this  generally  occurring  a  few  inches 
above  the  ileo-caecal  valve.  In  discussing  the  treatment  of  these 
lesions  it  will  be  convenient  to  take  the  perforation  due  to  typhoid 
fever  as  the  chief  type  and  to  deal  with  the  other  classes  more 
shortly. 

PERFORATION  OF  THE  INTESTINE  IN  TYPHOID  FEVER. 
The  subject  of  the  treatment  of  typhoid  perforation  assumes 
a  greater  importance  every  year ;  for  the  disease  remains  widely 
spread  all  over  the  world,  and  although  the  general  mortality 
has  been  greatly  reduced  by  such  means  as  hydrotherapy,  that 
from  intestinal  perforation  remains  as  high  as  ever,  or  indeed 
higher  than  ever  in  proportion  to  the  mortality  from  other 
causes.  First  proposed  by  Leyden  and  carried  out  by  Miculicz 
in  1884,  the  operative  treatment  of  this  condition  has  been 
universally  accepted  as  the  only  one  which  holds  out  any 
reasonable  hope  of  success.  And  whereas  Keen1  was  able  to 
collect  83  cases  in  1898,  Harte  and  Ashhurst 2  tabled  362  in  1903, 
and  since  then  the  operation  has  become  comparatively  common. 
But  when  the  total  death  rate  from  typhoid  perforation  of  the 
intestine  is  considered  it  will  be  readily  admitted  that  much 
remains  to  be  done  in  the  way  of  a  wider  adoption  of  operative 
measures  ;  for  whereas  in  the  United  States  alone,  according  to 
Professor  Osier,3  about  4,422  cases  die  from  typhoid  perforation 
annually,  only  362  cases  of  operation  are  recorded  in  twenty  years  for 
this  condition  all  over  the  world  ! 4  If  we  suppose  that  the  American 
mortality  is  half  that  of  the  whole  world  and  that  200  operations 
are  now  performed  annually  for  this  condition,  the  proportion  of 
cases  operated  upon  is  still  only  about  1  in  every  44.  It  is 
quite  clear,  then,  that  many  of  the  medical  profession  require  to 


Perforation  of  the  Intestine.  551 

have  the  great  importance  of  this  subject  brought  home  to  them  in 
order  that  a  greater  number  of  patients  may  have  the  only  chance 
of  life  afforded  to  them. 

The  possibility  of  a  case  of  perforated  typhoid  intestine  recover- 
ing without  an  operation  is  so  extremely  remote  as  to  require  the 
dismissal  of  its  consideration,  and  the  only  choice  of  treatment, 
therefore,  which  we  have  to  consider  is  the  choice  of  the  details  of 
the  operation. 

The  Best  Time  for  Operation. — It  would  seem  hardly  necessary 
to  emphasise  the  importance  of  operating  as  early  as  possible  if  it 
had  not  been  for  the  fact  that  so  eminent  an  authority  as  Professor 
Keen  had  expressed  the  opinion  that  it  is  wiser  to  wait  until  twelve 
hours  after  the  perforation  in  order  to  avoid  the  period  of  shock 
which  accompanies  the  rupture  of  the  intestine.  But  subsequent 
observation  has  proved  that  this  opinion  was  founded  on  insufficient 
data  (15  cases  operated  upon  within  twelve  hours,  with  4 
recoveries,  as  compared  with  20  operations  between  the  twelfth 
and  twenty-fourth  hours  with  6  recoveries).  The  larger  number  of 
figures  given  by  Harte  and  Ashhurst  show  that  the  best  results  are 
obtained  from  the  operations  performed  within  the  first  twelve 
hours,  but  there  is  not  that  striking  difference  which  one  might 
have  anticipated  between  the  first  and  second  twelve  hour  results 
(130  cases  in  first  twelve  hours  with  34  recoveries — mortality  73  per 
cent. — and  84  in  second  twelve  hours  with  22  recoveries — mortality 
73'8  per  cent.). 

It  is  quite  true  that  the  cases  operated  upon  at  comparatively  late 
periods  show  the  lowest  mortality  of  all  (55  cases  later  than  thirty-six 
hours  with  mortality  of  67'2  per  cent.),  but  this  is  due  to  the  fact 
that  only  mild  cases  of  small  perforation  with  localising  adhesions 
survive  to  this  period.  So  that  we  may  lay  down  the  rule  that  the 
operation  should  be  done  as  soon  after  perforation  as  possible,  and 
certainly  within  the  first  twenty-four  hours. 

The  Anaesthetic. — About  this  there  is  a  considerable  difference 
of  opinion,  the  alternatives  being,  general  anesthesia  by  open  ether 
or  gas  and  oxygen,  spinal  anesthesia  or  a  local  anaesthetic.  Theoreti- 
cally, spinal  anesthesia  is  the  ideal  method,  because  it  abolishes 
shock  and  gives  complete  freedom  from  pain  with  full  relaxation  of 
the  muscles.  Those  who  are  accustomed  to  its  use  will  therefore 
be  wise  in  employing  it.  Local  anesthesia  is  quite  efficient  for  the 
abdominal  incision,  but  it  does  not  abolish  the  peritoneal  sensibility 
nor  does  it  relax  the  muscles.  It  is  very  useful  in  those  cases 
when  the  diagnosis  is  in  great  doubt,  the  patient  being  very  ill, 
but  the  existence  of  a  perforation  not  being  certain.  Under  a  local 


552  Perforation  of  the  Intestine. 

anaesthetic  (2  per  cent,  solution  of  novocaine  with  adrenalin)  the 
abdomen  can  be  opened.  If  no  exudate  or  adhesions  are  found  the 
wound  can  be  closed  and  no  harm  is  done.  But  if  these  exist  and  the 
perforated  coil  requires  to  be  searched  for,  a  general  anaesthetic  can 
then  be  given,  gas  and  oxygen  being  very  suitable  for  this  purpose. 

But  as  a  matter  of  fact  the  great  majority  of  cases  have  been 
operated  upon  under  general  anaesthesia  by  ether  or  chloroform, 
and  if  the  operation  is  not  prolonged  it  is  doubtful  whether  this 
adds  very  much  to  the  risk. 

Incision. — About  this,  too,  there  is  no  general  agreement,  a 
median  incision  having  the  advantage  of  the  wider  access  to  all 
parts  of  the  pelvis,  but  the  right  lateral  approach  being  more 
nearly  over  the  probable  seat  of  perforation.  The  actual  mortality 
tables  seem  to  favour  the  lateral  incision,  but  it  is  only  fair  to  point 
out  that  the  median  incision  may  have  been  chosen  in 'the  more 
desperate  cases. 

The  main  question  in  choosing  the  incision  is  the  ready  facility 
for  quick  performance  of  the  operation,  and  any  thought  of  post- 
operative hernia  must  be  set  aside.  There  can  be  no  doubt,  then, 
that  a  long  lateral  incision,  made  boldly  down  through  all  the 
strata  of  the  abdominal  wall,  best  fulfils  these  conditions.  It 
should  be  about  one-third  of  the  distance  from  the  right  anterior 
superior  iliac  spine  to  the  navel  at  right  angles  to  the  line  between 
these  points.  It  is  very  easy  to  draw  coils  of  ileum  into  this 
wound,  even  if  the  perforation  is  8  feet  away  from  the  valve, 
whereas  it  •  is  often  difficult  in  an  adult  to  deal  with  the  ciecum  or 
appendix  through  a  median  incision. 

Location  of  the  Lesion. — The  probable  site  of  the  lesion  has 
already  been  mentioned  and  it  is  seldom  a  matter  of  any  difficulty 
to  find  it.  If  it  does  not  immediately  become  evident,  the  region 
of  the  ileo-caecal  valve,  caecum  and  appendix  is  identified,  and  then 
the  small  intestine  rapidly  followed  up.  The  perforation,  which  is 
generally  on  the  anti-mesenteric  border  of  the  gut,  may  be  very 
minute,  and  a  stream  of  fluid  exudate  is  often  the  guide  to  it. 
Having  found  one  perforation,  it  is  always  worth  while  to  examine 
at  least  the  terminal  18  inches  of  ileum  for  another  hole  or 
suspicious  ulcer. 

Suture  of  the  Perforation. — In  the  case  of  a  small  hole,  the 
edges  of  which  are  not  too  friable,  a  simple  suturing  by  Lembert's 
stitches  in  two  rows  should  be  done.  Perhaps  the  Halstead 
mattress-stitch  is  a  little  less  liable  to  cut  out.  It  is  important  to 
turn  in  all  the  doubtful  thin  edge  which  surrounds  the  perforation. 

If,  however,  the  hole  in  the  bowel  is  so  large  that  it  cannot  be 


Perforation  of  the  Intestine.  553 

sewn  up  without  seriously  diminishing  the  calibre  of  the  gut,  and 
if  there  are  multiple  perforations  or  several  doubtful  places,  the 
matter  is  much  more  difficult.  Such  conditions  have  been  dealt 
with  Iry  the  tying  in  of  a  Paul's  tube,  the  making  of  an  enteric  anus 
and  by  resection.  The  results  in  all  these  cases  has  been  very  bad, 
but  considering  the  desperate  state  of  the  case  it  is  perhaps  rather 
wonderful  that  success  has  ever  been  attained.  Four  cases  collected 
by  Harte  and  Ashhurst  in  which  an  artificial  anus  was  made  all 
died,  but  Wroth  5  had  one  success  by  this  method,  the  patient 
being  left  in  a  continuous  bath  from  the  twelfth  day  for  two  weeks. 
It  is  very  significant  that  of  16  cases  in  which  a  fistula 
developed  spontaneously  after  the  operation,  only  2  died,  thus 
showing  that  the  artificial  anus  in  typhoid  fever  is  not  per  se  very 
dangerous.  The  mortality  after  resection  is  given  differently  by 
various  writers.  Keen  notes  5  cases  with  2  recoveries ;  Harte 
and  Ashhurst  5  cases  with  only  1  recovery,  and  Zezas6  20 
cases  with  8  recoveries.  All,  however,  are  agreed  that  some  of 
even  these  cases  do  recover,  and  it  is  rather  remarkable  that  in 
several  of  which  the  details  are  published  life  was  prolonged  for 
two,  seven  or  eight  days  after  the  operation,  from  which  it  is 
probable  in  concluding  that  the  patient  recovered  from  the  per- 
foration and  operation,  but  died  of  the  original  disease. 

In  some  cases  a  patch  of  gut,  the  integrity  of  which  is  in  doubt, 
may  be  covered  over  with  the  fringe  of  the  great  omentum.  In  one 
case  when  no  actual  perforation  but  very  extensive  ulceration  was 
present,  Solieri7  wrapped  several  inches  of  ileum  round  with 
omentum,  and  had  the  satisfaction  of  seeing  his  patient  recover  in 
spite  of  very  severe  haemorrhage  from  the  bowel,  which  indicated 
progressive  ulceration. 

Probably  the  best  treatment  for  cases  with  extensive  ulceration, 
or  large  or  multiple  perforations,  will  be  to  bring  the  whole  of  the 
affected  segment  of  ileum  (i.e.,  the  last  2  feet)  outside  the 
abdomen,  to  rapidly  resect  the  whole  of  this  by  means  of  the 
thermocautery,  the  mesentery  being  securely  ligatured.  Two  small 
Paul's  tubes  are  then  tied  into  the  two  ends  of  the  gut ;  from  the 
proximal  the  faeces  are  allowed  to  drain  away  into  a  receptacle 
through  a  rubber  tube  and  into  the  distal  continuous  saline  infusion 
is  given  much  more  easily  than  into  the  rectum.  This  procedure 
ought  not  to  occupy  longer  than  suturing  several  ulcers,  and  it  will 
give  the  best  chance  of  immediate  recovery.  If  the  patient  survives 
until  the  tubes  come  away  (about  three  days)  he  can  be  treated  by  a 
continuous  bath  or  an  anastomosis  can  be  made  without  requiring 
any  further  anaesthetic.  This  method  will  remove  the  principal 


554 


Perforation  of  the  Intestine. 


focus  of  disease,  it  will  prevent  death  from  a  second  perforation 
(which  occurred  in  11  per  cent,  of  Harte  and  Ashhurst's  cases), 
and  it  will  greatly  facilitate  the  infusion  of  fluids. 

Peritoneal  Toilet. — It  is  best  to  swab  out  all  exudate  from  the 
affected  region  and  especially  from  the  pelvis  by  means  of  gauze 
mops.  It  is  useless  to  attempt  to  wash  out  the  infective  material 


FIG.  1. — Operation  suggested  for  the  excision  of  the  ulcer-bearing  area  of  the  ileum 
in  cases  of  Typhoid  perforation.  A  loop  consisting  of  the  last  two  feet  of  ileum 
is  brought  out  through  an  oblique  wound  in  the  right  linea  semi  lunaris.  The 
base  of  this  loop  is  clamped  in  two  places  in  the  manner  shown,  and  a  stout 
suture  passed  through  the  corresponding  part  of  the  mesentery.  The  whole  loop 
is  removed  with  its  mesentery  by  cutting  just  below  the  line  of  the  upper  forceps 

I  =  Ileum.  C  =  Caecum. 

A  =  Appendix.  M  =  Mesentery. 

S  =  Suture  for  tying  Mesentery. 

unless  one  is  prepared  practically  to  eviscerate  the  patient  and 
flush  every  corner  of  the  abdomen,  a  treatment  which  would 
almost  certainly  be  fatal  in  these  cases.  Any  flushing  less  thorough 
than  this  will  only  serve  to  carry  infective  material  into  parts  of  the 
peritoneal  cavity  which  are  not  yet  infected. 

Having  dried  the  peritoneum,  long  wide  drainage  tubes,  which 
may  be  provided  with  gauze  wicks,  are  placed  right  down  into 
Douglas's  pouch  and  in  the  right  loin  and  hypogastric  regions  if 


Perforation  of  the  Intestine. 


555 


these  are  affected.  Usually  a  single  large  tube  will  be  sufficient,  one 
end  of  this  being  at  the  bottom  of  the  pelvis  and  the  other  at  the 
upper  extremity  of  the  parietal  wound.  The  whole -operation  ought 
to  be  completed  within  half  an  hour  or  less. 

After-treatment. — The    shock    of    the  operation,    if    great,   is 


FIG.  2. — Completion  of  the  operation.  The  whole  of  the  bleeding  is  controlled  by 
tying  the  mesenteric  suture,  and  a  Paul's  tube  is  tied  into  both  cut  ends  of  the 
ileum  (P  and  D)  which  are  then  fixed  in  the  parietal  wound.  The  excised 
portion  of  the  ileum  (2  feet)  freed  from  its  mesentery  is  seen  above  the  operation 


treated  by  an  intravenons  infusion  of  2  pints  of  normal  saline, 
together  with  1  c.c.  of  pituitary  gland  extract;  or  if  a  willing 
relative  is  forthcoming  an  immediate  transfusion  of  blood  might  be 
performed.  Directly  shock  is  past,  the  patient  is  propped  up  in 
the  Fowler  position  (by  means  of  a  properly  constructed  bed  frame) 


556  Perforation  of  the  Intestine. 

and  a.  continuous  rectal  infusion  of  saline  is  begun.  If  an  enterec- 
tomy  has  been  done  this  infusion  should  be  given  into  the  distal 
piece  of  gut  fixed  in  the  abdominal  wall.  The  infusion  should  be  at 
the  rate  of  1  pint  an  hour  of  fluid  at  100°  F.,  and  should  go  on 
for  about  forty-eight  hours. 

Probably  the  efficient  carrying  out  of  this  infusion  is  the  most 
potent  life-saving  means  at  our  disposal  after  the  perforation  has 
been  dealt  with.  To  give  illustrations  of  what  success  may  some- 
times attend  this  method,  Wroth8  in  1910,  relates  4  cases,  3 
of  which  were  desperate  ones  with  very  large  perforations,  all  of 
whom  recovered ;  they  all  had  8  to  6  litres  of  saline  each  day 
by  the  rectum.  And  Davis,9  in  1908,  reports  9  cases  of  typhoid 
perforation  with  no  less  than  8  recoveries  obtained  by  following 
this  plan. 

The  Mortality  after  Operation  has  already  been  referred  to. 
Although  large  series  of  cases  are  available  which  show  that  if  opera- 
tion is  performed  within  twenty-four  hours  the  mortality  is  about 
73  per  cent.,  yet  it  must  be  borne  in  mind,  on  the  one  hand,  that 
many  fatal  cases  are  not  reported,  but,  on  the  other  hand,  the  series 
refer  to  cases  which  occurred  before  the  modern  methods  of  the 
Fowler  position  with  continuous  saline  infusion  were  introduced. 
The  improvement  in  results  which  we  may  expect  from  these 
methods  has  already  been  indicated.  Death  rarely  occurs  during 
the  operation  ;  in  the  majority  of  fatal  cases  it  takes  place  within 
twelve  hours,  and  in  a  still  greater  majority  within  twenty-four  hours. 
Death  after  this  period  is  probably  due  to  the  original  fever  or  to  a 
fresh  perforation.  In  89  cases  the  cause  of  death  was  said  to  be  : — 
Peritonitis  in  44 ;  toxaemia  and  "  exhaustion  "  in  14  ;  a  second  per- 
foration in  10  ;  haemorrhage  in  3  ;  obstruction  in  3,  and  other  causes 
uninfluenced  by  the  operation  in  15. lo 

In  conclusion,  it  may  be  fairly  urged  that  a  far  better  prospect  of 
success  would  be  achieved  if  the  very  bad  cases  (i.e.,  cases  with 
numerous  or  larger  lesions  and  those  with  much  peritonitis 
or  toxaemia)  were  treat  ad  by  the  method  suggested  above,  viz.,  by  an 
excision  of  the  terminal  2  feet  of  the  ileum,  tubes  being  tied  into 
both  ends  of  the  bowel.  Every  one  of  the  above-mentioned  causes 
of  death,  except  the  last  (i.e.,  in  75  out  of  89  cases),  would  be  com- 
bated by  it.  The  peritonitis  would  be  treated  by  the  most  efficient 
form  of  transfusion  into  the  upper  end  of  the  larger  bowel. 
Toxaemia  would  be  minimised  by  the  direct  evacuation  of  the 
infective  material  from  the  upper  bowel.  Second  perforation  and 
haemorrhage  would  be  prevented  by  removing  the  part  of  the  bowel 
where  these  occur  and  by  keeping  the  large  gut  empty.  Obstruction 


Perforation  of  the  Intestine.  557 

would  not  occur  if  it  were  not  for  ill-advised  attempts  at  excision 
of  large  ulcers  or  immediate  anastomosis  of  the  bowel. 

OTHER  FORMS  OF  PERFORATION  OF  THE  INTESTINE. 

Perforation  of  the  Duodenum. — See  Duodenal  Ulcer. 

Perforation  of  the  Jejunum. — The  jejunum  is  the  part  of  the 
alimentary  canal  least  liable  to  perforation  or  to  ulceration.  In 
fact  it  is  only  as  a  sequel  of  gastro-enterostouiy  that  either  of  these 
conditions  occurs  except  as  so  rare  a  phenomenon  as  not  to  require 
special  discussion.  Mr.  H.  J.  Paterson  u  has  collected  52  cases 
of  jejunal  ulcer  after  gastro-enterostomy,  of  which  42  were  anterior 
operations,  no  case  having  been  yet  recorded  after  the  posterior 
no-loop  operation.  In  19  of  these,  perforation  occurred  into  the 
peritoneal  cavity,  in  28  into  a  localised  inflammatory  mass  or 
through  the  parietes,  and  in  5  into  the  colon.  Of  these,  29  cases 
recovered,  all  living  as  the  result  of  operative  treatment ;  13  died 
without  treatment,  and  8  died  after  one  or  more  operations. 

The  formation  of  a  jejunal  ulcer  occurs  within  one  or  two  years 
of  the  gastro-enterostomy,  and  its  presence  is  indicated  by  a 
recurrence  of  dyspeptic  symptoms.  These,  however,  may  often  be 
cured  by  carefully  dieting  (especially  the  forbidding  of  meat),  and 
by  the  administration  of  bismuth  or  alkalies.  The  symptoms  of 
perforation  are  similar  to  those  of  a  gastric  rupture,  and  will 
demand  an  immediate  operation.  If  possible  the  ulcer  is  sutured, 
but  in  some  cases  it  has  been  necessary  to  resect  the  damaged 
bowel  and  to  reconstruct  the  gastro-enterostomy.  If  the  limb  of  an 
anterior  gastro-jejunostomy  has  perforated  and  formed  an  external 
fistula,  it  is  best  to  entirely  resect  this  part  of  the  gut,  close  the 
anterior  stomach  opening,  and,  if  the  necessity  for  a  short  circuit 
still  exists,  to  perform  the  posterior  no-loop  operation. 

Perforation  of  the  Colon, — This  is  the  most  fatal  form  of  per- 
foration of  the  alimentary  canal,  but  fortunately  it  is  a  very  rare 
event.  In  addition  to  such  cases  as  enteric,  tuberculosis,  or 
dysenteric  ulcers,  and  the  impaction  of  foreign  bodies,  there  are  two 
causes  of  perforation  almost  peculiar  to  the  colon.  One  is  the 
formation  and  rupture  of  diverticula  and  the  other  the  rupture 
above  a  malignant  stricture,  often  through  a  stercoral  ulcer.  The 
sigmoid  flexure  and  then  the  caecum  are  the  commonest  sites  of 
perforation.  The  process  may  be  preceded  by  protective  adhesions 
to  the  parietes  or  neighbouring  viscera,  in  which  case  the  perforation 
will  result  in  an  abscess  or  fistula,  either  external  or  bi-iuucous ;  or 
the  rupture  may  take  place  directly  into  the  peritoneal  cavity. 
Two  facts  are  remarkable  about  this  catastrophe:  First,  that  the 


558  Perforation  of  the  Intestine. 

symptoms  are  often  comparatively  mild  and  patients  have  been 
known  to  walk  to  the  hospital  when  the  peritoneal  cavity  is  filled 
with  faeces;  and  second,  its  almost  invariable  fatality.  It  is 
doubtful,  in  fact,  whether  there  has  yet  ever  been  recorded  a 
recovery  after  perforation  -  of  the  large  intestine  direct  into  the 
peritoneal  cavity,  although  many  cases  have  been  operated  upon. 

In  the  majority  of  these  cases,  however,  the  exact  diagnosis  can- 
not be  made  before  the  abdomen  has  been  opened.  When  the  lesion 
has  been  found  it  has  usually  been  sutured.  If  obstruction  exists 
below  the  rupture  it  will  certainly  be  necessary  to  tie  a  tube  into 
the  colon  and  fix  it  in  the  parietal  wound.  Probably  this  treatment 
would  give  some  success  if  applied  to  all  cases  of  ruptured  colon. 
The  peritoneal  cavity  is  cleaned  by  dry  swabbing  and  freely  drained. 
Continuous  or  intermittent  saline  infusions  are  to  be  given  by 
means  of  the  colostomy  tube. 

ERNEST  W.    HEY  GROVES. 

REFERENCES. 

1  Keen,  W.  W.,  "Surgical  Complications  of  Typhoid  Fever,"  Assoc.  Philad. 
Lond.  1898. 

2  Harte  and  Ashhurst,  "  Trans.  Amer.  Surg.,"  1903,  XXI.,  pp.  580—624. 

3  Macrae,  T.,  in  "Osier  and  Macrae's  System  of  Medicine,"  1907,  Vol.  II., 
p.  98. 

4  Quoted  by  Macrae,  loc.  cit. 

5  "  Annals  of  Surgery,"  1910,  LI.,  p.  842. 

6  Zezas,  "Wiener  Klinik,"  1904;  Abstract  in  "  Centralblatt  f.  Chirurgie," 
1905,  XXXII.,  p.  385. 

7  "Archiv.  f.  Klin.  Chir.,"  Berlin,  1910,  XCIL,  p.  816. 

8  Loc.  cit. 

9  "  Surgery,  Gynecology  and  Obstetrics,"  Chicago,  1908,  VII.,  p.  590. 

10  Harte  and  Ashhurst,  loc.  cit. 

11  "  Proc.  Eoy.  Soc.  Med.,"  1909,  II.  (Surg.  Sect.),  pp.  238—310. 


559 


DISEASES    OF    THE    COLON. 

ADHESIONS    OF   THE   COLON. 

Non-Operative  Treatment — While  much  can  be  done  by  non- 
operative  methods  to  prevent  the  formation  of  adhesions  after 
abdominal  operations  or  after  an  attack  of  peritonitis,  they  often 
fail  when  the  condition  has  become  well  established.  When 
abdominal  pain  and  discomfort  are  the  chief  symptoms  complained 
of,  a  thorough  trial  should  be  given  to  non-operative  methods 
before  proceeding  to  perform  laparotomy.  In  those  cases  where 
there  are  recurring  attacks  of  obstruction,  palliative  measures 
seldom  do  any  good,  and  operation  is  often  the  only  method  of 
relieving  the  symptoms. 

It  is  usually  impossible  to  tell  how  much  benefit  will  result  from 
careful  medical  treatment,  and  it  is  therefore  always  advisable, 
unless  serious  symptoms  are  threatening,  to  try  the  effect  of 
massage  and  exercises,  before  proceeding  to  perform  laparotomy. 

Much  can  often  be  done  by  properly  applied  massage.  For  this 
to  be  effective,  however,  it  must  be  well  done,  and  combined  with 
other  forms  of  treatment.  A  skilled  masseuse  is  essential.  All 
abdominal  massage  should  be  commenced  gently.  At  first  the 
patient  should  be  massaged  for  not  more  than  ten  minutes 
twice  a  day.  When  possible,  massage  should  be  combined  with 
electrical  treatment  to  stimulate  the  movements  of  the  bowel.  The 
electrical  application  should  be  given  first,  and  should  be  followed 
by  massage.  After  the  first  week,  exercises  against  resistance 
should  follow  the  massage.  These  exercises  should  be  those  which 
contract  the  abdominal  muscles  and  which  flex  the  spine  and  thigh. 
Such  exercises  do  good  by  moving  the  parietal  peritoneum  through 
the  agency  of  the  muscles  in  contact  with  it. 

Treatment  should  be  continuous  at  first,  and  the  shortest  time 
for  a  course  which  will  do  any  real  good  is  from  a  month  to  six 
weeks.  During  this  period  the  patient  should  not  be  kept  in  bed, 
except,  perhaps  for  the  first  few  days,  but  should  be  sent  out  daily 
for  a  short  time.  After  a  course  of  treatment  the  patient  should  be 
instructed  to  take  regular  exercise,  and  to  keep  the  bowels  acting 
daily.  The  best  forms  of  exercise  are  walking  and  riding.  If 
marked  improvement  follows,  the  patient  should  have  a  second  and 


560 


Adhesions  of  the  Colon. 


shorter  course  of  massage  and  electricity  in  about  two  months' 
time. 

Injections  of  fibrolysin,  a  drug  which  is  said  to  cause  softening  of 
adhesions,  have  also  been  used  in  these  cases,  and  good  results  are 
claimed.  The  treatment  is  too  new  to  warrant  any  opinion  as  to  its 
benefit,  but  as  the  injections  do  not  seem  to  cause  any  unpleasant 
results  the  drug  may  be  tried  in  conjunction  with  massage.  The 
injections  should  be  given  intramuscularly,  preferably  into  the 
muscles  of  the  buttocks,  every  two  or  three  days. 

In  many  cases,  although  some  improvement  follows  a  thorough 
course  of  massage,  the  patient  soon  relapses  to  the  old  condition, 
and  in  the  worst  cases  little,  if  any,  improvement  occurs.  Where 
a  definite  obstruction  from  kinking  has  occurred,  nothing  short  of 
operation  will  do  any  good.  Operation  is  indicated  when  there  is 


FIG.  1. — Diagram  illustrating  how  adhesions  of  the  colon  may  cause 
obstruction.  A.  Two  appendices  epiploicas  adherent  to  one  another. 
B.  Kink  caused  by  adhesions  between  two  limbs  of  pelvic  loop.  C.  Acute 
kink  caused  by  a  band  of  adhesion  in  meso-colon. — From  Mummery's 
"  Diseases  of  the  Colon,"  Wright. 

serious  difficulty  in  getting  the  bowels  to  act,  and  also  when  the 
patient  is  so  greatly  incapacitated  by  his  symptoms  that  he  is 
unable  to  attend  to  the  ordinary  affairs  of  life. 

Operative  Treatment. — The  operation  consists  in  separating  or 
dividing  adhesions  and  re-establishing  the  normal  course  of  the 
bowel.  It  is  not  sufficient  merely  to  divide  the  adhesions  in  any 
case,  since,  if  raw  surfaces  uncovered  by  peritoneum  are  left,  the 
adhesions  are  almost  certain  to  re-form  and  re-establish  the  original 
condition.  The  prevention  of  subsequent  adhesions  constitutes  the 
chief  difficulty  in  these  cases.  Various  methods  have  been 
advocated  by  different  surgeons,  and  various  substances  have  been 
used  to  cover  the  raw  surfaces  with  the  object  of  preventing  the 
formation  of  adhesions.  Thus,  painting  the  raw  surfaces  with  gum 
or  glucose  has  been  tried ;  covering  them  with  gold-leaf  has  also 
been  tried,  with  apparently  good  results.  Filling  the  abdomen 


Adhesions  of  the  Colon.  561 

with  salt  solution  and  subsequently  giving  large  rectal  or  sub- 
cutaneous injections  of  water  or  salt  solution  is  the  practice  of 
some  surgeons,  while  others  believe  in  abdominal  massage  and 
electricity  applied  to  the  abdomen  for  some  time  after  operation. 

Undoubtedly  the  best  method  is  careful  suture  of  the  peritoneum 
over  all  the  raw  surfaces  left  by  division  of  the  adhesions.  This 
involves  some  form  of  plastic  operation  and  considerable  care  and 
patience.  It  is  often  possible,  after  dividing  a  peritoneal  band 
transversely,  to  stitch  the  resulting  wound  in  the  peritoneum  in  a 
longitudinal  direction,  so  as  completely  to  cover  in  the  raw  surface 
and  at  the  same  time  straighten  the  bowel.  By  these  means,  and 
by  utilising  loose  folds  of  peritoneum,  appendices  epiploicae,  or 
omentum  to  cover  in  defects  in  the  peritoneum,  much  may  be  done 
to  prevent  the  recurrence  of  adhesions.  Absolute  asepsis  and 
great  care  in  removing  all  bloodclot  from  the  peritoneal  cavity 
are,  however,  the  most  important  factors  in  preventing  their 
formation ;  and  a  subsequent  course  of  massage  and  electricity  is 
advisable. 

When  the  adhesions  are  very  firm,  or  serious  difficulty  is 
experienced  in  straightening  the  bowel,  the  best  procedure  is  to 
resect  the  involved  loop  and  unite  ends  of  the  bowel  if  this  can 
be  done,  or  to  short-circuit  the  obstructing  angle  by  lateral 
anastomosis. 

P.  LOCKHART  MUMMERY. 


S.T. VOL.    II.  36 


562 


COLITIS. 

COLITIS  may  be  due  to  many  causes  and  the  treatment  must  to  a 
certain  extent  depend  upon  the  cause  ;  thus,  for  example,  one  of  the 
most  severe  forms  of  inflammation  of  the  colon  with  which  we  are 
acquainted  is  that  which  occurs  behind  an  obstruction,  e.g.,  that 
met  with  when  there  is  a  malignant  stricture   of  the  rectum  or 
sigmoid,  but  in  such  a  case  it  would  be  folly  to  treat  the  colitis 
unless  we  first  recognised  the  cause  of  it.      Still,  there  are  certain 
general  principles  underlying  the  treatment  of  colitis,  and  the  first 
of  these  is  to  keep  the  bowel  empty.     No  inflammation  of  the  colon 
can  be  expected  to  heal  so  long  as  the  mucous  membrane  is  bathed 
in  faeces.     Thus,  when  there  is  a  general  enteritis,  in  which  the 
colon  often  participates,  due  to   decomposing  or   improper    food, 
the  variety  of  enteritis  so  frequently  seen  especially  in  the  summer 
among  the  children  of  the  poor,  the  first  thing  to  do,  except  in  the 
few  instances  in  which  the  child  is  too  collapsed,  is  to  give  an 
aperient  such,  for  example,  as  castor  oil  or  calomel  or  grey  powder, 
to  empty  the  bowel  and  clear  away  the  irritating  article  of  food 
and  also  the  faeces.     It  is  true  that  nature  often  tries  to  do  this  by 
the  diarrhoea  which  is  commonly  associated  with  colitis,  but  usually 
the  attempt  is  ineffectual  and  must  be  helped  by  the  administration 
of  a  non-irritating  aperient.     When  the  natural  diarrhoea  is  very 
excessive,  e.g.,  some  cases  of  cholera,  some  of  dysentery,    some  of 
summer  diarrhoea,  the  drain  of  fluid  from  the  body  may  be  so 
great  that  it  may  not  be  justifiable  to  give  an  aperient  at  once,  and 
then  some  astringent — unless  the  patient  is  very  young  or  has 
nephritis,   opium   in   some    form    is    best — must    be    given   and 
chlorodyne  is  very  useful,  and  at  the  same  time  a   subcutaneous 
saline  infusion  will  be  necessary  to  compensate  for  the  loss  of  fluid 
from  the  bowel.     Normal  saline,  at  100°  F.,  should  be  slowly  run 
into  the  subcutaneous  tissue  of  the  axilla  or  thigh  ;  it  will  run  in  at 
about  the  right  rate  if  the  receptacle  containing  the  infusion  is  a 
foot  above  the  point  of  entrance  of  the  needle  into  the  subcutaneous 
tissue.     Again,  with  the  object  of  keeping  the  bowel  empty,  very 
little   food   should   be   given    to   a  person    suffering    from   acute 
colitis  ;  for  the  first  twenty-four  hours  albumin- water  is  enough. 
This  is  made  by  mixing  the  white  of  two  or  three  eggs  with  a  pint 
of  water,  and  it  may  be  sipped  in  small  quantities   every  hour. 


Membranous    Colitis.  563 

Then  next  day  milk,  either  citrated  (2  gr.  of  sodium  citrate  to 
each  fluid  ounce  of  milk)  or  peptonised  to  prevent  curdling,  may 
be  given  in  small  quantities  every  hour.  A  patient  with  acute 
colitis  should  always  remain  in  bed  and  be  kept  warm.  Nothing 
is  more  foolish  than  for  patients  to  struggle  about  while  they  have 
severe  diarrhoaa.  Acute  colitis  is  nearly  always  due  to  a  micro- 
organism, and  therefore  some  cases  are  benefited  by  soured  milk. 
About  a  pint  or  a  pint  and  a  half  a  day  may  be  used,  and  the  milk 
must  be  properly  soured  by  the  Bulgarian  bacillus.  There  are 
many  useless  soured  milks  sold,  and  the  administration  of  the 
tablets  that  are  taken  by  many  patients  is  quite  ineffectual.  The 
milk  may  either  be  bought  ready  prepared  or  prepared  in  one  of 
the  various  apparatus  that  are  sold.  The  determination  of  the 
micro-organism  which  causes  the  colitis  is  often  difficult,  but  if  in 
any  way  the  more  likely  micro-organism  can  be  found,  the  use  of 
a  vaccine  prepared  from  it  sometimes  appears  to  do  good.  I  think 
I  have  seen  benefit  from  the  employment  of  vaccines  of  bacillus 
coli  and  those  of  pneumococci  in  suitable  cases.  Acute  colitis  is 
not  an  infrequent  accompaniment  of  nephritis.  Perhaps  here  it 
is  an  attempt,  by  means  of  the  diarrhcea  associated  with  it,  to  get 
rid  of  some  of  the  ursemic  poison ;  indeed,  diarrhoaa  is  one  of  the 
symptoms  of  uraemia.  When  there  is  reason  to  believe  that 
diarrhea  is  really  the  means  of  ridding  the  body  of  some  poison 
we  should  not  be  in  a  hurry  to  restrain  it. 

Membranous  Colitis. — A  certain  number  of  persons,  mostly 
women,  pass  mucus  with  their  motions.  This  mucus,  while  still 
applied  to  the  inner  surface  of  the  bowel,  has  become  coagulated 
so  that  sometimes  a  hollow  tube  of  coagulated  mucus  which  is  a 
cast  of  the  interior  of  the  intestine  is  passed.  More  often  the  tube 
is  incomplete,  and  often  by  the  time  it  is  passed  it  is  broken  up  into 
many  little  pieces ;  the  patient  then  often  complains  that  she 
passes  "  skins."  In  rare  instances  the  inflammation  of  the  colon 
which  leads  to  the  formation  of  these  membranes  is  due  to  some 
cause  outside  the  colon  ;  thus,  it  may  be  caused  by  injury,  for 
instance,  it  was  present  in  a  case  in  which  a  cab  wheel  passed 
over  the  abdomen  ;  it  has  followed  the  swallowing  of  corrosive 
sublimate  ;  it  is  a  rare  accompaniment  of  severe  pysemia  ;  it  may 
be  associated  with  Bright's  disease,  pneumonia  or  diabetes ;  but 
in  all  these  cases  it  is  of  quite  secondary  importance  and  calls  for 
no  special  treatment. 

Ordinary  membranous  colitis  arises  from  local  trouble  within  the 
large  bowel  itself,  and  this  trouble  is  nearly  always  constipation. 
Sometimes  the  constipation  is  due  to  an  organic  cause  ;  thus 

36—2 


564  Membranous   Colitis. 

membranous  colitis  may  be  due  to  malignant  disease  of  the  bowel 
or  to  appendicitis,  and  in  every  case  careful  search  must  be  made 
for  some  organic  cause.  It  is  important  to  try  from  the  history 
and  other  points  to  discover  whether,  when  associated  with 
inflammation  of  the  appendix,  the  membranous  colitis  is  secondary 
to  the  trouble  in  the  appendix,  for  then  removal  of  the  appendix 
will  benefit  the  membranous  colitis,  or  whether  the  trouble  in  the 
appendix  is  merely  part  of  the  membranous  colitis,  in  which  case 
removal  of  the  appendix  will  not  benefit  the  patient.  When  all 
the  points  here  mentioned  have  been  considered  it  will  usually  be 
found  that  there  is  no  organic  disease  in  the  abdomen  to  which 
the  membranous  colitis  can  be  ascribed,  and  then  the  case  is  one 
of  ordinary  membranous  colitis.  The  cause  of  the  disorder  in 
women  is  nearly  always  constipation,  and  even  if  at  the  time  the 
patient  is  first  seen  she  does  not  complain  of  constipation  (in 
exceptional  cases  she  may  have  diarrhrea),  yet  a  survey  of  the 
history  will  almost  always  show  that  the  trouble  began  with  con- 
stipation. The  patient  will  not  be  cured  unless  the  constipation 
is  overcome  and,  as  in  other  varieties  of  colitis,  it  is  necessary  in 
order  to  effect  a  cure  to  keep  the  large  bowel  empty.  Experience 
has  shown  that  in  these  cases  by  far  the  most  satisfactory  way  to 
do  this  is  by  giving  castor  oil,  and  many  cases  of  membranous 
colitis  may  be  completely  cured  with  this  drug.  The  patient  should 
take  it  every  morning  on  waking,  and  if,  as  many  people  do,  she 
wakes  about  5  a.m.  and  falls  asleep  again,  she  should  take  it  about 
five.  A  few  prefer  to  take  it  on  going  to  bed,  for  in  women  it  often 
takes  a  long  while  to  act.  Whenever  it  is  taken  the  dose  should 
be  such  as  to  ensure  that  the  bowels  are  thoroughly  and  com- 
fortably open  after  breakfast.  Often  £  oz.  or  1  oz.  is  necessary ; 
the  patient  may  take  it  in  any  way  she  likes.  Some  prefer  it  by 
itself ;  others  float  it  in  a  little  brandy  or  a  little  coffee  ;  others 
like  lemon  juice,  or  the  oil  may  be  added  to  a  teaspoonful  of 
peppermint  water  and  then  a  little  brandy  added  till  the  oil 
neither  sinks  nor  swims.  If  the  inside  of  the  glass  and  the  rim 
are  moistened  with  whatever  vehicle  is  chosen  and  the  castor  oil  is, 
as  far  as  possible  between  two  layers  of  the  vehicle,  it  is  hardly  tasted 
when  swallowed.  There  are  many  varieties  of  castor  oil  in  the 
market  which  are  almost  tasteless.  The  pharrnacopreal  mixture  is 
not  to  be  recommended  as  it  is  nasty.  Many  patients  who  at 
first  declare  they  cannot  take  the  oil  soon  overcome  their  repug- 
nance to  it  and  a  thorough  trial  should  be  given  to  it,  for  there  is 
no  doubt  that  it  is  the  best  drug  to  use,  and  many  women  liable  to 
membranous  colitis  keep  it  permanently  in  check  by  taking  castor 


Membranous   Colitis.  565 

oil.  There  is  no  harm  in  this,  indeed  usually  the  dose  may  with 
safety  be  gradually  diminished,  and  in  many  instances  after  a 
time  the  oil  may  be  left  off,  but  some  women  take  a  little 
regularly  every  evening  or  once  or  twice  a  week.  Should  it  be 
quite  impossible  for  the  patient  to  take  castor  oil,  sulphate  of 
magnesium  may  be  employed  instead,  and  if  this  too  disagrees 
calomel  overnight  may  be  tried. 

Many  patients  suffering  from  membranous  colitis  go  to 
Plombieres.  Here  the  same  principle,  namely,  that  of  keeping  the 
large  bowel  empty,  is  carried  out  by  washing  out  the  bowel  from 
the  anus  with  water.  This  is  done  by  skilled  assistants,  and  the 
pressure  is  controlled  by  varying  the  height  of  he  receptacle  con- 
taining the  water.  When  properly  done,  this  method  undoubtedly 
can  be  made  to  wash  out  the  colon,  and  many  patients  are  much 
benefited  by  a  course  of  intestinal  lavage  once  a  year  at  Plombieres. 
When  it  is  decided  to  try  intestinal  lavage,  which  may  be  reserved 
for  cases  in  which  the  taking  of  castor  oil  has  not  been  a  success, 
it  is  best,  if  possible,  to  send  the  patient  to  Plombieres,  which, 
however,  is  only  open  from  early  in  May  to  the  end  of  September  ; 
should  Plombieres  be  impossible,  trial  may  be  made  of  Buxton  or 
Harrogate,  where  similar  treatment  is  carried  out.  The  attempt  to 
wash  the  bowel  out  systematically  at  home  is  nearly  always  a 
failure,  for  it  is  not  an  easy  thing  to  do,  and  often  a  tube  which  it 
is  believed  has  passed  up  into  the  sigmoid  is  really  coiled  up  in  the 
rectum.  From  1  to  2  pints  of  plain  water  may  be  used ;  its 
temperature  should  be  about  100°  F. 

Because  the  cause  of  the  membranous  colitis  is  constipation, 
and  this,  in  women  at  least,  is  often  due  to  deficient  muscular 
power  of  the  abdomen,  abdominal  massage  is  very  useful.  It 
should  be  carried  out  by  someone  who  has  been  thoroughly  trained. 
The  best  time  is  in  the  morning  before  breakfast;  it  should  be 
done  daily.  After  it  is  finished  the  patient  should  lie  still  for  a 
quarter  of  an  hour,  then  get  up,  have  her  bath  and  breakfast.  It 
is  often  of  great  advantage  before  the  massage  to  make  her  perform 
exercises  with  a  view  of  strengthening  the  muscles.  Any  good 
masseuse  ought  to  be  able  to  teach  them  to  the  patient.  They 
should  never  be  done  long  enough  to  cause  fatigue.  The  following 
are  useful :  Exercise  1  :  The  patient  should  lie  flat  on  her  back  on 
a  firm  bed  or  the  floor,  with  her  hands  by  her  sides.  The  knees 
should  be  drawn  up  to  the  chest  and  then  the  legs  straightened  out 
at  right  angles  to  the  trunk.  With  the  knees  kept  stiff,  the  legs 
should  then  be  slowly  lowered  until  they  again  touch  the  bed. 
Exercise  2 :  With  the  patient  lying  as  before,  the  right  leg,  with 


566  Membranous  Colitis. 

the  knee  kept  stiff,  should  be  slowly  raised  till  it  is  at  right  angles 
with  the  body.  It  should  then  be  slowly  lowered  again,  still  with 
the  knee  stiff,  stopping  for  a  few  seconds  at  different  angles  with 
the  trunk.  Two  or  three  stops  should  be  made  before  the  leg  again 
rests  on  the  bed.  The  same  exercise  should  be  carried  out  with  the 
left  leg.  Exercise  3 :  The  patient  should  lie  on  the  floor,  with 
her  hands  by  her  sides.  Then,  while  her  legs  are  held  down,  she 
should  slowly  raise  herself  into  a  sitting  posture  without  using  her 
hands.  The  body  should  then  be  twisted  round,  first  in  one 
direction  and  then  in  the  other  ;  she  should  then  slowly  lie  down 
again.  Exercise  4  :  The  patient  stands  up  and  slowly  raises  first 
one  leg  and  then  the  other.  Each  knee  should  be  brought  up 
until  it  touches  the  chest.  Exercise  5  :  The  patient  stands  with 
her  hands  on  her  hips,  and  slowly  rotates  the  body  first  in  one 
direction  and  then  in  another.  Exercise  6  :  Repeat  Exercise  2, 
but  with  both  feet  together  instead  of  alternately.  Exercise  7  :. 
The  patient  sits  on  the  floor,  and  the  feet  are  held  down  ;  she  then 
slowly  sways  herself  backwards  and  forwards  from  the  hips. 
Exercise  8:  With  the  hands  on  the  hips,  the  patient  squats  down 
on  her  heels,  then  slowly  raises  herself  into  the  standing  position, 
and  again  slowly  lowers  herself  until  she  is  sitting  on  her  heels. 
This  should  be  repeated  two  or  three  times. 

It  is  not  uncommon  to  find  that  patients  who  suffer  from 
membranous  colitis  have  one  or  both  kidneys  abnormally 
movable.  Their  abdominal  muscles  are  lax,  and  in  a  few  cases  their 
intestines  and  stomach  have  dropped.  The  wearing  of  a  proper 
abdominal  support  is  of  great  help  in  such  cases,  and  this  is  best 
effected  by  stays  made  to  grip  the  iliac  crests  instead  of  the  ribs. 
These  stays  should  have  a  centre  vertical  piece  and  lace  up  in  two 
lateral  lines,  each  about  2  inches  from  the  middle  line  ;  the  centre 
piece  is  fixed  by  being  attached  to  the  stockings  by  means  of 
tapes.  The  patient  stands  in  the  erect  posture  and  draws  a  deep 
breath,  by  which  means  the  abdominal  muscles  are  drawn  in  and 
the  viscera  are  forced  up,  while  she  holds  her  breath  the  stays  are 
then  laced  up  firmly  from  below  upwards. 

Sufferers  from  membranous  colitis  often  attach  an  exaggerated 
importance  to  the  effect  of  diet.  Whatever  food  the  patient  takes 
she  should  masticate  it  well.  The  diet  should  be  ample.  Most  of 
these  patients  decline  first  one  article  of  food  and  then  another, 
until  at  last  their  dietary  is  so  restricted  that  they  are  not  only 
underfed  but  their  digestive  powers  are  overtaxed  in  some  par- 
ticular direction.  An  obviously  indigestible  dietary,  such  as  one 
consisting  largely  of  made  dishes  or  an  undue  preponderance  of 


Membranous    Colitis.  567 

sweets,  should  be  avoided,  but  the  patient  should  partake  of  any 
ordinary  food  that  is  put  before  her.  It  should  be  well  cooked  and 
the  meals  should  be  made  as  tempting  as  possible  to  the  slender 
appetite.  Even  if  it  is  an  effort  she  must  eat  well.  She  should 
have  her  meals  at  regular  times  and  should  go  to  bed  early  and 
always  have  eight  hours  sleep.  Some  have  advised  that  the  food 
should  be  predigested  and  others,  as  von  Noorden,  have  advised 
that  the  diet  should  contain  much  bulky  indigestible  food.  I  have 
known  both  these  succeed,  but  ordinary  diet  succeeds  as  often  as 
either  and  has  the  advantage  that  it  does  not  foster  valetudinarian 
habits. 

Between  the  severe,  attacks  the  patient  should  in  all  respects  lead 
as  healthy  a  life  as  possible.  She  should  take  plenty  of  outdoor 
exercise  of  a  kind  to  interest  her  and  take  her  out  of  herself ; 
riding  or  playing  golf  is  infinitely  preferable  to  dull  solitary  walks 
taken  merely  for  the  sake  of  exercise.  A  holiday  and  change  of 
scene  to  some  such  bracing  place  as  Switzerland  or  Norway,  or  a 
yachting  cruisel  are  often  of  the  greatest  benefit.  Indeed,  these 
patients  derive  much  benefit  from  such  a  holiday,  even  when  they 
are  not  passing  membrane.  For  a  severe  case,  rest  in  bed,  possibly 
morphine  injected  subcutaneously,  and  the  application  of  hot 
fomentations  to  the  abdomen  may  be  necessary ;  but  opiates  should 
not  be  prescribed  unless  they  are  absolutely  necessary,  for  not  only 
do  they  increase  the  constipation  but  sufferers  from  membranous 
colitis  are  just  the  sort  of  people  who  may  become  addicted  to  an 
excessive  use  of  these  agents.  In  some  cases  the  daily  passage  of 
high-frequency  currents  has  certainly  done  good. 

Some  patients  are  unrelieved  even  if  all  the  above  methods  of 
treatment  have  been  tried,  still  our  object  must  be  to  keep  the  large 
bowel  empty  of  faeces.  This  might  be  done  by  a  short  circuiting  opera- 
tion, but  there  are  objections  to  this,  for  it  does  not  entirely  prevent 
the  presence  of  faeces  in  the  colon  nor  does  it  allow  of  a  satisfac- 
tory discharge  of  the  natural  secretions  of  the  colon.  In  1895 
Mr.  Golding-Bird  and  I  published  an  account  of  a  case  in  which  an 
artificial  anus  was  established  by  opening  the  colon  immediately 
above  the  ccecnm.  The  fasces  were  passed  through  this  and  the 
colon  was  washed  through  from  the  artificial  to  the  natural  anus. 
By  this  treatment  many  cases  of  membranous  colitis  which 
have  not  improved  by  non-operative  treatment  may  be  cured ;  but 
there  are  two  objections  to  the  operation,  the  most  important  is 
that  the  faeces  on  the  right  side  are  very  liquid  and  it  may  be  very 
difficult  to  prevent  their  causing  inflammation  of  the  skin  and 
secondly,  to  cure  the  disease  it  may  be  necessary  to  keep  the 


568  Ulcerative    Colitis. 

opening  patent  for  a  year,  and  in  that  time  the  colon  may  become 
so  shrunken  from  disease  that  it  may  be  difficult  to  get  the  faeces 
to  pass  along  it.  A  far  better  operation  is  to  open  the  appendix 
(appendicostomy)  and  wash  the  colon  through  the  opening.  See 
pp.  571—573. 

Ulcerative  Colitis. — The  colon  may  be  ulcerated  as  a  result  of 
many  diseases,  e.g.,  tubercle,  cancer  and  typhoid  fever,  but  in  this 
country  we  understand  by  ulcerative  colitis  a  disease  in  which  the 
ulceration  is  not  due  to  any  easily  recognised  cause,  is  extensive, 
often  destroying  almost  all  the  mucous  membrane  and  looking  very 
much  like  the  ulceration  produced  by  dysentery.  This  is  not  the 
place  in  which  to  discuss  whether  ulcerative  colitis  and  dysentery 
are  the  same  disease,-but  even  if  in  all  cases  of  ulcerative  colitis  the 
ulceration  is  previously  caused  by  one  of  the  micro-organisms 
which  cause  dysentery,  yet  by  the  time  the  case  comes  under 
observation  the  ulceration  is  at  any  rate  kept  up  by  bacillus  coli. 
The  treatment  is  difficult,  indeed  many  sufferers  die.  The  patient 
must  be  put  to  bed  and  kept  there  many  weeks.  Citrated  milk 
with  eggs  beaten  up  in  it  forms  a  good  diet.  Three  pints  of  milk 
with  an  egg  beaten  up  in  each  £  pint  may  be  taken  in  twenty- 
four  hours.  This  is  hardly  enough  food,  so  if  possible  two  feeds  a 
day  of  Benger's,  Allen  and  Hanbury's,  or  some  similar  infant's  food, 
may  be  given.  Often  the  diarrhoea  is  so  excessive  that,  as  it 
weakens  the  patient,  it  is  necessary  to  give  opium  to  check  it. 
There  is  no  better  way  of  doing  this  than  giving  chlorodyne,  but  if 
there  is  not  much  diarrhoea  it  will  be  well  to  give  small  doses  of 
castor  oil  to  keep  the  bowels  thoroughly  cleared  out.  When  one 
sees  the  state  of  the  intestines  after  death  it  seems  extremely 
unlikely  that  intestinal  antiseptics  can  be  any  use,  but  soured  milk 
may  be  tried  or  3  min.  of  cyllin  in  capsules  may  be  given  four  or 
five  times  a  day. 

Whatever  may  have  been  the  original  cause  of  the  ulceration,  by 
the  time  that  many  of  these  cases  reach  the  chronic  stage  the 
dominant  micro-organism  is  probably  often  bacillus  coli  and  some- 
times good  may  follow  vaccine  treatment,  the  vaccine  being 
prepared  from  the  patient's  own  bacillus  coli.  An  instance  of  the 
good  that  may  follow  is  the  case  of  a  boy  aged  seventeen,  seen  in  May, 
1908.  He  had  had  severe  ulcerative  colitis  for  many  months, 
passing  blood  and  mucus.  He  was  wasted,  confined  to  bed,  had 
seen  many  doctors,  but  no  treatment  had  done  good.  Bacillus  coli 
communis  was  isolated  from  the  faeces  and  a  vaccine  prepared. 
He  was  given  small  initial  doses,  rapidly  increased  to  50,000,000  at 
each  dose  given  fortnightly.  He  gradually  improved.  The  vaccine 


Ulcerative   Colitis.  569 

treatment  was  continued  until  March,  1909,  although  in  February, 
1909,  he  was  well,  the  diarrho3a  and  passage  of  blood  and  mucus 
having  ceased  for  a  long  while.  He  gained  weight,  went  to  his 
work,  and  was  still  quite  well  two  and  a  half  years  after  he  was 
first  seen.  The  following  is  another  instance :  The  patient,  a  boy 
aged  twelve  years,  had  had  ulcerative  colitis  for  four  years,  passing 
blood  and  mucus  and  having  pyrexia,  pain  and  tenderness.  Bacillus 
coli  communis  was  isolated  from  the  fteces,  an  autogenous  vaccine 
was  prepared  ;  he  had  doses  varying  from  5,000,000  to  50,000,000 
at  intervals  of  a  week  for  three  months.  At  the  same  time  he  was 
given  2  pints  of  soured  milk  and  three  drops  of  cyllin  three  times  a 
day.  The  improvement  was  immediate  and  rapid  and  he  was  soon 
well,  and  when  seen  some  months  later  was  still  well.  ,, 

If  the  patient  does  not  improve  after  any  of  the  treatments  here 
mentioned  or  he  relapses  after  a  fair  trial  of  vaccine  treatment, 
the  appendix  should  be  opened  and  the  bowel  washed  through  with 
boiled  water  at  the  temperature  of  the  body  two  or  three  times  a 
day.  I  have  seen  some  remarkable  successes  after  this  operation. 

W.    HALE   WHITE. 


57° 


THE    SURGICAL    TREATMENT    OF    COLITIS. 

CHRONIC   MUCOUS   COLITIS. 

IT  cannot  be  too  strongly  insisted  upon  that  it  is  quite  useless  to 
attempt  the  treatment  of  this  condition  either  medically  or 
surgically  unless  the  diagnosis  has  been  carefully  verified. 

The  mere  fact  that  a  patient  is  passing  large  quantities  of  mucus, 
either  in  the  form  of  shreds  or  membrane,  in  the  stools,  and  is 
suffering  from  attacks'of  abdominal  pain,  is  not  sufficient  to  warrant 
a  diagnosis  of  chronic  colitis.  Such  symptoms  may  and  often  do 
result  from  such  widely  different  lesions  as  cancer  of  the  colon, 
chronic  appendicitis  and  floating  kidney.  From  the  symptoms 
alone  these  conditions  cannot  b'e  diagnosed  with  certainty  from  true 
cases  of  chronic  colitis.  If  steps  are  not  taken  to  eliminate  such 
causes  for  the  symptoms  before  proceeding  to  treat  the  case,  failure 
is  more  than  probable.  The  greatest  care  must,  therefore,  be  taken 
to  verify  the  diagnosis  by  examination  of  the  abdomen,  if  necessary 
under  an  anaesthetic,  by  microscopical  examination  of  the  stools 
and  by  all  the  other  means  at  our  disposal.  Of  these  by  far  the 
most  important  is  a  direct  examination  of  the  pelvic  colon  by 
means  of  the  sigmoidoscope.  In  true  cases  of  chronic  mucous 
colitis  a  sigmoidoscopic  examination  will  reveal  a  chronic  inflam- 
matory condition  of  the  mucosa  of  the  pelvic  colon.  Quite 
frequently,  however,  the  examination  reveals  a  healthy  condition 
of  the  mucosa,  but  some  localised  lesion  is  discovered  in  this  or 
some  other  portion  of  the  large  bowel.  The  symptoms,  in  fact, 
may  result  from  any  irritative  lesion  in  the  colon,  and  an  actual 
inflammatory  condition  is  only  present  in  about  40  per  cent,  of 
the  cases  presenting  themselves  for  treatment.  I  do  not  personally 
believe  in  the  so-called  hysterical  or  neurasthenic  type  of  colitis. 
Undoubtedly  neurasthenia  is  often  present  to  a  marked  extent,  but 
this  is  no  proof  that  it  is  a  cause  of  the  bowel  symptoms,  and  in 
almost  all  cases  a  careful  examination  will  reveal  some  definite 
pathological  cause.  In  some  cases  an  exploratory  laparotomy  may 
be  necessary  to  ascertain  the  cause  of  the  condition,  but  this  should 
not  be  done  until  other  methods  have  failed. 

The  treatment  of  those  cases  in  which  an  examination  has 
demonstrated  the  presence  of  some  definite  local  lesion  cannot  be 
discussed  here,  as  it  will  naturally  depend  upon  what  is  found,  but 


The  Surgical  Treatment  of  Colitis.        571 

the  treatment  will  be  found  elsewhere  under  the  appropriate 
heading,  the  obvious  indication  being  to  remove  the  cause  when 
possible.  I  shall  here  only  describe  the  treatment  for  those  cases 
in  which  there  is  a  definite  chronic  inflammatory  condition  of  the 
mucosa ;  that  is  to  say  the  cases  in  which  a  true  colitis  is  present. 
Surgical  treatment  is  only  indicated  after  a  thorough  trial  has  been 
given  to  medical  treatment  and  this  has  failed  to  give  permanent 
relief.  There  are  a  large  number  of  cases  in  which  no  improve- 
ment occurs  after  medical  treatment,  or  which  improve  only  to 
quickly  relapse  again,  and  it  is  in  these  cases  that  surgical  treat- 
ment often  gives  relief  and  saves  the  patient  from  becoming  a 
chronic  invalid. 

We  have  to  bear  in  mind  that  the  condition  is  not  a  fatal  one, 
and  that  it  is  not,  therefore,  justifiable  to  perform  operations  which 
involve  a  serious  risk  to  life. 

Surgery  has  attempted  to  deal  with  chronic  mucous  colitis  in 
two  ways  :  (1)  By  deflecting  the  faecal  current  so  as  to  give  rest  to 
the  colon  ;  (2)  by  establishing  an  opening  through  which  the  colon 
can  be  washed  out  daily. 

Of  these  the  first  was  the  method  adopted  in  all  the  early  cases, 
a  colotomy  or  caecostomy  opening  being  established  on  the  right 
side  and  the  faeces  being  prevented  from  passing  to  the  anus. 

Csecostomy. — The  results  of  this  operation  are  quite  satisfactory 
as  regards  getting  rid  of  the  symptoms,  but  it  is  necessary  to  retain 
the  opening  for  a  considerable  time,  at  least  a  year  in  most  cases, 
or  the  symptoms  will  recur.  The  inconveniences  of  a  csecostomy 
opening,  however,  are  so  great  that  they  more  than  counterbalance 
any  advantages  from  the  operation.  Fluid  faeces  are  constantly 
coming  away  from  the  opening,  and  the  patient  is  rendered  more 
or  less  of  a  chronic  invalid  while  the  opening  is  maintained. 
Moreover,  a  caecostomy  opening  is  sometimes  very  difficult  to  close, 
and  may  become  permanent.  i  -, 

Appendicostomy  or  Valvular  Caecostomy.- — By  this  is  meant 
establishing  an  opening  into  the  caecum  through  which  the  colon 
can  be  washed  out.  This  operation  is  open  to  none  of  the  objec- 
tions of  caecostomy  or  colotomy.  If  properly  made  the  opening 
does  not  leak  at  all  and  causes  the  patient  no  inconvenience 
whatever  ;  moreover,  it  can  be  closed  at  any  time  without  an  opera- 
tion. It  is  practically  free  from  risk  in  experienced  hands,  and  the 
patient  is  in  no  way  prevented  from  attending  to  his  ordinary 
occupation. 

The  Operation  of  Ajytendicostomy. — The  operation  is  performed 
as  follows  :  An  oblique  incision  is  made  over  McBurney's  point 


572        The  Surgical  Treatment  of  Colitis. 

in  the  same  way  as  in  the  ordinary  operation  for  appendicectomy. 
The  incision  need  only  be  a  short  one,  and  1£  inches  is  often 
sufficient.  The  "  gridiron "  incision  is  an  excellent  one,  the 
muscles  being  split  in  their  length  instead  of  being  divided.  The 
peritoneal  cavity  is  opened  and  the  appendix  found."  The  rneso- 
appendix  is  then,  if  necessary,  divided  close  to  the  appendix 
for  from  ^  to  1  inch,  depending  upon  the  length  of  the  appendix  ; 
but  in  any  case  care  should  be  taken  not  to  sever  the  artery  of  the 
appendix.  If  it  is  cut  there  is  risk  of  the  appendix  sloughing 
through  lack  of  adequate  blood  supply.  The  appendix  is  then 
brought  out  of  the  wound  and  pulled  up  until  the  c<ecal  wall  comes 
well  up  against  the  parietal  peritoneum.  One  or  two  catgut  sutures 
are  inserted,  so  as  to  anchor  the  csecal  wall  to  the  fascia  and 
parietal  peritoneum.  Two  or  three  stitches  will  then  suffice  to 
close  the  remainder  of  the  wound.  Lastly,  a  single  stitch  should 
be  passed  through  the  wall  of  the  appendix,  so  that  it  can  be 
anchored  to  the  skin  and  prevented  from  retracting.  The  dressings 
are  then  applied  and  the  operation  is  finished.  In  applying  the 
dressings  a  roll  of  gauze  should  be  placed  on  each  side  of  the 
appendix  to  prevent  the  blood  supply  being  damaged  by  the  pressure 
of  the  bandage. 

If  there  is  any  doubt  about  the  patency  of  the  appendix  it  should 
be  opened  at  once,  but  if  it  is  large  and  healthy  it  may  be  left,  and 
opened  two  or  three  days  later. 

In  performing  the  operation,  and  especially  in  closing  the  wound, 
the  importance  of  preserving  the  blood  supply  of  the  appendix 
should  be  borne  in  mind. 

On  the  second  or  third  day  after  operation  the  dressings  should 
be  removed  and  the  appendix  should  be  cut  off  about  i  to  ^  inch 
from  the  skin.  It  is  better  not  to  cut  it  flush  with  the  skin.  An 
appendicostomy  catheter  (No.  7  or  No.  10)  can  then  be  passed  into 
the  caecum  through  the  stump  of  the  appendix,  and  irrigation 
commenced.  Later,  any  mucous  membrane  that  projects  above  the 
skin  level  can  be  cut  away,  but  it  is  advisable  in  doing  this  to  cut 
one  half  at  a  time  or  to  dissect  out  the  mucous  membrane  and 
suture  it  to  the  fibrous  coat  of  the  appendix  stump  or  to  the  skin. 
When  the  appendix  is  cut  through  the  mucous  membrane  tends  to 
retract  into  the  abdomen,  and  this  if  not  detected  will  destroy  the 
opening.  In  dividing  the  appendix,  therefore,  care  must  be  taken 
to  prevent  the  mucous  membrane  retracting.  Some  surgeons  get 
over  this  difficulty  by  passing  a  catheter  into  the  appendix  and 
ligaturing  the  appendix  on  to  it  flush  with  the  skin.  In  a  few  days 
the  ligature  cuts  through  and  the  catheter  can  be  withdrawn.  The 


The  Surgical  Treatment  of  Colitis.        573 

objection  to  this  is,  that  if  the  catheter  is  at  all  a  tight  fit  it 
may  cause  the  mucous  membrane  to  slough  from  the  pressure 
it  exerts. 

If  the  appendix  is  cut  off  at  or  soon  after  the  operation,  a  certain 
amount  of  superficial  suppuration  in  the  wound  will  probably 
occur,  and  this  often  leads  to  some  stricture  at  the  orifice.  The 
catheter  should  only  be  inserted  in  the  canal  for  irrigation.  The 
fluid  used  for  irrigation  of  the  colon  through  the  appendix  should 
be  plain  water.  Very  weak  solutions  of  argyrol  or  protargol  may 
be  used  (about  0'5  per  cent.),  but  ordinary  antiseptics  are  not 
permissible,  as  a  large  amount  of  absorption  takes  place  in  the 
colon. 

It  may  happen  that  at  the  operation  the  appendix  is  found  to  be 
diseased,  deformed  or  rudimentary  ;  in  such  cases  considerable 
modification  of  the  technique  will  be  necessary,  and  in  some  cases 
it  may  not  be  possible  to  utilise  the  appendix  at  all.  Under  these 
circumstances  it  should  be  removed  and  some  form  of  valvular 
caecostomy  should  be  performed. 

Valvular  Ccecostomy. — A  small  opening  is  made  in  the  wall  of 
the  caecum  just  large  enough  to  admit  the  end  of  a  No.  10  rubber 
catheter.  The  end  of  the  catheter  is  passed  through  this  hole  for 
about  f  of  an  inch.  A  series  of  Lembert  sutures  is  then  commenced, 
well  beyond  the  hole,  and  continued  over  the  catheter  for  about 
1£  inches.  These  should  be  so  placed  that,  when  they  are  tied  up, 
the  catheter  will  be  buried  in  the  wall  of  the  csecum  for  about 
1  inch.  That  part  of  the  ceecal  wall  through  which  the  catheter 
passes  is  then  anchored  firmly  to  the  bottom  of  the  wound,  the 
base  of  the  catheter  is  brought  out  of  the  wound,  and  the  remainder 
of  the  wound  is  closed. 

This  makes  a  very  good  opening  which  does  not  leak,  but  it  is 
necessary  that  a  small  rubber  plug  should  be  worn  to  prevent  the 
opening  from  contracting.  In  any  case  the  opening  should  not  be 
closed  too  hastily,  and  at  least  nine  months  should  be  allowed  to 
elapse.  If  at  the  end  of  this  time  there  has  been  no  recurrence  of 
the  symptoms,  the  opening  may  be  allowed  to  close.  This  it  will 
do,  as  a  rule,  by  the  skin  healing  over  it.  If  it  is  allowed  to  close 
in  this  manner  there  will  be  no  difficulty  in  reopening  it  later  if 
necessary. 

As  a  rule,  the  symptoms  rapidly  clear  up  and  the  improvement 
in  the  patient's  general  condition  is  quite  remarkable. 

Other  operations  which  have  been  suggested  for  this  condition 
are  ileo-sigmoidostomy  and  left  inguinal  colotomy.  The  latter  is 
quite  useless  and  unjustifiable,  as  it  does  not  get  above  the  disease. 


574        The  Surgical  Treatment  of  Colitis. 

Ileo-sigmoidostomy  is  a  serious  operation  and  leads  to  considerable 
trouble  later,  owing  to  the  accumulation  of  faecal  material  in  the 
occluded  colon. 


KUEMORRHAGIC   COLITIS. 

This  is  a  most  serious  disease  characterised  by  profuse  and 
intractible  diarrhoea,  much  blood  in  the  stools  and  a  high 
temperature.  It  is  an  acute  condition,  and  due,  at  any  rate  in 
some  cases,  to  a  primary  infection  by  the  diplococcus  pneurnonise. 
Dangerous  anaemia  and  emaciation  occur  rapidly  and  any  tem- 
porising with  palliative  measures  is  contra-indicated.  The  con- 
dition can  be  diagnosed  with  certainty  by  a  sigmoidoscopic  exami- 
nation. The  best  treatment  is  immediate  appendicostomy,  and  the 
colon  should  then  be  washed  out  with  water  or  a  weak  solution  of 
Witch  hazel  until  the  solution  leaves  the  anus  quite  clean.  The 
colon  should  then  be  washed  out  every  few  hours  until  all  bleeding 
has  stopped,  after  which  it  may  be  washed  out  twice  daily. 

This  treatment  rapidly  controls  the  haemorrhage  and  gets  rid  of 
the  poisons  which  are  being  absorbed  from  the  colon. 

PERICOLITIS. 

By  this  we  mean  an  inflammation  (usually  chronic)  around  the 
colon.  In  the  characteristic  condition  there  is  much  thickening 
(often  tumour  formation)  and  stricture,  and,  in  addition,  there  may 
be  abscess  formation.  This  condition  often  gives  rise  to  much  diffi- 
culty in  diagnosis,  as  it  is  easily  mistaken  for  inoperable  cancer.  In 
the  more  acute  form  it  closely  resembles  in  symptomology  chronic 
appendicitis,  except  that  the  locality  is  different.  Pericolitis  may 
call  for  operation  for  any  of  the  following  reasons :  (1)  Stricture 
of  the  colon ;  (2)  tumour  formation  with  or  without  stricture ; 
(3)  abscess  formation  ;  (4)  perforation  and  peritonitis. 

When  there  is  a  stricture  with  tumour  formation  the  condition 
may  so  closely  resemble  an  inoperable  cancer  that  it  can  only  be 
distinguished  by  microscopical  examination,  and  many  of  the  cases 
in  which  patients  apparently  suffering  from  cancer  of  the  bowel  have 
recovered  after  colotomy  or  exploratory  laparotomy  have  been 
cases  of  this  description. 

When  stricture  or  a  tumour  due  to  pericolitis  has  been  diagnosed 
the  best  treatment,  in  fact  the  only  treatment,  is  operation.  The 
affected  portion  of  bowel  should  be  resected  and  the  ends 
anastomosed  or  brought  out  and  Paul's  tubes  tied  into  them. 
While  the  former  is  the  ideal  operation,  the  latter  is  the  safer 


The  Surgical  Treatment  of  Colitis. 


575 


operation,    and   should   be  preferred  when  the  patient's  condition 
causes  anxiety. 

Very  good  results  also  follow  operations  in  which  the  affected 
portion  of  colon  is  short-circuited  by  lateral  anastomosis,  and  this 
operation  should  be  chosen  in  place  of  resection,  when,  owing  to 


FIG.  1. — X-ray  photograph  showing  a  stricture  in  the  pelvic  colon 
due  to  pericolitis  ;  note  the  narrow  lumen  and  diverticulae  which 
have  caused  the  condition. 

surrounding  adhesions  or  fixation  of  the  colon,  resection  is  likely 
to  be  attended  with  much  difficulty. 

Localised  Abscess.  -The  obvious  treatment  is  to  open  the 
abscess  and  adequately  drain  it,  while  at  the  same  time  preserving, 
as  far  as  possible,  the  natural  adhesions  which  are  protecting  the 
general  peritoneal  cavity.  The  abscess  may  be  very  extensive,  and 
in  order  to  establish  adequate  drainage,  counter-openings  in  the 


576        The  Surgical  Treatment  of  Colitis. 

loin  may  be  required  (see  also  Subphrenic  Abscess,  p.  643).  Much 
difficulty  may  be  experienced  in  locating  the  abscess  owing  to 
dense  and  extensive  adhesions. 

Perforation  and  General  Peritonitis. — In  these  cases,  though 
a  careful  toilet  of  the  peritoneum  and  the  establishment  of  adequate 
drainage  may  suffice,  it  is  advisable,  if  possible,  to  find,  and  close 
by  sutures,  the  perforation  in  the  colon.  Where  the  perforation  is 
due  to  the  rupture  or  sloughing  of  a  diverticulum  it  may  not  be 
single,  or  other  diverticula  may  be  so  nearly  in  the  same  condition 
as  to  threaten  to  perforate.  Also  when,  as  often  happens,  the  per- 
foration has  occurred  in  a  dense  mass  of  fibrous  tissue  and  adhesions, 
very  great  difficulty  may  be  experienced  in  closing  the  perforation. 

ULCERATIVE  COLITIS. 

I  do  not  propose  here  to  deal  with  tropical  dysentery,  but  only 
with  ulcerative  colitis  as  seen  in  this  country.  The  condition  is  a 
very  serious  one,  and  until  quite  recently,  had  a  mortality  of  over 
50  per  cent.  The  diagnosis  is  readily  made  by  means  of  the 
sigmoidoscope ;  it  need  hardly  be  said,  however,  that  in  these  cases 
the  instrument  should  only  be  employed  by  an  expert  in  its  use. 

Immediate  operation  is  indicated  in  all  cases,  as  although  some 
cases  recover  without  operation,  recovery  under  these  circumstances 
is  slow  and  tedious  and  recurrences  are  frequent. 

There  are  two  methods  of  treatment  by  operation  :  (1)  The 
formation  of  an  artificial  anus  in  the  caecum  to  give  rest  to  the 
colon  ;  (2)  appendicostomy  and  irrigation  of  the  colon. 

Ileo-sigmoidostomy  has  also  been  suggested,  but  as  it  will  almost 
certainly  involve  performing  an  anastomosis  with  ulcerated  bowel, 
it  is  contra-indicated.  Moreover,  apart  from  this,  the  patient  is 
seldom  in  a  condition  to  stand  so  serious  an  operation. 

A  right-sided  colotomy  usually  causes  arrest  of  the  ulcerative 
process,  and  good  results  follow  the  operation,  but  it  is  not  always 
possible  to  close  the  opening  and  the  operation  leaves  a  most 
objectionable  condition. 

By  far  the  best  operation  for  these  cases  is  appendicostomy, 
and  this  operation  has  given  excellent  results ;  the  ulcers  quickly 
heal  and  the  diarrhoea  is  controlled.  It  acts  in  two  ways  ;  by 
keeping  the  ulcerated  areas  clean  it  enables  healing  to  occur,  and 
by  removing  from  the  colon  the  poisonous  products  of  inflammation 
and  decomposition  it  prevents  their  absorption.  It  has  none  of 
the  disadvantages  of  a  right-sided  colotomy,  and  the  results  are 
even  better. 

The  operation  should  be   performed  as  early  as  possible  before 


The  Surgical  Treatment  of  Colitis.        577 

the  patient  has  become  seriously  emaciated,  though  it  will  often 
save  life  even  when  done  as  a  last  resort. 

For  a  description  of  the  operation  the  reader  is  referred  to  the 
article  on  Mucous  Colitis. 

The  colon  should  at  first  be  washed  out  at  frequent  intervals 
and  later,  when  the  diarrhoea  has  been  controlled,  twice  daily.  At 
first  some  astringent,  such  as  Witch  hazel,  may  be  added  to  the 
water  used  for  irrigation,  or  a  weak  silver  solution  may  be  tried, 
such  as  5  per  cent,  argyrol  or  protargol,  but  only  a  small  quantity 


FIG.  3. — Ulcers  in  the  colon,  as  the 
result  of  chronic  constipation 
in  an  old  woman. 
(From  Mummery's  "  Sigm'oidoscope,"  Bailliere.) 


FIG.  2. — Ulcerative  Colitis,  us  seen 
through  the  Sigmoidoscope. 


should  be  used,  say  \  pint,  and  it  should  be  washed  out  again  in  ten 
minutes  with  plain  warm  water. 

When  the  symptoms  have  all  cleared  up,  the  irrigation  may  be 
stopped,  but  the  opening  should  be  kept  patent  for  at  least  nine  or 
ten  months. 

P.  LOCKHART  MUMMERY. 


REFERENCE 

"  Discussion  on  Ulcerative  Colitis,"  Prop.  Roy.  Soc.  of  Med.,  1909,  II.  (Med. 
Sect.),  pp.  59—99. 


S.T. — VOL.   II. 


37 


578 


CANCER   OF  THE   COLON. 

CANCER  of  the  colon  may  be  very  successfully  treated  by  opera- 
tion, and  excellent  results  can  be  obtained  as  regards  both  the 
subsequent  comfort  of  the  patient  and  freedom  from  recurrence  of 
the  growth. 

Growths  of  the  colon  tend  to  remain  localised  in  the  bowel  wall 
for  a  long  time  and  do  not  readily  cause  secondary  involvement  of 

glands.  They  increase  slowly,  and 
but  seldom,  and  only  in  their  later 
stages,  give  rise  to  metastatic  deposits 
in  other  parts  of  the  body.  They  do 
not  readily  become  adherent  to  im- 
portant organs,  though  an  exception 
to  this  statement  must  be  made  in 
the  case  of  growths  of  the  transverse 
colon,  which  frequently  involve  the 
stomach.  Large  portions  of  the 
colon  can  be  removed  without 
causing  the  patient  any  serious  sub- 
sequent inconvenience  or  preventing 
him  from  enjoying  life. 

The  most  important  factor,  as  in 
cancer  anywhere  else  in  the  body,  is  early  diagnosis.  Our  methods 
of  diagnosing  cancer  of  the  bowel  have  much  improved  in  recent 
years,  and  it  is  now  the  exception  for  a  growth  to  reach  a  large 
size  before  it  is  recognised.  Perhaps,  fortunately,  cancer  of  the 
colon  draws  attention  to  itself  at  an  early  stage  by  producing 
obstruction.  In  many  cases  cancer  is  first  detected  at  an  operation 
undertaken  for  the  relief  of  obstruction.  (For  the  treatment  of 
Acute  Intestinal  Obstruction  the  reader  is  referred  to  p.  528.) 

I  shall  deal  here  only  with  those  cases  in  which  cancer  of  the 
colon  has  been  diagnosed  or  is  suspected,  and  cases  in  which  an 
operation  is  undertaken  on  account  of  chronic  obstruction  in  the 
colon. 

When  there  is  chronic  obstruction  the  choice  of  method  must 
depend  upon  whether  or  not  it  is  possible  to  empty  entirely  the 
bowel  above  the  stricture.  If  it  is  possible  by  means  of  aperients 
satisfactorily  to  empty  the  bowel,  and  the  surgeon  is  certain  that 


FIG.   1. — Cancer   of  the   colon,   as 
seen  through  the  Sigmoidoscope. 
(From    Mummery's    "  Sigmoido- 
scope," Bailliere). 


Cancer  of  the  Colon.  579 

there  is  no  accumulation  of  faecal  material  above  the  growth,  then 
resection  of  the  growth  and  immediate  end-to-end  or  lateral 
anastomosis  of  the  bowel  is  indicated. 

But  if  the  bowel  cannot  be  so  emptied  the  case  should  be  treated 
in  the  same  way  as  if  acute  obstruction  existed,  viz.,  by  removal  of 
the  growth  and  the  establishment  of  a  temporary  artificial  anus,  or 
by  simple  colotomy  above  the  growth.  This,  though  it  entails  the 
patient  undergoing  at  least  two  operations,  is  infinitely  safer  than 
performing  an  anastomosis  with  an  accumulation  of  faeces  above 
the  line  of  suture. 

An  operation  for  cancer  of  the  colon  should  aim  at  removal  of 
the  growth,  and  also  of  the  whole  of  the  neighbouring  lymphatic 
area.  This  can  be  done  without  serious  difficulty  in  most  parts  of 
the  colon,  but  it  often  entails  sacrificing  considerable  lengths  of 
bowel  in  order  to  preserve  the  blood  supply.  The  bowel  should  be 
divided  at  least  2  inches  away  from  the  growth,  both  above  and 
below.  Also,  a  large  wedge-shaped  portion  of  the  mesocolon 
should  be  removed,  together  with  the  growth  ;  and  if  any  enlarged 
glands  are  discovered  in  the  root  of  the  mesentery  the  peritoneum 
should  be  stripped  up  and  the  fat  and  lymphatics  cleared  out  as 
freely  as  possible.  Glands  should  be  looked  for  along  the  inferior 
mesenteric  artery,  as  the  main  chain  of  lymphatic  glands  lies  in 
close  relation  to  this  vessel. 

The  mere  fact  that  the  growth  is  large  is  no  contra-indication  to 
its  removal ;  adhesions,  also,  are  not  necessarily  contra-indications, 
provided  that  they  do  not  involve  important  structures  which 
cannot  be  dealt  with.  Portions  of  the  stomach  and  bladder  have 
been  successfully  removed,  together  with  the  growth,  without 
serious  consequences.  Other  portions  of  bowel  adherent  to  the 
growth  can  be  dealt  with  by  resection.  It  is  well  to  remember 
that  all  enlarged  glands  in  the  neighbourhood  of  a  growth  are  not 
malignant.  There  have  been  several  instances  in  which  a  growth 
of  the  colon  has  been  removed  and  enlarged  glands  left  behind,  in 
which  no  recurrence  has  taken  place. 

Methods  of  Dealing  with  the  Colon  after  Resection  of  the 
Growth. — There  is  considerable  choice  of  methods,  and  the  one 
selected  must  depend,  to  a  large  extent,  upon  the  conditions  present. 

(1)  Immediate  Anastomosis. — This  should  only  be  performed 
when  we  are  quite  certain  that  the  bowel  above  the  point  of  union 
is  free  from  any  collection  of  faeces.  The  bowel  may  be  joined 
either  by  end-to-end  or  by  lateral  anastomosis.  End-to-end 
anastomosis  is  only  suitable  when  dealing  with  the  pelvic  colon. 
The  ends  of  the  bowel  are  controlled  by  clamps  and  brought  out  of 

37—2 


580  Cancer  of  the  Colon. 

the  abdomen.  Any  mucous  membrane  which  projects  beyond  the 
other  coats  is  trimmed  off,  and  then  the  two  mesenteric  edges  are 
carefully  stitched  together  by  a  suture  taking  up  all  the  coats. 
The  sutures  are  then  continued  round  each  side  of  the  bowel  until 
they  meet  at  a  point  opposite  the  mesocolon.  The  knots  should  be 
tied  on  the  inner  aspect  of  the  bowel.  When  this  line  of  suture  is 
completed,  another  uniting  the  peritoneal  coats  only  is  inserted. 
Lastly,  the  two  edges  of  the  mesocolon  are  sewn  together. 

Lateral  anastomosis  is  performed  in  the  same  way  as  for  the 
small  bowel.  Most  of  the  failures  which  occur  after  anastomosis  of 
the  colon  are  due  to  sloughing,  owing  to  the  blood  supply  having 
been  damaged,  and  great  care  must  be  taken  to  see  that  there  is  an 
adequate  blood  supply  to  the  edges  of  the  anastomosed  bowel. 

(2)  A  Preliminary  Short-Circuiting  Operation  followed  by  Excision. 
—This  is  a  less  severe   operation    than   immediate   anastomosis, 

but  entails  two  operations.  A  portion  of  the  colon  above  the 
growth  should  be  united  to  a  portion  below  by  lateral  anasto- 
mosis, care  being  taken  to  go  well  wide  of  the  growth  or  difficulty 
will  be  met  with  when  the  growth  is  removed.  The  second  opera- 
tion should  be  performed  three  weeks  later ;  the  growth  is  removed 
and  the  ends  of  the  bowel  are  closed. 

(3)  Paul's  Operation. — This  consists  in  bringing  the  two  ends  of 
the  bowel  out  of  the  abdomen  after  resection,  and  tying  a  glass 
tube  into  each.     The  two  ends  of  bowel  are  joined  side  by  side 
with  sutures  for    about    2    inches.     A   fortnight  later    the   spur 
between  the  two  ends  of  bowel  is  destroyed  by  an  enterotome  and 
the  opening  allowed  to  close.     This  operation,  though  it  entails  a 
temporary  colotomy,  is  by  far  the  safest  method,  and  has  a  very 
low  mortality. 

Excision  of  Growths  in  the  Csecal  Region. — These  lend  them- 
selves readily  to  extensive  resection,  as  the  entire  caecal  angle  of 
the  colon  can  be  freed  and  removed  together  with  the  growth. 
Any  attempts  to  resect  portions  of  the  caecum  will  probably  end  in 
failure,  both  as  regards  removal  of  the  disease  and  also  satisfactory 
restoration  of  the  parts.  The  best  method  of  dealing  with  the 
bowel  after  resection  is  to  implant  the  ileum  into  the  ascending 
colon  after  closing  the  latter. 

Palliative  Operations. — Even  when  the  growth  cannot  be 
removed  much  may  be  done,  by  the  performance  of  a  suitable 
operation,  to  render  the  patient  more  comfortable  and  to  prolong 
his  life.  The  operations  which  may  be  performed  for  this  purpose 
are : 

(1)  Excision  of  as  much  of  the  growth  as  possible. 


Cancer  of  the  Colon.  581 

(2)  Short-circuiting  the  growth. 

(3)  Making  an  artificial  anus  above  the  growth. 

Some  surgeons  have  advised  that,  even  when  it  is  found  at  the 
operation  that  there  are  glands  which  cannot  be  removed,  or 
metastatic  deposits  in  the  liver,  the  best  plan  still  is  to  excise  the 
primary  growth,  and  that  this  will  give  the  patient  a  longer  lease 
of  life  than  short-circuiting.  There  is  a  good  deal  to  be  said  for 
this  view.  If  the  primary  growth  can  be  easily  removed  without 
much  danger  to  the  patient,  this  is  probably  the  best  treatment ; 
but  it  does  not  seem  right  to  subject  the  patient  to  a  dangerous  and 
prolonged  operation  if  there  are  secondary  deposits  already  present. 
Short-circuiting  the  growth  is  undoubtedly  the  best  method  when 
it  is  found  that  excision  is  impossible.  It  obviates  the  danger  of 
obstruction  and  saves  the  patient  from  the  discomforts  of  a 
colotomy. 

Colotomy  above  the  growth  should  only  be  performed  when  there 
is  acute  obstruction,  or  when  short-circuiting  is  impossible  owing 
to  the  growth  being  too  low  in  the  pelvis  to  leave  any  bowel  below 
it,  with  which  an  anastomosis  can  be  established. 

COLOTOMY. 

The  commonest  form  of  colotomy  is  left  inguinal  colotomy. 
There  are  a  few  cases,  however,  in  which  lumbar  colotomy 
is  more  suitable,  and  this  operation  will  also  be  described. 
Transverse  colotomy  does  not  differ  in  any  important  particular 
from  the  left  inguinal  operation.  "When  it  is  necessary  to  establish 
an  opening  into  the  right  side  of  the  colon,  caecostorny  or  a  right 
lumbar  colotomy  is  performed :  the  latter  is  preferable,  as  the 
control  obtained  is  better. 

Left  Inguinal  Colotomy. — A  small  vertical  incision  is  made 
through  the  abdominal  wall  over  the  junction  of  the  middle  and 
outer  thirds  of  the  left  rectus  muscle,  and  with  its  upper  end  just 
below  the  level  of  the  umbilicus.  The  fibres  of  the  rectus  muscle 
are  separated  with  a  blunt  instrument  and  the  posterior  sheath  of 
the  muscle  and  peritoneum  divided.  Through  this  opening  a  loop 
of  sigmoid  is  pulled  out.  The  bowel  is  then  pulled  down  until 
that  portion  nearest  to  the  descending  colon  which  can  be  made  to 
reach  the  opening  is  found,  and  this  is  used  to  form  the  colotomy. 
A  spur ''is  now  made,  either  by  means  of  a  mattress-stitch  passed 
through  the  meso- sigmoid,  or  preferably  by  a  glass  rod  or  a  clip 
which  is  passed  through  the  meso- sigmoid  and  allowed  to  rest  on  the 
skin  on  each  side  of  the  wound.  A  stitch  is  passed  through  the  skin 
at  the  end  of  the  incision  and  through  the  anterior  longitudinal 


582 


Cancer  of  the  Colon. 


band.  Such  a  stitch  should  be  inserted  at  both  ends  of  the  wound, 
to  anchor  the  bowel  and  prevent  any  further  prolapse.  Unless  a 
large  incision  has  been  made,  one  stitch  at  each  end  is  usually 
sufficient.  If  there  are  any  large  appendices  epiploicas,  they  should 
be  ligatured  and  removed. 

In  many  text-books  the  position  for  the  incision  is  given  as  the 
junction  of  the  middle  and  outer  thirds  of  a  line  between  the 
umbilicus  and  the  left  anterior  superior  spine.  While  this  incision 
is  directly  over  the  colon,  it  has  the  disadvantage  that  afterwards, 


l-lG.2. — Method  of  performing  inguinal  colotomy,  using  a  clip  to 
form  the  spur.     (From  Mummery's  "  Dis.  Colon,"  Wright.) 


when  a  cup  has  to  be  fitted  over  the  colotomy  opening,  the  end  of 
the  cup  tends  to  ride  up  on  the  iliac  crest  as  the  patient  walks  or 
moves,  and  this  results  in  leakage  and  discomfort. 

The  bowel  is  usually  opened  on  the  second  day  after  operation. 
No  anaesthetic  is  required  for  this  purpose.  A  small  transverse  cut 
is  made  into  the  bowel  with  a  pair  of  scissors.  An  alternative 
method  which  makes  it  possible  to  keep  the  wound  clean  until 
healing  is  almost  complete,  and  which  also  is  preferable  if  it  is 
advisable  to  open  the  colon  at  once,  is  to  tie  a  Paul's  tube  into  the 
bowel.  Eight  days  after  operation  the  bowel  should  be  completely 


Cancer  of  the  Colon.  583 

divided   by   cutting   it   right   across,  and   at   the  same  time   any 
redundant  bowel  projecting  above  the  skin  can  be  cut  off. 

Several  new  methods  of  performing  colotomy  have  been  devised 
with  the  object  of  giving  the  patient  better  control  over  the  open- 
ing. The  earliest  of  these  consisted  in  giving  a  twist  to  the  bowel 
above  the  opening,  or  in  stricturing  it  by  means  of  a  ligature ; 
these,  however,  did  not  prove  satisfactory,  and  have  been  abandoned. 
Witzel  was  the  first  to  suggest  making  a  valvular  opening  in  the 
abdominal  wall.  This  was  done  as  follows :  A  loop  of  sigmoid 
colon  was  first  brought  out  through  the  usual  colotomy  incision, 
and  another  smaller  incision  was  made  below  the  pelvic  brim.  A 
space  was  then  opened  up  between  these  two  incisions  by  separating 
the  internal  and  external  oblique  muscles,  and  the  loop  of  bowel  was 
dragged  through  this  space  and  stitched  to  the  skin  at  the  lower 
opening,  the  upper  opening  being  completely  closed. 

Bailey's  modification  of  this  method  consists  in  opening  up  a 
space  between  the  skin  and  external  oblique  muscle,  and  bringing 
the  colon  out  through  an  incision  just  above  Poupart's  ligament. 

The  writer's  experience  of  these  methods  of  valvular  colotomy 
is  that  they  give  no  better  control  than  the  operation  already 
described,  as  the  opening  tends  after  a  short  time  to  straighten  out 
and  the  valvular  arrangement  is  obliterated.  Also,  they  result  in 
the  opening  being  very  inconveniently  placed. 

Lumbar  Colotomy. — The  patient  is  laid  upon  his  side  with  a 
firm  cushion  or  sand-bag  under  the  loin,  in  order  to  flex  the  trunk 
sideways  and  open  out  the  space  between  the  last  rib  and  the  iliac 
crest.  The  position  of  the  colon  is  indicated  by  a  vertical  line 
drawn  upwards  from  a  point  ^  inch  behind  the  mid-point  between 
the  anterior  and  posterior  superior  spines  of  the  ileum. 

An  oblique  incision  is  made,  with  its  centre  over  this  line  and 
midway  between  the  last  rib  and  the  crest  of  the  ilium.  The 
incision  should  be  about  3  inches  long.  The  anterior  edge  of  the 
quadratus  lumber um  should  be  exposed  in  the  back  of  the  incision, 
and,  if  necessary,  partly  divided.  The  wound  is  then  deepened 
until  the  transversalis  fascia  is  met  with.  On  dividing  this  the 
cellular  tissue  and  fat  are  seen,  and  when  these  are  separated  the 
back  of  the  colon  will  be  exposed  in  the  bottom  of  the  wound. 
The  colon  is  pulled  up  into  the  wound  and  fixed  to  the  skin  by 
sutures  all  round,  an  oval  surface  of  colon  being  left  exposed.  If  it 
should  be  necessary  to  open  the  colon  at  once,  a  Paul's  tube  or  one 
of  the  writer's  rubber  tubes  should  be  tied  in,  otherwise  the  colon 
is  opened  by  a  longitudinal  incision  at  the  end  of  twenty-four 
hours. 


584  Cancer  of  the  Colon. 

If  the  colon  is  found  to  have  a  mesentery,  and  it  is  not  possible 
to  expose  it  extra-peritoneally,  the  peritoneum  should  be  opened  in 
front  of  the  colon  and  the  bowel  brought  out  in  the  same  way  as  in 
performing  inguinal  colotomy.  The  colon  is  more  likely  to  have 
a  mesentery  on  the  right  than  on  the  left  side. 

Colotomy  by  Paul's  Method. — This  is  frequently  the  best 
and  safest  method  of  dealing  with  the  bowel  after  resection  of  part 
of  the  colon. 

The  colon  is  exposed  and  brought  out  of  the  wound  in  the  same 
way  as  in  performing  inguinal  colotomy.  The  wound  having  been 
first  shut  off  by  gauze  packing,  the  colon  is  divided,  and  a  Paul's 
glass  tube  of  suitable  size  tied  into  each  end  by  a  silk  ligature. 
The  two  portions  of  colon  are  then  sewn  together  side  by  side  for 
about  2  inches  of  their  length  with  silk  sutures,  with  the  object  of 
ensuring  the  walls  being  in  contact  later,  when  the  enterotome 
is  used. 

The  tubes  come  away  in  about  a  week,  and  some  three  weeks 
later  the  spur  is  destroyed  by  means  of  an  enterotome.  After  the 
spur  has  been  destroyed,  the  continuity  of  the  bowel  is  re-established, 
but  a  faecal  fistula  still  remains,  which  in  course  of  time  usually 
closes  of  itself ;  but  it  may  be  many  months  before  this  occurs, 
and  it  is  better,  as  a  rule,  to  close  it  by  operation. 

Caecostomy. — This  operation  is  performed  when  it  is  not  possible 
to  perform  colotomy,  or  when  a  colotomy  opening  will  not  be  above 
the  seat  of  obstruction.  It  is  also  sometimes  done  to  deflect  the 
faecal  current  from  the  colon  in  cases  of  ulcerative  colitis. 

The  caecum  is  exposed  through  an  oblique  incision,  the  centre  of 
which  lies  over  a  point  halfway  between  the  umbilicus  and  the 
right  anterior  superior  spine  of  the  ileum.  The  anterior  wall  of 
the  caecum  is  drawn  out  of  the  wound,  and  a  small  circular  area  of 
the  caecal  wall  about  |  inch  in  diameter  is  enclosed  in  a  purse- 
string  suture.  This  portion  of  the  caecal  wall  is  then  held  up  by 
an  assistant,  and  a  small  incision  into  the  caecum  is  made  in  the 
centre  of  the  circular  area ;  through  this  one  end  of  a  Paul's  tube 
is  pushed,  and  the  purse-string  suture  is  then  tied  firmly  on 
to  the  tube.  The  caecal  wall  is  stitched  into  the  wound  and  the 
latter  closed,  leaving  the  Paul's  tube  projecting. 

Owing  to  the  liquid  nature  of  the  contents  of  the  caecum,  the 
control  over  this  opening  is  very  unsatisfactory,  and  the  surround- 
ing skin  often  becomes  sore  and  excoriated.  This  may  to  some 
extent  be  prevented  by  keeping  the  parts  well  greased  with  lanolin. 

P.  LOCKHART  MUMMERY. 


585 


CONGENITAL   ABNORMALITIES    OF   THE   COLON. 

VERY  few  congenital  abnormalities  of  the  colon  can  be  diagnosed 
during  life  or  are  within  the  scope  of  surgical  interference  when 
detected.  Congenital  abnormalities  of  the  mesocolon  are  an 
important  cause  of  volvulus,  but  their  treatment  falls  under  that 
heading.  The  only  condition  which  we  need  consider  in  detail 
is  congenital  dilatation  and  hypertrophy  of  the  colon  (some- 
times called  "  Hirschsprung's  Disease  ")• 

When  treating  cases  of  this  condition  it  is  necessary  to  remember 
that  we  have  to  deal  with  a  colon  which  has  become  converted  into 
an  enormous  sac,  often  6  or  8  inches  in  diameter,  and  that 
this  dilated  colon  is  acting  as  a  cesspool  for  faecal  material.  The 
symptoms  calling  for  treatment  are  usually  those  of  obstruction 
due  to  the  outlet  from  the  sac  having  become  blocked  or  to  the 
formation  of  a  mass  of  hard  faecal  material  which  cannot  be 
passed  on. 

J[7/<'»  xtittiptoms  of  acute  obstruction  hare  occurred  every  effort 
should  be  made  to  relieve  the  obstruction  without  resorting  to 
operation,  for  colotorny  usually  proves  fatal,  as  the  weight  and  size 
of  the  colon  cause  the  stitches  to  tear  out.  In  the  vast  majority  of 
cases,  if  not  in  all,  the  obstruction  can  be  relieved  by  repeated 
large  enemata  injected  into  the  bowel,  and  this  treatment  should  be 
persisted  in  until  the  obstruction  has  been  removed.  If  the  dilata- 
tion extends  down  to  the  rectum  the  mass  of  faeces  can  sometimes 
be  broken  up  by  the  fingers  or  instruments,  assisted  by  enemata. 
In  some  cases  the  administration  of  an  anaesthetic  has  relieved 
the  obstruction,  probably  owing  to  the  relief  of  spasm,  and  if 
enemata  alone  fail,  this  should  be  tried. 

We  have  also  to  consider  how  this  disease  can  be  treated  apart 
from  the  obstruction  to  which  it  gives  rise. 

Non-Operative  Treatment. — The  non-operative  treatment  of 
this  condition  consists  principally  in  getting  the  bowels  to  act  regu- 
larly by  the  administration  of  enemata  and  aperients.  Aperients 
alone  are  usually  of  little  use,  and  enemata  will  have  to  be  employed. 
Large  enemata,  if  carefully  administered,  will,  in  some  cases,  keep 
the  patient  in  comparative  comfort ;  but  they  will  have  to  be  used 
daily  in  order  to  prevent  accumulation  of  faeces  in  the  dilated 
bowel.  Large  doses  of  magnesium  sulphate  will  sometimes  relieve 


586     Congenital  Abnormalities  of  the  Colon. 

the  constipation  by  rendering  the  contents  of  the  colon  fluid. 
Stimulants  of  the  intestinal  muscle,  such  as  strychnine,  nux 
vomica  and  ergot,  may  be  tried,  and  abdominal  massage  and 
application  of  the  galvanic  current  will  often  allay  the  symptoms 
for  a  time. 

When  these  measures  fail  recourse  must  be  had  to  operation, 
which  in  most  cases  becomes  necessary  sooner  or  later. 

Operative  Treatment. — Whenever  possible  operation  should  be 
avoided  when  there  are  obstructive  symptoms  and  the  dilated  bowel 
is  loaded  with  solid  faeces.  Every  effort  should  first  be  made  to 
empty  the  bowel;  even  then  the  dilated  colon  is  not  easily  dealt 
with,  and  when  loaded  with  many  pounds  of  semi-solid  faeces  the 
greatest  difficulty  may  be  experienced. 

Colotomy. — The  record  of  cases  operated  upon  show  that  the 
mortality  attending  colotomy  for  this  condition  is  very  high, 
higher  in  fact  than  for  any  other  procedure.  Thus,  out  of  four- 
teen cases  collected  by  the  writer,  treated  by  colotomy,  eleven  died. 
This  might  to  some  extent  be  accounted  for  if  the  operation  had 
been  performed  only  for  the  relief  of  acute  obstruction  ;  but  the 
cases  show  that,  even  in  the  cases  in  which  colotomy  was  per- 
formed when  no  acute  symptoms  existed  at  the  time  of  operation, 
it  often  proved  fatal.  Death  occurred  in  most  cases  from  general 
peritonitis  following  the  operation,  and  it  was  found  at  the  post- 
mortem examination  that  the  bowel  had  torn  away  from  the 
abdominal  wall  or  had  leaked  into  the  peritoneal  cavity.  If 
colotomy  has  to  be  performed  on  account  of  obstruction,  the 
lumbar  operation  should  be  done. 

Resection  of  the  Dilated  Portion  of  the  Colon.— This  is  the 
operation  which  has  been  attended  with  the  best  results  in  these 
cases,  and  in  spite  of  the  difficulty  of  resecting  such  an  enormously 
dilated  bowel,  it  has  not  been  attended  by  a  high  mortality. 

In  all  but  two  of  the  collected  cases  in  which  this  operation  was 
performed  the  dilatation  was  confined  to  the  pelvic  colon.  In  one 
case,  however,  the  entire  colon  was  successfully  resected  for  this 
condition. 

When  the  dilatation  is  confined  to  the  sigmoid  flexure,  resection 
of  the  dilated  loop  seems  to  be  the  best  method  of  treatment.  (For 
description  of  operation,  see  Resection  of  Colon.) 

When  the  whole  or  the  greater  portion  of  the  colon  is  involved 
the  operation  is  certain  to  be  attended  by  such  difficulties,  owing  to 
the  size  and  fixity  of  the  bowel,  that  it  is  doubtful  if  it  is  justifiable, 
and  a  preliminary  short-circuiting  operation  is  preferable. 

In  one  case  I  performed  appendicostomy  for  this  condition.    The 


Congenital  Abnormalities  of  the  Colon.      587 

operation  was  done  in  the  hope  of  being  able  to  prevent  accumu- 
lation in  the  distended  sigmoid  by  washing  out  the  whole  colon 
daily  with  water  through  the  appendix.  The  patient,  a  man 
aged  twenty-two,  was  quite  well  between  the  attacks  of  obstruction 
from  which  he  suffered,  and  it  did  not  seem  justifiable  to  subject  him 
to  the  danger  of  excision  of  the  enormous  loop  of  dilated  bowel, 
unless  every  other  method  failed.  After  the  operation  it  was  found 
possible  for  him  to  keep  his  dilated  sigmoid  practically  empty  by 
daily  washing  through  from  the  appendix.  A  year  after  operation 
he  was  still  well. 

It  would  appear  that  this  operation  is  well  worth  trying  before 
proceeding  to  more  serious  measures. 

Ileo-sigmoidostomy  has  been  performed  in  a  few  cases;  but, 
although  it  may  afford  temporary  relief,  it  cannot  cure  the  con- 
dition unless  followed  by  resection  of  the  dilated  loop.  The  opera- 
tion of  narrowing  the  dilated  bowel  by  means  of  Lembert  sutures, 
in  a  similar  manner  to  the  operation  of  gastroplication  for  the 
relief  of  gastric  dilatation,  has  also  been  tried,  but  no  good  results 
have  followed  it.  Fixation  of  the  colon  has  also  been  unsuccessful. 

P.  LOCKHART  MUMMERY. 


KEFERENCES. 

Mummery,  J.  P.  Lockhart,  "  Diseases  of  the  Colon."  Lockwood,  C.  B., 
Brit.  Med.  Journ.,  1882,  II.,  p.  574.  Osier,  S.,  Johns  Hopkins  Hosp.  Bull., 
1893,  IV.,  p.  41. 


588 


MULTIPLE   POLYPI  OF  THE   COLON. 

THIS  is  a  rare  disease  in  which  there  are  large  numbers  of  polypi 
growing  from  the  mucous  membrane  of  the  colon.  As  a  rule,  the 
whole  colon  is  more  or  less  affected.  The  chief  symptoms  are 
bleeding,  profuse  diarrhoea  and  progressive  wasting.  In  most 
cases  the  condition  has  only  been  detected  in  the  rectum,  and  it 
has  been  supposed  that  the  polypi  were  confined  to  this  part  of  the 
bowel,  whereas  they  really  exist  more  or  less  throughout  the  large 
bowel.  Most  of  the  operations  performed  for  this  condition  have 
consisted  merely  in  the  removal  of  as  many  polypi  as  possible  from 
the  rectum.  Needless  to  say,  such  operations  have  done  no  good 
or  have  merely  given  temporary  relief. 

Caecostomy  has  been  performed.  This  was  done  in  Lienthall's 
case,  and  the  patient's  symptoms  were  somewhat  alleviated  ;  but  no 
diminution  in  the  size  or  number  of  the  polypi  resulted.  Colotomy 
does  not  relieve  the  symptoms  and  only  adds  to  the  patient's 
distress. 

The  disease  is  a  very  serious  one  and  there  is  every  probability 
that  cancer  will  develop,  if  it  has  not  already  done  so. 

Under  these  circumstances  any  operation  would  seem  justifiable 
that  affords  a  possibility  of  removing  the  disease.  The  only 
method  that  offers  any  reasonable  prospect  of  dealing  adequately 
with  it  is  resection  of  the  entire  colon.  This  was  done  in 
a  case  of  Lienthall's  after  a  previous  ileo-sigmoidostomy,  and  the 
patient  recovered. 

Unfortunately,  the  rectum  is  usually  affected  together  with  the 
colon,  so  that  the  whole  of  the  disease  cannot  be  removed ;  but  if 
anastomosis  is  made  low  down,  the  polypi  in  the  rectum  can  in 
most  cases  be  removed  later  ;  and,  at  any  rate,  this  operation 
seems  to  be  the  only  one  at  all  worth  considering. 

Eesection  of  a  cancer  of  the  colon  which  is  found  to  be  associated 
with  multiple  polypi  is  apparently  not  worth  performing,  unless  the 
rest  of  the  colon  is  either  removed  at  the  same  time  or  subsequently. 
The  evidence  available  seems  to  show  that  cancer  will  recur  in  some 
other  part  of  the  colon,  if  it  is  not  already  present. 

P.  LOCKHART  MUMMERY. 


589 


PERFORATING  ULCER  OF  THE  COLON. 

THIS  condition  bears  a  close  resemblance  to  perforating  gastric 
ulcer,  for  which  it  can  easily  be  mistaken.  There  is  often  no 
evidence  of  ulceration  before  the  onset  of  symptoms  of  acute 
peritonitis.  The  ulcer  is  often  a  single  one  and  may  be  situated  in 
any  part  of  the  colon,  though  the  commonest  situation  is  in  the 
sigmoid  flexure. 

Treatment  consists  in  opening  the  abdomen  and  either  excising 
the  ulcer  or  closing  it  by  suture,  and  treating  the  patient  for 
general  peritonitis.  Another  method  of  dealing  with  the  ulcer 
is  to  tie  a  glass  tube  into  the  hole  formed  by  it.  The  chief 
difficulty  in  these  cases  lies  in  finding  the  ulcer,  which  may  be 
in  any  part  of  the  colon.  Not  infrequently  these  ulcers  cause 
large  abscesses,  either  sub-diaphragmatic  or  retro-peritoneal. 

P.  LOCKHART  MUMMERY. 


590 


TUBERCULOSIS  OF  THE  COLON. 

THERE  are  two  forms  of  tuberculosis  of  the  colon  which  may  be 
met  with  :  (1)  Tuberculous  ulcerationof  the  colon  ;  (2)  hyperplastic 
tuberculosis  of  the  colon.  Tuberculous  ulceration  of  the  colon 
usually  occurs  as  a  terminal  complication  of  advanced  phthisis,  and 
there  is  little  possibility  of  treating  it  by  surgical  means.  If  there 
is  serious  diarrho3a  or  haemorrhage,  and  the  patient's  condition 
renders  it  possible,  appendicostomy  and  irrigation  of  the  bowel  may 
help  to  ameliorate  the  condition. 

Hyperplastic  Tuberculosis  of  the  Colon  causes  tumour 
formation  and  obstruction  from  stricture  of  the  bowel.  It  is 
usually  mistaken  for  malignant  disease.  The  proper  treatment 
when  the  condition  is  diagnosed  or  suspected  is  either  to  resect  the 
affected  portion  of  the  colon  or  to  short-circuit  it  by  lateral  anasto- 
mosis. The  best  results  have  followed  resection.  When  the  lower 
part  of  the  pelvic  colon  is  affected,  colotomy  may  be  performed, 
but  it  is  necessary  to  make  certain  that  the  opening  is  above  the 
diseased  portion  of  colon. 

The  following  table  gives  the  results  of  operation  in  eighty-nine 
cases : 


Operation. 

No.  of  Cases. 

Recovered. 

Died. 

Mortality  per  cent. 

Resection 

63 

47 

16 

24-5 

Short-circuiting 

16 

13 

3 

18-7 

Exclusion  with  colotomy 

7 

1 

6 

85 

Exclusion    with     lateral 

3 

1 

2 

66 

anastomosis. 

Totals 

89 

62 

27 

— 

P.  LOCKHART  MUMMERY. 


VOLVULUS   OF  THE  COLON. 

THE  treatment  of  acute  obstruction  due  to  volvulus  of  the  colon 
will  be  found  in  the  article  on  Acute  Intestinal  Obstruction  (p.  533), 
to  which  the  reader  is  referred,  and  I  shall  only  deal  here  with 
cases  in  which  the  obstruction  has  been  relieved  by  untwisting 
of  the  volvulus  or  in  which  a  chronic  volvulus  giving  rise  to 


FIG.  1. — Diagram  showing  method  of  shortening  the  mesocolon  by 
Lembert  sutures.  The  stitches  pass  through  the  outer  peritoneum 
only,  so  as  not  to  constrict  the  vessels.  The  method  of  passing 
additional  sutures  in  order  to  remove  a  kink  is  also  shown. 
(From  Mummery's  "  Dis.  Colon,"  Wright.) 

repeated  attacks  of  partial  obstruction  has  been  diagnosed  or  is 
suspected. 

The  cause  of  a  volvulus  of  the  colon  being  some  abnormality 
of  the  mesocolon,  it  is  obvious  that  even  though  the  volvulus 
is  untwisted  and  the  acute  symptoms  relieved,  there  is  a  risk 
of  its  recurring  unless  something  further  is  done,  since  the  pre- 
disposing cause  is  still  present. 

The  treatment  adopted  to  prevent  a  recurrence  of  acute  volvulus 
is  the  same  as  that  for  chronic  volvulus,  which  will  alone  be 
described.  No  treatment  other  than  operation  can  be  of  any  use. 

It  must  be  remembered  that  at  the  operation  it  is  most  unlikely 


592  Volvulus  of  the  Colon. 

that  any  twist  of  the  colon  will  be  found ;  but  a  careful  examina- 
tion of  the  pelvic  colon  after  the  abdomen  has  been  opened  will 
reveal  an  abnormal  condition  of  the  pelvic  mesocolon  allowing  a 
partial  or  complete  twist  to  occur  ;  thus  the  mesocolon  may  be  too 
long  or  narrowed  from  side  to  side,  or  caught  up  in  the  middle  by 
adhesions.  The  most  effectual  means  of  dealing  with  the  condition 
is  excision  of  the  loop  of  colon  and  end-to-end  anastomosis.  This 
is  the  only  certain  way  of  ensuring  that  no  recurrence  will  occur. 

The  operation  is,  however,  a  somewhat  serious  one,  and  a  good 
result  may  often  be  obtained  by  measures  involving  less  risk. 
Since  the  condition  is  in  most  cases  due  to  a  deformity  of  the 
mesentery,  the  indication  is  to  correct  this,  and  the  procedure 
which  has  most  to  recommend  it  is  to  shorten  the  mesocolon  by 
means  of  suitably  placed  sutures. 

Another  method  which  is  sometimes  used  is  to  anchor  the  apex 
of  the  loop  to  the  parietal  peritoneum  by  means  of  sutures ;  but 
while  this  may  succeed  in  the  case  of  volvulus  of  the  caecal  angle, 
it  is  more  than  likely  to  fail  when  the  sigmoid  flexure  is  involved) 
owing  to  the  weight  of  this  part  of  the  colon  when  filled  with  solid 
faeces,  causing  the  adhesions  to  tear  away. 

Operation  for  Shortening  the  Mesocolon. — The  loop  of  bowel 
forming  the  volvulus  is  drawn  out  of  the  abdominal  wound  and 
held  towards  the  inner  side  of  the  wound  by  an  assistant,  so  that 
the  mesocolon  is  put  slightly  on  the  stretch.  A  row  of  Lenibert 
sutures  is  then  inserted,  taking  up  the  peritoneum  only,  right 
across  the  mesocolon  to  within  a  short  distance  of  the  bowel  on 
each  side.  These  sutures  should  be  inserted  on  the  outer  or  iliac 
side  of  the  mesocolon,  and  when  inserting  them  care  should  be 
taken  to  avoid  injuring  any  blood-vessels.  When  this  row  of 
sutures  is  tied  it  should  form  a  pleat  in  the  mesocolon.  A  second 
similar  row  of  sutures  is  then  inserted  over  the  first,  so  as  to 
shorten  still  further  the  mesentery,  and  if  necessary  a  third  row. 
After  the  sutures  have  been  inserted  it  will  be  found  that  a  kink 
has  been  formed  in  the  colon  at  either  end  of  the  suture  line.  To 
get  rid  of  this  a  few  more  Lembert  sutures  should  be  inserted 
parallel  to  the  bowel  wall  and  opposite  any  such  kink  (see  Fig.  1). 
If  the  sutures  are  properly  placed  the  kink  can  be  straightened  out. 
It  is,  of  course,  necessary  to  see  that  the  blood  supply  of  the  loop 
has  not  been  interfered  with  by  suturing,  but  if  the  stitches  have 
been  carefully  placed  this  should  not  occur. 

P.  LOCKHART  MUMMERY. 


593 


DISEASES    AND    MALFORMATIONS    OF 
THE    RECTUM    AND    ANUS. 

DISEASES   OF   THE   ANO-RECTAL    AREA, 

So  many  of  the  ordinary  diseases  of  the  rectum  originate  at  the 
line  of  junction  of  the  proctodeum  and  the  blind  end  of  the  gut  that 
it  seems  desirable  to  group  them  under  the  above  heading. 

The  diseases  included  under  this  heading  are  as  follows : 

(1)  Pruritus ;  (2)  fissure ;  (3)  abscess  ;  (4)  fistula,  including 
that  due  to  tubercle  ;  (5)  infective  ulceration ;  (6)  proctitis. 

It  is  necessary  to  appreciate  the  smallness  of  the  area  which  is 


c.s. 


FIG.  1. — The  fusion  line  of  the  proctodeum. 
(From  Wallis's  Surgury  of  the  Rectum,  Bailliere.) 

concerned  in  the  production  of  these  ailments,  and  the  diagram 
shown  in  Fig.  1  demonstrates  this  fact ;  a  practical  point  which 
may  be  remembered  here  is  that  the  ordinary  rectal  examination 
need  not  extend  beyond  1|  to  2  inches,  except  for  the  purposes  of 
examining  a  growth  or  the  upper  limitations  of  a  swelling. 

PRURITUS    ANI. 

The  essential  symptom  of  pruritus  ani  is  itching  of  a  more  or  less 
intense  character,  and  it  is  necessary  to  differentiate  between  what 
may  be  termed  transient  conditions  and  the  chronic  state.  The 
former  are  due  to  such  things  as  excessive  perspiration,  errors  of 
diet  and  excessive  smoking,  eczematous  or  gouty  conditions  and, 
rarely,  threadworms  and  pediculi. 

When  the  irritation  is  caused  by  perspiration  it  usually  occurs  in 

S.T. VOL.    II.  88 


594 


Pruritus  Ani. 


summer.  In  these  cases  the  irritation  is  not  so  much  at  the  anus 
as  where  the  buttocks  meet  and  get  chafed  by  the  dried  skin 
secretion;  if  this  is  allowed  to  proceed  unchecked  a  raw  tender 
area  may  gradually  form  on  either  buttock,  which  may  even  go 
on  to  cellulitis.  Associated  also  with  it  there  may  be  suppurative 
folliculitis. 

The  treatment  of  this  is  primarily  cleanliness  and  then  the 
application  of  some  emollient,  such  as  vaseline  or  lanoline.  If  the 
case  is  seen  when  the  skin  is  definitely  affected  and  possibly 
cellulitis  is  commencing,  the  patient  should  be  treated  by  continuous 


Flu.  2. — Three  abrasions  in  the  region  of  the  proctodeum.      The  central  abrasion  is  in 
the  most  common  situation.      (From  Wallis's  Surgery  of  the  Rectum,  Bailliere.) 

warm  boracic  hip  baths  until  the  inflammatory  period  is  past,  when 
simple  dressing  of  plain  sterilised  gauze  dusted  over  with  starch 
and  zinc  powder  may  be  applied  until  the  skin  is  completely 
healed. 

Chemical  irritants,  such  as  carbolic,  perchloride  and  the  like, 
are  to  be  avoided ;  never  use  iodoform  or  orthoform,  as  they  are 
likely  to  do  more  harm  than  good.  Should  suppurative  foUicuUtia 
be  present  it  must  be  treated  on  the  same  lines  as  when  it  occurs  in 
the  axilla,  and  the  suppurating  follicles  must  be  opened  up  and 
cleaned  out  with  a  spoon,  and  then  swabbed  with  pure  peroxide 
of  hydrogen.  The  after-treatment  consists  in  warm  boracic  baths 
and  boracic  fomentations. 


Pruritus  Ani. 


595 


When  the  irritation  is  due  to  errors  of  diet  it  will  be  more  often 
found  that  the  error  is  in  something  that  is  drunk  rather  than  in 
something  that  is  eaten.  Beer,  champagne,  claret,  whisky,  are  all 
causes  of  transient  pruritus  ani  in  people  who  are  gouty,  and  the 
abstention  from  the  particular  beverage  will  often  correct  the 
condition.  If,  however,  there  is  already  a  skin  abrasion  around  the 
anus  some  local  application  is  desirable,  and  that  which  probably 
gives  more  relief  than  any  other  is  resinol  ointment.  Two  or  three 
applications  of  this  are  usually  all  that  is  necessary. 

When  there  is  a  marked  eczematous  condition  of  the  skin  this 
must  be  treated  in  the 
same  way  as  eczema  in 
any  other  skin  area, 
and  local  treatment  is, 
of  course,  associated 
with  constitutional 
treatment  (see  Eczema, 
Vol.  III.). 

The  following  pres- 
criptions of  lotions  will 
be  found  beneficial  in 
most  cases  of  pruritus 
due  to  eczema:  f^. 
Prepared  Calamine,  3^  ; 
Oxide  of  Zinc,  3  J  ; 
Solution  of  Subacetate 
of  Lead,  fl.5j ;  Glycerine, 
fl.5J  ;  Lime-water,  to 
fl.5J;  or  fy.  Wright's 
Liq.  Carbonis  Deterg., 
5 j ;  Glycerine,  3] ;  Oxide 

of  Zinc,  3^;  Precipitated  Calamine  Powder,  3^  ;  Prepared  Sulphur, 
5^ ;  water,  3vj.  The  part  affected  to  be  painted  thickly  over 
twice  daily  and  allowed  to  dry.  This  was  a  favourite  prescription 
of  the  late  Mr.  Startin  and  was  also  used  by  the  late  Mr.  Allingharn. 

In  what  may  be  termed  genuine  chronic  pruritus  ani  none  of 
these  remedies  avail  except  as  transitory  palliatives,  because  in  these 
cases  there  is  a  definite  lesion  which  produces  both  the  symptoms 
and  the  external  appearance  of  the  skin  (see  Fig.  3).  The  folds  of 
skin  around  the  anus  are  hypertrophied  and  usually  between  the  folds 
the  skin  is  cracked.  Theperineal  ridge  is  also  thickened  and  in  the  mid- 
posterior  line  between  the  buttocks  the  skin  is  often  raw  and  tender. 
It  will  be  found  on  enquiry  that  these  people  have  suffered  for  years, 

38—2 


FIG.  3. — The  anal  skin  in  a  case  of  chronic 
pruritus  ani. 


596 


Pruritus  Ani. 


and  their  night's  rest  is  broken,  their  digestion  is  impaired,  their 
nerves  are  wrong  and  life  is  a  misery.  It  is  of  little  use  trying  to 
patch  these  patients  up  with  a  local  application.  In  these  cases 
there  exists  a  definite  lesion  at  the  ano-rectal  junction  (see  Fig.  2) 
which  is  the  cause  of  the  disease.  It  is  not  easy  to  see  the  lesion 
except  when  the  patient  is  under  an  anaesthetic,  but  with  a  good 
light  and  a  bi-valve  speculum  one  can  usually  demonstrate  it.  The 
commonest  place  for  the  lesion  is  in  the  mid-posterior  line,  and  the 
speculum,  well  anointed,  is  introduced  gently  through  the  sphincter 


FIG.  4. — The  line  of  incision  in  Sir  C. 
Ball's  operation. 


FIG.  5.— Skin  flap  dissected, 
showing  nerves. 


and  then  opened,  when,  if  the  lesion  is  present,  it  will  be  at  once 
obvious.  More  than  one  may  be  present  or  the  actual  abrasion  may 
be  hidden  by  a  hypertrophied  papilla.  If  the  lesion  is  not  seen  in 
the  mid-posterior  line,  the  speculum  must  be  gently  worked  round  the 
circumference  of  the  bowel  and  each  segment  carefully  investigated. 
Whether  the  lesion  can  be  seen  by  an  ordinary  examination  or 
not,  there  is  no  question  as  to  its  presence,  and  as  nothing  but  some 
form  of  operation  will  cure  these  cases  it  is  better  that  the  patient 
should  be  prepared  for  an  operation  and  then  the  demonstration  of 
the  lesion  can  be  followed  by  an  operation  for  its  cure. 


Fissure. 


597 


When  the  case  is  comparatively  recent  and  there  is  no  marked 
hypertrophy  of  the  skin,  but  only  an  obvious  internal  lesion,  one 
application  of  the  cautery  or  painting  the  lesion  with  pure  lactic 
acid  will  often  check  at  once  the  irritation,  and  the  lesion  will  heal, 
but  this  can  only  be  hoped  for  under  the  conditions  which  I  have 
mentioned. 

The  operations  for  the  cure  of  this  distressing  malady  are  three 
in  number  :  (1)  Sir  Charles  Ball's  method  of  dissecting  the  skin  flaps 
and  dividing  the  terminal  cutaneous  nerve  twigs  (see  Figs.  4  and  5). 
(2)  A  modification  of  this,  recently  invented  by  Dr.  Louis  J.  Krouse 
(arc  Fig.  6),  in  which,  as  will  be 
seen,  the  skin  flaps,  instead  of 
being  dissected  towards  the  anus, 
are  dissected  from  it;  the  results  of 
this  operation  are  said  to  be  quite 
good,  but  the  risks  of  suppura- 
tion of  the  skin  with  subsequent 
stenosis  must  not  be  forgotten. 

(3)  The  other  operation,  one 
which  has  always  been  adopted  by 
the  writer,  is  the  dissection  of 
the  complete  ring  of  the  ano-rectal 
tissue,  bringing  down  the  healthy 
mucous  membrane  to  the  skin, 
and  at  the  same  time  cauterising 
any  hypertrophied  skin  folds. 

The  success  of  this  treatment 
has  been  most  marked,  and 
although  I  cannot  claim  that  I 
have  never  had  a  failure,  there  is 
no  doubt  that  the  operation  is  a 

sound  surgical  procedure  which  has  the  marked  advantage  of 
removing  the  cause  of  the  trouble.  In  two  instances,  both  in  elderly 
gentlemen,  there  has  been  some  subsequent  return  of  the  pruritus, 
which  has  yielded  completely  after  a  few  exposures  to  X-rays. 

FISSURE. 

Fissure  is  produced  by  a  tearing  down  of  one  of  the  anal  valves 
(Fig.  7).  The  lesion  is  usually  in  the  mid-posterior  line.  Con- 
stipation is  the  usual  cause. 

The  treatment  of  a  fissure  will  depend  upon  its  depth.  When  the 
lesion  is  merely  through  the  mucous  membrane  it  is  possible  that 
palliative  measures  may  heal  it ;  at  the  same  time  the  results  of  such 


FIG.  6. — Dr.  Krouse's  modification  of 
Ball's  operation. 


598 


Fissure. 


treatment  are  too  often  disappointing  ;  but  under  the  above  circum- 
stances it  may  be  as  well  to  try  for  a  few  days  what  laxatives 
will  do,  associated  with  the  application  of  the  following  ointment : 
1^.  Subchloride  of  Mercury,  gr.  20;  Lanoline,  3J. 

When  the  lesion  is  deeper  than  this  and  involves  the  fibres  of  the 
external  sphincter  and  possibly  also  there  is  some  thickening  of  the 
skin  edges,  it  is  useless  to  attempt  any  palliative  measures  and  keep 
the  patient  longer  in  a  state  of  suffering  which  is  often  extremely 
acute.  Moreover,  as  I  have  pointed  out  elsewhere  (Surgery  of  the 


FIG.  7. — An  anal  valve  torn  down,  causing  fissure. 
(From  Wallis's  Surgery  of  the  Rectum,  Bailliere.) 

Rectum),  serious  infection  may  arise  through  this  source  and  lead 
to  a  prolonged  illness. 

The  operative  treatment  for  fissure  consists  of : 
(1)  Forcible  dilation  of  the  muscle,  tearing  through  the  affected 
tissues,  and  at  the  same  time  "  paralysing"  the  muscle.  The  result 
of  this  is  that  spasm  ceases  and  with  it  the  pain,  and  if  the  sphincter 
remains  sufficiently  long  inert  the  fissure  may  heal.  It  must  be 
remembered,  however,  that  when  the  fissure  has  existed  for  some 
time  the  sphincter  becomes  rapidly  hypertrophied  and  unless  the 
stretching  is  sufficient  to  cause  inertia  for  ten  days,  it  is  more  than 
possible  that  before  the  wound  is  healed  the  sphincter  again  becomes 
active  and  the  trouble  commences  once  more. 

Another  warning  must  be  given  as  to  sphincter  stretching.    This 
muscle  differs  materially  in  different  people  and  the  stretching  of 


Fissure. 


599 


the  sphincter  of  a  young  woman  is  a  totally  different  affair  to  that 
of  a  middle-aged  labouring  man.  Should  the  sphincter  be  over- 
stretched or  too  much  torn  it  may  be  months  before  proper  control 
is  obtained,  and  indeed  it  is  quite  possible  for  some  permanent 
weakness  to  remain.  It  will  be  gathered  from  these  remarks  that 
although  the  method  is  a  recognised  practice  it  is  not  one  which  is 
to  be  recommended. 

(2)  The  best  treatment  is  to  divide  the  fibres  of  the  external 
sphincter  in  the  following  manner  : 

The  patient  is  anaesthetised  and  the  bowel  is  emptied.  It  is 
necessary  to  mention  this,  as  usually,  in  spite  of  all  preparation, 


FIG.  8. — The  finger  in  the  anus.     The  dotted  line  shows  the  incision. 

patients  do  not  voluntarily  assist  to  empty  the  bowel  because  of 
the  pain.  With  the  patient  on  the  side  or  in  the  lithotomy  position 
a  proper  examination  is  made  of  the  fissure,  and  with  one  finger  in 
the  bowel,  putting  the  fissure  itself  on  the  stretch,  the  outer  fibres  of 
the  sphincter  are  divided  in  a  straight  line  by  a  blunt-ended  scalpel 
held  in  the  other  hand  (see  Fig.  8).  It  is  not  necessary  to  divide 
the  whole  sphincter.  The  incision  is  washed  over  with  pure 
peroxide  of  hydrogen  and  some  plain  sterilised  gauze  is  placed 
in  it.  The  wound  is  washed  with  saline  and  diluted  peroxide  each 
day  and  an  aperient  is  given  on  the  third  day,  when  the  plug 
either  comes  out  or  is  removed.  After  this  the  bowels  should  act 
once  a  day,  and  in  addition  to  the  dressing,  which  consists  only  of 


600  Rectal  Abscess. 

plain  sterilised  gauze,  the  patient  should  sit  in  a  boracic  hip  bath 
once  or  twice  a  day  for  at  least  fifteen  to  twenty  minutes.  Com- 
plete recovery  usually  takes  place  in  from  ten  to  fourteen  days. 

If  circumstances  do  not  admit  of  the  patient  taking  a  general 
anaesthetic,  and  also  if  he  is  unable  to  lie  up,  the  operation  can  be 
done  in  the  following  manner : 

(3)  The  patient  is  placed  in  the  knee-elbow  position  and  a 
4  per  cent,  solution  of  eucaine  is  injected  £  inch  behind  the 
posterior  limit  of  the  fissure,  and  after  a  few  seconds  the  needle  is 
pushed  on  behind  the  fissure,  and  so  the  whole  area  is  anaesthetised 
and  the  muscle  is  divided  in  the  way  already  mentioned. 
Haemorrhage  is  controlled  by  adrenalin  or  hazeline,  and  the  patient 
must  not  be  allowed  to  leave  the  house  until  it  is  certain  that  all 
haemorrhage  has  ceased.  This  is  a  rule  that  should  be  carefully 
observed,  as  otherwise  serious  trouble  from  haemorrhage  may  occur. 
It  is  not  desirable  to  adopt  this  latter  plan  if  by  any  means  a 
general  anaesthetic  can  be  given. 

It  has  been,  and  still  is,  a  common  practice  to  treat  fissure  by  the 
application  of  solid  nitrate  of  silver,  but  this  treatment  is  usually 
of  no  avail  as  far  as  healing  goes,  and  often  is  the  cause  of 
considerable  increase  of  pain,  and  cannot  in  any  way  be  recom- 
mended. 

lodoform  or  orthoform  powders  should  not  be  used  ;  they  do  no 
good,  and  iodoform  has  a  most  unpleasant  smell,  and  finally  both 
these  powders  frequently  cause  acute  dermatitis. 

ABSCESS. 

Abscesses  of  the  rectum  or  of  the  tissues  immediately  outside 
originate  from  a  lesion  in  the  bowel  at  the  ano-rectal  junction  (as 
in  the  case  of  fissure),  and  according  to  the  line  along  which  the 
infection  spreads,  the  abscess  will  be  either  :  (1)  Subcutaneous  ; 
(2)  submucous  ;  (3)  ischio-rectal ;  (4)  pelvi-rectal ;  (5)  retro-rectal. 

In  dealing  with  all  these  abscesses  it  must  be  remembered  that 
the  usual  sequel  is  a  fistula,  and  it  is  unwise  not  to  make  this  clear 
to  patients,  as  if  this  is  not  done  the  resulting  fistula  is  too  often 
put  down  to  bad  treatment.  If  the  abscess  heals,  leaving  no 
fistula,  which  is  rare,  so  much  the  better,  and  if  the  possibilities  of 
a  fistula  have  been  put  forward,  all  the  more  credit  is  given  to  the 
medical  man  who  has  so  successfully  avoided  it. 

One  or  two  observations  on  the  examination  and  diagnosis  of 
these  cases  are  of  practical  value  in  the  treatment. 

The   subcutaneous  abscess  is  easily  diagnosed.     It  is  treated 


Ischio-Rectal  Abscess. 


60 1 


by  incision,  as  any  other  abscess,  and  this  is  all  that  need  be  said 
about  it. 

The  ischio-rectal  abscess  is  the  next  easiest  to  recognise,  but 
it  is  frequently  overlooked  until  the  abscess  has  assumed  large 
dimensions,  and  this  is  particularly  the  case  when  the  abscess  is 
bi-lateral.  The  symptoms  complained  of  are  dull  aching  pain, 
and  a  feeling  of  weight  and  throbbing.  All  the  symptoms  are 
referred  to  the  rectum,  and  therefore  an  examination  should 
always  be  made,  when  it  will  be  found  that  there,  is  definite  hard- 
ness of  the  peri-rectal  tissues  and  tenderness  on  one  or  both  sides. 


FIG.  9.— Abscesses.     1,  Subteguinentary  ;  2,  Submucous  ;  3,  Ischio-rectal; 
4,  Pelvi-rectal.     (From  Wallis's  Surgery  of  the  Rectum,  Bailliere.) 

If,  as  is  more  usual,  the  abscess  is  limited  to  one  side,  a  comparison 
of  the  two  sides  will  establish  the  diagnosis.  There  is  always  a 
rise  of  temperature  locally,  and  if  the  general  temperature  is  taken 
it  will  often  be  found  to  have  risen.  But  this  is  not  always  the 
case,  and  many  instances  have  occurred  of  large  abscesses  being 
present  with  a  normal  body  temperature. 

The  treatment  of  this  abscess  is  by  incision,  but  there  are 
two  ways  of  doing  this.  Fig.  10  shows  what  is  too  often  done 
in  the  treatment  of  these  abscesses,  viz.,  a  small  incision  is 
made  over  the  most  prominent  part  of  the  swelling  and  relief  is 
given  to  the  tension,  with  comfort  to  the  patient.  Much  the  same 


602 


Ischio-Rectal  Abscess. 


relief  occurs  when  the  abscess  bursts  through  the  skin,  but  this 
relief  is  in  no  way  curative,  and  the  patient  continues  with  a  foul 
septic  cavity  in  the  ischio-rectal  region,  the  infectivity  of  which  is 
kept  up  by  the  original  lesion  already  spoken  of. 

When  possible,  a  general  anaesthetic  should  be  given,  and  a  free 
incision,  as  in  Fig.  11,  should  be  made,  and  if  necessary,  another 
incision  should  cross  this,  making  the  opening  cruciform,  the  main 
point  aimed  at  being  to  obtain  as  perfect  drainage  as  possible.  In 
addition  to  this,  after  the  opening  has  been  made,  the  finger  should 
be  inserted  into  the  abscess  cavity,  which  should  be  thoroughly 
explored,  and  any  ramifications  of  the  abscess  made  out;  as 


f 


FIG.  10. — A  small  incision  which  relieves  tension,  but 
does  not  properly  drain  the  abscess  cavity. 

far  as  possible,  any  obstructions  such  as  bands,  etc.,  should  be 
broken  down  and  the  interior  made  into  one  cavity,  and  thus  the 
best  drainage  is  obtained.  The  cavity  is  then  scraped  with  a  blunt 
spoon,  and  thoroughly  irrigated  at  the  same  time  with  warm  saline 
solution.  After  this  the  cavity  is  swabbed  out  with  pure  peroxide 
of  hydrogen  (strength  20  vols.).  This,  again,  is  washed  away 
with  saline,  and  the  cavity  is  packed  firmly  with  plain  sterilised 
gauze.  If  the  contents  of  the  abscess  cavity  are  very  foul  it  will 
be  found  that  a  solution  of  iodine  and  water  (1  drachm  to  the 
pint  of  water),  used  instead  of  the  saline,  is  an  excellent  deodoriser 
as  well  as  a  disinfectant.  Before  packing  off  the  cavity  the 
operator  should  never  forget  to  look  for,  and  establish,  the  presence 


Ischio-Rectal   Abscess. 


6o- 


of  the  internal  opening,  which  is  at  the  ano-rectal  junction.  If 
the  track  is  a  straight  run  into  the'  bowel,  a  probe-pointed  director 
is  passed  along  it ;  the  end  is  brought  out  at  the  internal  opening 
and  all  the  super jacent  structures  are  divided  (see  Fistula).  If,  on 
the  other  hand,  it  is  thought  that  the  track  is  not  a  simple  one, 
but  that  there  are  divergent  ways,  then  it  is  not  wise  to  do 
more  than  thoroughly  clear  out  the  abscess  cavity  in  the  manner 
just  related. 

After-treatment. — An  aperient  is  given  on  the  third  day  (castor 
oil  for  choice,  about  5  drachms).     After  this  has  acted  the  gauze 
should  be  removed,  and  as  it  is   always  extremely  foul,  for  the 
comfort    of    all    parties 
concerned,  it  should  be 
pulled   out  with  forceps 
into  a  bowl  containing  a 
solution  of  1  in  20  car- 
bolic, or  a  strong  solution 
of  lysol  or  iodine.    After 
the   gauze  has  been  re- 
moved    the     cavity     is 
irrigated  with  hydrogen 
peroxide    (20   vols.    per 
cent.),    with     an    equal 
quantity  of  water  added, 
and  after  this  has  been 
washed  away  with  saline, 
the  cavity  is  now  liyhtlii 
packed  with  gauze.    One 
of  the  points  of  interest 
in    these    cases    is    the 
rapidity  with  which  these 
cavities   close   up,  and   it    is   for   this    reason  that  light  packing 
is  necessary   after   the   first   dressing   has   been   removed.      The 
wound  is  now  to  be  dressed  daily,  and  in   addition,   the   patient 
should    sit    in    a    warm   boracic    sitz   bath   night   and   morning 
for   about   fifteen   to   twenty   minutes.      This   boracic   bath    has 
done   more  than  anything  else  to  hasten  the  recovery  of   rectal 
wounds,  and  at  the  same  time  is  of  the  greatest  comfort  to  the 
patient.      When  the  original  abscess  has  been  a  large  one  and 
there  has  consequently  been  a  large  space  to  granulate  up,  it  will 
be  found  that  after  ten  to  fourteen  days  a  change  of  dressing  is 
beneficial;    lotio   rubra    [U.S.P.    Zinci    Sulphatis,   gr..2;    Tinct. 
Lavand.  Co.,  111  10 ;  Aquani,  ad  3  j] ,  tincture  of  iodine,  or  a  strong 


FlG.  11. — A  crucial  incision  which  gives  good 
drainage  and  allows  thorough  investigation 
of  the  cavity. 


604 


Sub-mucous  Rectal  Abscess. 


solution  of  perchloride  of  mercury  (strength  1  in  500),  may  be 
used.  Healing,  as  a  rule,  goes  on  well,  but  sometimes  in  the 
large  cavities  the  last  inch  or  two  defies  all  the  remedies  used 
and  continues  in  a  chronic  state.  When  such  is  the  case,  or 
even  earlier,  it  will  be  found  that  the  ionic  treatment,  by  means 
of  zinc  cataphoresis,  often  heals  this  indolent  remaining  sinus 
after  one  application.  This  form  of  treatment,  which  was 
introduced  for  rectal  work  by  Dr.  Ironside  Bruce  and  myself  some 
two  years  ago,  will  be  more  fully  dealt  with  in  discussing  the 
treatment  of  ulceration. 

The  treatment  of  the  pelvi-rectal  and  retro-rectal  abscesses 
does  not  differ  much  from  that  of  the  ischio-rectal,  but  as  the 
abscess  is  above  the  levator  ani  muscle  the  recognition  is  not 

always  easy,  unless  a 
man  has  a  knowledge 
of  how  the  ordinary 
normal  rectum  feels  on 
examination. 

Treatment.  —  When 
the  abscess  has  been 
diagnosed  the  patient 
is  put  under  an  anaes- 
thetic and  then  placed 
in  the  lithotomy  posi- 
tion ;  an  incision  is 
made  well  away  from 
the  external  sphincter, 

i.e.,  about  midway  between  the  tuber  ischii  and  the  anus,  and  when 
the  skin  is  incised  the  finger  of  the  opposite  hand  is  passed  into  the 
rectum,  and  with  this  guide  in  the  bowel,  a  pair  of  sinus  forceps  is 
passed  through  the  incision  steadily  on  until  the  abscess  is  reached 
and  pus  is  seen  to  escape  from  the  wound.  The  finger  in  the  rectum 
prevents  the  mucous  membrane  from  being  wounded.  When  the 
abscess  has  been  opened  the  skin  incision  is  enlarged  sufficiently 
to  admit  the  finger  into  the  abscess  cavity.  This  is  thoroughly 
explored  with  the  finger  and  any  diverticula  are  made  out ;  after 
the  finger  is  withdrawn  a  large  spoon  is  introduced  and  the  cavity 
is  scraped  out  and  then  irrigated  with  warm  saline  until  it  is  quite 
clean.  The  rest  of  the  treatment  is  the  same  as  in  the  case  of  the 
ischio-rectal  abscess. 

The  case  of  the  sub-mucous  abscess  (Fig.  12)  is  somewhat 
different.  This  abscess  is  diagnosed  by  the  fact  that  there  is  a 
definite  swelling  with  inflamed  mucous  membrane  immediately 


FIG.  12.- — A  sub-mucous  abscess. 
(From  Wallis's  Surgery  of  the  Rectum,  Bailliere.) 


Sub-mucous   Rectal  Abscess. 


605 


above  the  ano-rectal  line,  and  if  a  speculum  is  introduced  pus  will 
often  be  seen  to  escape  from  the  initial  lesion  at  the  ano-rectal 
junction. 

Treatment. — The  patient  is  put  under  an  anaesthetic  and  the 
sphincter  is  moderately  stretched ;  the  internal  opening  of  the 
abscess  is  found  and  enlarged  with  a  pair  of  sinus  forceps ;  a  blunt- 
pointed  hooked  probe  is  now  passed  into  the  cavity  and  pulled  down 
(see  Fig.  13)  until  the  point  of  the  director  can  be  felt  on  the  skin 
outside  the  sphincter  ;  an  incision  is  now  made  over  the  point  and  a 
straight  fistula  director  is  passed  in  from  the  outside  to  the  opening 


a 
I 


FIG.  13. — -Method  of  treating  sub-mucous  abscess. 


inside,  and  the  point  brought  out  through  the  sphincter.  All  the 
tissues  lying  above  the  sphincter  are  divided,  including  the  external 
sphincter  muscle.  By  this  procedure  perfect  drainage  is  obtained 
and  a  rapid  recovery  ensues. 

The  wrong  treatment  in  these  cases  is  to  incise  the  mucous 
membrane  and  trust  to  chance  that  the  abscess  will  heal.  The 
chances  are  greatly  against  healing  for  many  reasons,  and  a  serious 
state  of  infective  ulceration  is  more  than  likely  to  arise,  and  in  any 
case  no  time  is  gained  and,  indeed,  a  great  deal  may  be  lost  in 
many  ways,  by  not  adopting  the  method  of  treatment  mentioned 
above. 


606  Rectal  Fistulae. 

Abscesses  in  connection  with  the  prostate  occasionally  burst  into 
the  rectum,  and  may  be  mistaken  for  an  original  bowel  abscess ;  but 
the  symptoms  of  a  prostatic  abscess  are  pronounced  and  urgent,  and 
are  scarcely  likely  to  be  mistaken. 

Abscesses  in  connection  with  bone  (usually  tuberculous)  may 
discharge  externally  in  the  same  region  as  an  ischio-rectal  abscess. 
The  direction  of  the  examining  probe  will  not  be  towards  the 
bowel,  and  on  digital  examination  the  mucous  membrane  will  be 
found  healthy. 

FISTULA 

As  was  mentioned  when  discussing  abscesses,  a  fistula  is  always 
the  residue  of  an  abscess  which  is  produced  by  an  infection 
originating  in  the  bowel.  This  may  be  caused  by  the  bacillus  of 
tubercle,  the  bacillus  coli  communis  or  a  combination  of  the  latter 
with  pyogenic  cocci.  The  extent  of  the  fistula  depends  upon  the 
size  and  situation  of  the  original  abscess,  the  possibility  of  side- 
tracks, and  the  virulence  of  the  infecting  micro-organisms. 

The  fistulae  are  either  complete  or  internal,  and  a  variety  of  these 
two  is  seen  in  the  horseshoe  or  semi-horseshoe  variety.  Further 
fistulas  may  have  various  tracks  leading  from  the  main  one  ;  there 
may  be  multiple  external  openings  on  the  skin,  and  there  may  be 
more  than  one  internal  opening,  but  this  is  not  common. 

Before  embarking  upon  the  treatment  of  a  fistula  it  is  essential 
to  appreciate  that  this  disease  presents  many  varieties  and  that  the 
treatment  of  it  may  be  a  most  simple  matter  or  one  which  will  tax 
all  the  ingenuity  of  the  surgeon,  and  must  certainly  exhaust  all  the 
patience  of  the  patient. 

As  fistulae  are  the  results  of  abscesses,  it  follows  that  to  a  great 
extent  the  varieties  resemble  each  other,  so  that  a  subcuticular 
abscess,  when  not  treated,  leaves  a  subcuticular  fistula,  and  an 
ischio-rectal  abscess  which  bursts  externally  leaves  a  complete 
fistula.  A  sub-mucous  abscess  may  leave  a  tortuous  blind  internal 
fistula,  and  the  pelvi-rectal  or  retro-rectal  abscess,  as  well  as  the 
large  ischio-rectal  abscess,  will  leave  a  fistula  of  the  horseshoe  variety. 

From  any  of  these  fistulae,  except  perhaps  the  subcuticular,  side- 
tracks may  lead  off  from  the  main  in  any  direction,  and  it  is  this 
possibility  which  is  so  often  the  cause  of  failure  of  treatment  of 
fistulas,  because  one  of  these  tracks  is  overlooked. 

In  the  subcuticular  variety  the  treatment  consists  of  merely 
laying  open  the  sinus,  scraping  away  the  'granulation  tissue,  at  the 
same  time  removing  any  redundant  skin  ;  the  wound  is  then  packed 
with  gauze  and  allowed  to  granulate  up. 


Rectal  Fistulae.  607 

In  the  complete  variety  a  fistula  director  is  passed  in  at  the 
external  opening  and  worked  along  the  track,  which  is  usually 
obvious,  to  the  internal  opening,  which  can  be  felt  somewhere 
between  the  two  sphincters. 

When  the  external  opening  is  situated  in  the  posterior  half  of  a 
line  drawn  transversely  across  the  middle  of  the  sphincter,  the 
internal  opening  will  be  found  in  the  mid -posterior  line.  When 
the  external  opening  is  in  the  anterior  half,  the  internal  opening  is 
in  a  line  opposite  to  the  external  one. 

When  the  internal  opening  has  been  located,  the  probe  is  pushed 
on  towards  it  and  pushed  sufficiently  far  so  that  the  probe  point  and 
a  part  of  the  groove  of  the  director  can  be  brought  outside  the 
sphincter.  When  this  has  been  accomplished  all  the  tissues  lying 
above  the  groove  in  the  director  are  divided  by  a  sharp  pointed 
bistoury.  This  incision  usually  includes  the  larger  portion  of  the 
external  sphincter.  The  incision  should  be  further  enlarged  by  a 
free  division  of  the  skin  away  from  the  bowel. 

The  haemorrhage,  which  may  be  temporarily  copious,  is  soon 
checked  by  pressure  and  a  clip  where  necessary.  The  edges  of  the 
wound  are  then  held  apart  and  careful  investigation  is  made  for 
any  side-tracks  ;  these  are  recognised  by  the  unhealthy  granulation 
tissue ;  also  they  will  readily  admit  a  probe.  These  tracks  are 
freely  divided  or  enlarged,  until  their  absolute  limit  is  arrived  at, 
after  which  the  whole  of  the  infected  track  is  carefully  curetted  and 
then  swabbed  out  with  hydrogen  peroxide,  and  after  this  has  been 
washed  away  with  saline,  the  cavity  and  any  diverticula  are  care- 
fully and  firmly  packed  with  plain  sterilised  gauze.  No  chemically 
prepared  gauze  should  be  used,  nor  should  iodoform  or  orthoform 
l)e  dusted  into  or  around  the  wound.  The  subsequent  treatment  is 
the  same  as  in  the  case  of  an  abscess. 

There  is  one  detail  which  must  not  be  forgotten,  and  that  is  the 
possibility  of  what  is  known  as  "  bridging "  occurring,  which 
means  that  some  deep  part  of  the  track  breaks  down  whilst  the 
more  superficial  part  remains  healthy.  This  usually  occurs  after 
the  tenth  day,  and  careful  investigation  must  be  made  with  a 
proper  rectal  probe  to  see  whether  any  such  weak  point  exists,  and 
when  this  is  found  to  be  the  case,  the  bridge  must  be  broken  down, 
the  cavity  thoroughly  swabbed  out  and  firmly  packed  until  healthy 
granulations  arise  to  the  same  height  as  the  remainder  of  the 
wound. 

The  treatment  of  an  internal  fistula  is  much  the  same  as  that 
for  a  sub- mucous  abscess.  When  the  internal  opening  has  been 
established  a  curved  director  is  passed  into  the  opening  and  the 


608  Rectal  Fistulae. 

point  is  dragged  down  until  it  can  be  felt  through  the  skin  on  the 
buttock  external  to  the  external  sphincter  ;  the  skin  is  then  incised 
over  the  point  and  all  the  tissues  are  divided,  as  in  the  treatment 
of  sub-mucous  abscess. 

But  now  the  difficulty  of  these  cases  begins,  as  it  is  rare  to  find 
the  track  of  an  internal  fistula  to  be  absolutely  simple,  since  they 
are  more  often  sinuous  and  frequently  involve  a  part  of  the 
internal  sphincter.  The  best  way  to  treat  the  remainder  of  the 
sinus  is,  after  laying  open  the  tissues  up  to  the  internal  opening, 
to  pass  a  pair  of  sinus  forceps  up  the  remaining  part  of  the  track 
and  gradually  stretch  the  tissues  until  the  limit  of  the  track  can  be 
definitely  established.  Into  this  track  a  spoon  is  passed  and  the 
granulation  tissue  is  scraped  away,  after  which  the  whole  cavity  is 
swabbed  out  with  hydrogen  peroxide  and  then  irrigated  with  saline, 
and  the  sterilised  gauze  is  passed  up  to  the  end  of  the  track. 

The  subsequent  treatment  is  the  same  as  in  the  other  cases 
already  mentioned. 

It  will  thus  have  been  seen  that  when  once  the  whole  area  of  the 
track  has  been  made  out  the  treatment  is  then  a  simple  matter  ; 
but  for  all  its  simplicity  it  will  be  found  that  unless  scrupulous  care 
is  paid  to  the  various  details  mentioned,  troubles  arise  only  too 
soon.  The  great  point  to  bear  in  mind  is  that  the  personal  care  of 
the  man  in  charge  is  of  the  greatest  importance  with  regard  to  the 
well-doing  of  the  case.  An  abdominal  operation  usually  wants 
little,  if  any,  care  from  the  surgeon  after  the  operation;  but  in 
practically  all  rectal  operations  careful  inspection  and  careful 
supervision  must  be  made  until  the  case  is  practically  well,  and  in 
no  operation  is  this  so  much  the  case  as  in  the  operation  for  a  bad 
fistula. 

Complicated  Fistulae. — As  has  been  mentioned  in  the  treat- 
ment of  abscess,  there  is  occasionally  a  secondary  opening  high  up 
in  the  bowel  which,  indeed,  is  often  large  and  ragged  and  the  only 
obvious  opening  to  be  found.  Formerly  it  was  the  practice  in 
these  cases  to  pass  in  a  long  director  and  to  feel  the  point  emerge 
from  this  high  lying  internal  opening,  and  then  with  a  pair  of 
fistula  scissors,  or  with  a  large  bistoury,  the  whole  of  the  tissues 
above  the  director  were  divided.  This  included  the  external  and 
internal  sphincters  and  also  a  large  portion  of  the  levator  ani 
muscle,  with  of  course  all  the  intervening  mucous  membrane,  and 
the  ultimate  result  of  this  was  that,  whether  it  cured  the  fistula  or 
not,  it  was  certain  to  leave  the  patient  with  more  or  less  incon- 
tinence for  the  rest  of  his  life,  and  in  the  way  of  results  nothing 
can  be  worse  than  this.  Here,  again,  the  treatment  is  similar  to 


Rectal  Fistulae.  609 

that  already  mentioned  in  the  treatment  of  abscesses,  viz.,  make 
as  free  an  opening  as  possible  on  the  buttock,  but  never  divide  the 
internal  sphincter  and  certainly  "  never  divide  the  levator  ani. 
When  the  last  1^  or  2  inches  of  a  long  fistulous  track  refuses  to 
heal,  it  will  be  found  that  the  ionic  treatment  by  means  of  zinc 
cataphoresis  will  frequently  act  like  a  charm,  and  often  one 
exposure  to  this  is  sufficient  to  cure. 

The  most  distressing  cases  of  fistula  to  treat  are  those  which,  by 
a  gradual  spread  of  the  infective  process,  involve  the  bladder  and 
open  into  it.  Often  this  is  first  recognised  by  the  patient  himself 
in  that  he  notices  that  flatus  is  passed  by  the  urethra  and  then 
later  the  urine  becomes  foul  and  faecal  matter  is  passed  with  it. 
These  patients  become  very  ill  with  all  the  signs  of  chronic  septic 
absorption  and  they  gradually  drift  into  a  "  typhoidal  "  state  and  die. 

There  is  only  one  thing  to  do  under  these  circumstances,  and 
that  is  a  colotomy.  If  this  is  done  and  the  affected  bowel  is  well 
irrigated,  the  patient  will  rapidly  improve  and  the  opening  into  the 
bladder  will  close.  Whether  eventually  it  will  be  advisable  to 
close  up  the  colotomy  opening  will  largely  depend  on  the  amount 
of  destruction  which  the  fistula  has  done,  and  in  any  case  it  is  not 
a  matter  which  should  be  in  any  way  hurried. 

Recto-vaginal  Fistulae,  when  low  down  and  recent,  will  often 
close  of  themselves.  When  they  are  rather  larger  or  higher  up  a 
plastic  operation  through  the  vagina  is  necessary,  and  great  care 
must  be  taken  not  to  allow  any  large  accumulation  of  faeces  to 
pass  suddenly.  When  the  communication  is  high  up  and  large  a 
temporary  colotomy  is  necessary,  after  which  a  plastic  operation  can 
be  done  for  the  closure  of  the  fistulous  opening  under  the  best 
auspices. 

>  Fistulae  due  to  Tuberculosis. — Although  the  original  site  of 
infection  in  tuberculous  fistula  is  the  same  as  in  the  other  diseases 
already  mentioned,  namely,  at  the  ano-rectal  junction,  the  onset  of 
a  tuberculous  fistula  is  quite  different  from  that  which  has  just 
been  discussed,  which  is  invariably  preceded  by  an  abscess.  Tuber- 
culous fistulae  commence  insidiously,  and  often  attention  is  not 
called  to  them  until  they  are  far  advanced. 

The  local  appearances  show  considerable  undermining  of  the  skin, 
which  has  a  livid  appearance  around  the  affected  area.  Induration 
is  generally  absent,  and  the  internal  opening,  i.e.,  the  original  area 
of  infection,  is  often  large,  ragged  and  ulcerated. 

Pulmonary  tuberculosis  is  usually  present,  and  the  patient  pre- 
sents the  characteristic  features  which  are  usually  present  in 
tuberculous  people. 

S.T. — VOL.  ii.  39 


6io  Infective  Ulcerative  Proctitis. 

Treatment. — The  first  thing  to  do  is  to  disabuse  one's  mind  of 
the  old-fashioned  idea  that  because  a  fistula  is  tuberculous,  it 
must  not  be  operated  on.  This,  as  I  have  pointed  out  elsewhere, 
is  erroneous  and  harmful. 

It  is  certainly  not  desirable  to  give  a  general  ansesthetic  when 
pulmonary  tuberculosis  is  markedly  active ;  the  condition  is  then 
best  treated  in  the  following  way.  The  affected  area  is  anaesthetised 
by  injecting  a  4  per  cent,  solution  of  eucaine  subcutaneously.  The 
fistulous  track  is  then  laid  open,  broken  down  granulation  tissue  is 
scraped  off,  and  any  overhanging  skin  is  removed.  Another 
application  of  eucaine  is  made  on  the  surface  thus  treated,  after 
which  the  whole  area  is  freely  swabbed  over  with  pure  carbolic 
acid.  The  greyish-black  appearance  which  follows  this  application 
soon  disappears  and  the  surface  assumes  a  vascular  appearance. 
Care  must  be  taken  that  none  of  this  strong  acid  trickles  over  on 
to  the  surrounding  healthy  skin.  The  part  thus  treated  is  packed 
with  sterilised  wool  and  is  kept  as  dry  as  possible.  The  after- 
treatment  consists  of  daily  boracic  baths,  after  which  the  wound  is 
packed  with  dry  sterilised  gauze.  The  healing  of  the  wound  will 
be  materially  hastened  by  an  exposure  to  X-rays  for  about  ten  to 
fifteen  minutes  three  times  a  week. 

The  general  health  must  also  be  attended  to,  and  it  is  most 
essential  that  these  patients  should  not  be  kept  in  bed  a  day  longer 
than  is  necessary.  The  more  they  are  in  the  open-air  the  better 
for  their  local  as  well  as  their  general  condition.  Patients 
treated  on  these  lines  do  extremely  well ;  not  only  do  their 
fistulge  heal,  but  their  general  condition  is  also  much  improved, 
especially  if  bovine  tuberculin  is  given  (see  Vaccine  Therapy, 
Vol..  III.). 

INFECTIVE    ULCERATIVE    PROCTITIS. 

Infective  ulcerative  proctitis  is  much  more  common  in  women 
than  in  men,  and  may  occur  in  quite  young  children.  The 
symptoms  are  pain  both  during  and  after  defaecation,  lasting  for 
some  time,  a  sanious  discharge  from  the  rectum,  a  rise  of  tempera- 
ture, and  often  the  anal  tissues  are  swollen  and  oedematous.  In 
some  instances  one  or  more  joints  become  at  times  hot,  swollen 
and  distended  with  fluid,  and  there  is  a  considerable  rise  of 
temperature. 

This  disease  may  originate  in  some  ano-rectal  lesion,  or  it  may 
be  a  sequel  to  a  gonorrhoeal  infection  from  the  vagina.  In  men  it 
may  be  a  sequela  of  acute  prostatitis,  especially  when  an  abscess  of 
the  prostate  has  burst  into  the  rectum  ;  but  this  is  of  so  rare  an 


Infective  Ulcerative  Proctitis.  611 

occurrence  that  it  need  hardly  be  taken  into  consideration.  Some 
of  the  worst  cases  are  due  to  a  protracted  labour.  Finally,  it  may 
occur  after  an  operation  upon  the  rectum,  such  as  an  operation  for 
fistula. 

Probably  in  no  disease  does  the  rapidity  of  the  recovery  depend 
on  early  diagnosis  so  much  as  in  ulcerative  proctitis.  When 
it  is  recognised  in  the  quite  early  stage  it  can,  as  a  rule,  be  cured 
by  one  application  of  zinc  cataphoresis ;  but  to  ensure  this 
desirable  result  it  is  essential  that  the  mucous  membrane  should 
not  have  been  destroyed. 

In  the  later  stages  cataphoresis  is  still  by  far  the  most  effective 
agent  in  stopping  the  further  progress  of  the  disease  and  getting 
the  already  infected  tissues  into  a  healthy  state.  In  these  more 
advanced  cases,  however,  when  once  the  mucous  membrane  has 
been  destroyed,  it  is  not  an  easy  matter,  in  fact  it  may  be  impossible, 
to  prevent  the  re-infection  of  the  granulation  tissue  from  time  to 
time,  unless  great  care  is  taken  to  keep  the  surface  clean  and 
re-apply  the  cataphoresis  once  every  two  weeks. 

The  eventual  result  of  the  healing  is  the  formation  of  scar  tissue, 
with  an  amount  of  contraction  dependent  on  the  extent  of  i.he 
ulceration,  its  depth  and  the  position  of  the  ulceration ;  that  is  to 
say,  whether  it  has  encircled  the  bowel  or  whether  the  complete 
lumen  has  not  been  involved. 

This  contraction  is  one  of  the  most  common  forms  of  rectal 
stenosis,  apart  from  malignant  disease.  When  it  has  spread  up 
the  bowel  for  3  or  more  inches,  the  effects  on  the  expulsory 
powers  of  the  muscles,  apart  from  the  absolute  contraction  itself, 
are  such  that  chronic  intestinal  stasis  gradually  supervenes. 

Under  these  circumstances  there  is  only  one  really  effective 
treatment,  and  that  is  a  complete  excision  of  all  the  affected  tissue 
right  up  to  and  beyond  the  strictured  part,  until  healthy  mucous 
membrane  has  been  reached  and  separated  sufficiently  to  enable  it 
to  be  brought  down  to  the  skin  edge. 

This  operation  is  better  performed  from  the  perineum  than  by 
any  other  method ;  but  it  must  not  be  undertaken  without  a  proper 
appreciation  of  the  extreme  difficulty  of  the  operation,  which  is  a 
far  more  serious  matter  than  an  ordinary  excision  of  the  mucous 
membrane.  The  cause  of  the  difficulty  is  the  amount  of  fibrous 
tissue  which  has  to  be  cut  through.  This  tissue  is  very  dense  and 
has  a  large  number  of  adventitious  blood-vessels  in  it,  which  when 
cut  do  not  retract,  but  simply  gape  in  the  non-elastic  tissue  and 
bleed  profusely,  and  as  there  may  be  2  or  8  inches  of  this  tissue  to 
dissect  away  it  can  easily  be  imagined  that  the  operation  is  not 

89—2 


6i2  Infective  Ulcerative  Proctitis. 

easy.  Should  the  operation  be  undertaken  it  is  important  to 
remember  that  the  loss  of  blood  is  easily  checked  by  the  introduc- 
tion of  some  cotton -wool,  soaked  in  hazeline  and  water  at  the 
temperature  of  110°,  and  the  strength  1  drachm  to  the  pint. 
This  soon  checks  the  haemorrhage,  and  the  other  side  can  be 
attacked  whilst  the  plugging  remains  in  the  opposite  one,  and  so 
one  gradually  works  up  through  the  fibrous  tissue  to  healthy 
mucous  membrane. 

There  is  often  a  considerable  amount  of  shock  after  this  operation, 
and  the  patients  require  careful  nursing  for  some  days. 

In  some  instances,  where  the  ulceration  has  gone  so  high  that 
any  such  operation  as  has  just  been  described  is  out  of  the  question, 
it  is  far  better  to  dismiss  any  idea  of  a  radical  removal  and  to  be 
content  with  a  colotomy.  Probably  in  no  other  disease  is  this 
operation  so  permanently  beneficial  as  here. 

F.  C.  WALLIS. 


613 


MALFORMATIONS    OF    THE   RECTUM. 

A  NUMBER  of  malformations  of  the  rectum  are  described,  but  for 
the  practical  purposes  of  this  work  it  is  not  necessary  to  enumerate 
them. 

In  the  case  of  an  imperforate  anus  the  commonest  form  is  one  in 
which  a  thin  membrane  stretches  across  the  anal  outlet,  and  this 
can  be  made  tense  by  a  pressure  on  the  abdomen,  or  by  making 
the  child  cry.  This  malformation  is  easily  rectified  by  incising  the 
membrane  and  dilating  the  orifice  with  the  little  finger,  and  the 
dilatation  should  be  done  at  least  once  a  day  for  a  week  or  ten 
days. 

Should,  however,  the  blind  end  of  the  gut  be  separated  from 
the  anal  outlet  for  any  considerable  depth,  such  as  J  or  J  inch, 
the  child  must  be  placed  in  the  lithotomy  position  and  a  careful 
dissection  carried  out,  keeping  strictly  to  the  middle  line  until  the 
end  of  the  gut  is  found  and  opened. 

Stenosis  in  this  case  is  much  more  likely  to  occur  and  is 
difficult  to  overcome. 

In  cases  in  which  the  bowel  is  still  further  away  the  only  opera- 
tion worth  considering  is  a  colotomy  ;  but  this  is  a  severe  operation 
to  which  these  small  infants  often  succumb. 

F.  C.  WALUS. 


614 


RECTAL  NEUROSES   AND  OBSCURE   RECTAL  PAIN. 

THESE  are  misleading  terms  which  have  hitherto  been  associated 
with  a  certain  set  of  symptoms  for  which  no  cause  could  be 
assigned.  The  symptoms  are  pains  of  more  or  less  intense 
character  which  may  start  acutely  and  end  suddenly,  or  may  start 
quietly  and  gradually  work  up  to  intense  paroxysms,  the  attack 
lasting  for  some  hours  and  leaving  the  patient  in  an  exhausted 
condition. 

They  are  not  necessarily  associated  with  any  action  of  the 
bowels,  although  this  act  is  not  unfrequently  the  starting  point  of 
the  pains,  but  apart  from  this  the  paroxysms  of  pain  may  start  at 
any  time  without  any  warning,  and  may  even  wake  the  patient  up, 
and  they  are  therefore  not  necessarily  dependent  on  any  form 
of  exercise.  As  a  rule,  these  patients  suffer  for  years  before  any 
relief  is  sought,  and  when  this  time  arrives  they  are  often  in  a 
pitiable  nervous  condition,  and  their  whole  life  is  quite  spoilt  by 
this  untoward  trouble. 

In  every  case  of  this  kind  that  has  come  under  my  notice  I  have 
found  one  or  more  sub-mucous  tracks  running  up  from  the  sinuses 
of  Morgagni,  under  the  mucous  membrane  for  a  distance  of  f  inch 
to  1^  inches,  and  in  all  these  cases  an  absolute  cessation  of  all  the 
symptoms  has  been  effected  by  the  excision  of  a  complete  ring  of 
mucous  membrane,  going  well  above  the  sub-mucous  tracks  and 
bringing  healthy  mucous  membrane  to  the  margin. 

These  cases  require  careful  treatment  for  some  weeks  after  the 
operation,  and  special  care  must  be  taken  that  the  bowels  act 
regularly  ;  otherwise,  if  constipation  occurs  or  the  bowel  becomes 
distended  with  flatus,  the  paroxysmal  pain  may  for  the  time  being 
return  ;  this,  however,  is  easily  avoided  by  care  in  diet  and  a 
suitable  laxative. 

F.  C.  WALLIS. 


HEMORRHOIDS. 

FOE  the  purposes  of  treatment  haemorrhoids  may  be  divided  into 
two  classes,  external  and  internal. 

An  external  htemorrhoid  is  simply  a  clot  of  blood  in  the  super- 
ficial anal  tissues.  There  is  usually  only  one,  but  there  may 
be  more;  the  swelling  is  about  the  size  of  a  filbert,  tense  and  hard, 
the  skin  over  it  is  inflamed,  and  the  whole  swelling  is  extremely 
tender. 

When  these  cases  are  left  alone  they  may  either  gradually  sub- 
side, leaving  a  large  tag  of  skin,  or  they  may  suppurate  and  an 
abscess  may  form  and  burst,  often  leaving  a  small  subcuticular 
fistula. 

These  swellings  should  at  once  be  dealt  with  in  the  following 
manner  : 

The  swelling  is  frozen  by  spraying  it  with  ethyl-chloride  and  it 
is  incised  from  end  to  end  with  a  sharp-pointed  curved  bistoury, 
the  blood  clot  is  turned  out  and  an  elliptical  piece  of  the  skin 
removed.  The  remains  of  the  cavity  are  swabbed  out  with  pure 
hydrogen  peroxide  and  packed  with  dry  sterilised  gauze.  No 
chemical  irritants  or  powders  should  be  used.  The  gauze  is  soaked 
off  in  a  hip  bath  the  next  morning  and  vaseline  is  applied. 

The  relief  afforded  by  this  operation  is  immediate  and  the  small 
wound  is  healed  in  three  or  four  days. 

If  the  blood  clot  has  been  allowed  to  suppurate  the  case  must  be 
treated  as  any  other  abscess  and  fomented,  and  at  the  same  time  a 
freer  opening  for  the  discharge  of  pus  must  be  made  if  necessary. 

Internal  haemorrhoids  exist  in  the  neighbourhood  of  the  internal 
sphincter,  and  they  frequently  prolapse  and  bleed.  If  by  any 
chance  they  are  painful,  advice  for  them  is  sought  much  sooner 
than  when  the  main  symptom  is  haemorrhage. 

The  treatment  of  haemorrhoids  is  either  palliative  or  operative. 
As  far  as  palliative  measures  go,  there  is  no  complaint  for  which 
such  a  variety  of  drugs  is  advertised  as  there  is  in  the  case  of 
haemorrhoids,  and  all  sorts  of  special  cures  are  advertised  at  some 
length  and  considerable  expense  in  various  papers,  periodicals  and 
journals,  and  as  these  are  repeated  day  after  day,  week  after  week, 
and  month  after  month,  it  can  only  be  supposed  that  there  is  a 
large  sale  for  such  preparations,  but  as  for  their  efficacy  one  is 


616  Haemorrhoids. 

unable  to  get  many  facts,  except  in  the  form  of  statements  from 
interested  individuals.  The  great  trouble  in  these  instances  is 
that  the  patient  always  diagnoses  his  own  state,  and  such  a 
diagnosis  must  often  be  wrong,  and  thus  much  valuable  time  is 
lost.  But  apart  from  this,  there  is  no  doubt  that  much  may  be 
done  in  certain  cases  by  palliative  treatment. 

Diet. — This  in  a  large  number  of  cases  will  do  much  to  relieve 
symptoms  and  often  will  cure  the  patient  altogether.  And  it  is 
well  that  such  should  be  the  case,  as  the  patients  who  are  benefited 
by  this  treatment  are  usually  those  who  eat  and  drink  more  than 
is  good  for  them,  and  are  therefore  bad  subjects  for  operation. 
The  determining  factor  as  to  the  success  of  this  treatment  is  the 
patient  himself,  and  it  depends  whether  he  has  sufficient  moral 
courage  to  go  without  those  things  which  he  likes  only  too  well. 
If  a  patient  of  "  full  habit "  will  go  on  a  rigorous  diet  and  become 
a  teetotaller  and  keep  the  bowels  well  regulated  by  mild  aperients, 
he  will  not  only  give  himself  the  best  chance  of  getting  altogether 
rid  of  a  troublesome  complaint,  but  he  will  also  improve  his  general 
health  enormously.  He  will  not  only  prolong  his  life,  but  will  also 
enjoy  it  in  a  manner  which  he  will  soon  appreciate,  is  far  different 
from  the  transient  enjoyment  and  certain  subsequent  depression 
which  follows  on  the  periodic  excesses  which  were  his  former 
habit. 

Drags. — It  is  useless  to  try  and  keep  pace  with  all  the  drugs  that 
come  out  every  month  as  cures  for  haemorrhoids,  and  the  best 
method  to  adopt  is  to  remember  what  are  the  most  prominent 
symptoms  and  to  know  of  something  which  gives  this  or  that 
symptom  relief. 

The  main  symptoms  complained  of  are  haemorrhage,  pain  and 
prolapse. 

Haemorrhage. — This  symptom,  especially  when  associated  with 
prolapse,  is  often  severe,  and  a  quantity  of  blood  may  be  lost.  As 
an  immediate  treatment  nothing  is  better  or  more  effective  than 
the  use  of  hot  water  at  a  temperature  of  105°,  with  1  drachm 
of  the  extract  of  witch  hazel  to  the  pint  of  water.  Bathing  with 
this,  and  after  a  few  minutes  firm  pressure  with  some  cotton -wool 
steeped  in  this  hot  solution  will  not  only  stop  the  haemorrhage, 
but  will  also  enable  the  piles  to  be  reduced,  and  at  the  same  time 
alleviate  the  pain. 

Profound  anaemia  is  often  the  result  of  daily  small  losses  of 
blood,  and  I  have  seen  more  than  one  case  of  extreme  anaemia  due 
to  this  cause  which  had  been  treated  for  everything  but  the 
absolute  cause,  because  it  had  not  been  mentioned  by  the  patient 


Haemorrhoids.  617 

and  was  not  thought  of  by  the  medical  man.  These  cases  are  more 
commonly  met  with  in  women,  who  are  not  apt  to  notice  or  at 
least  to  pay  much  attention  to  these  daily  small  losses  of  blood. 
It  is  as  well,  therefore,  in  any  case  of  anaemia,  when  the  cause  is 
not  obvious,  to  make  it  a  routine  matter  to  enquire  whether  there 
is  any  loss  of  blood  from  the  rectum. 

Suppositories  of  hazeline  or  hemisine,  made  up  in  a  particular 
form  by  Burroughs  &  Wellcome  and  called  "  enules,"  are  par- 
ticularly serviceable  in  checking  rectal  haemorrhage,  and  should  be 
introduced  into  the  bowel  after  it  has  acted,  and  this  may  be  done 
every  day  for  about  ten  days,  and  will  either  greatly  modify  the 
bleeding,  or  in  a  fair  number  of  cases  will  stop  it  altogether  for  a 
time  ;  but  I  have  not  seen  any  cases  of  well-established  haemorrhoids 
ever  get  cured  by  this  treatment. 

The  following  ointment  will  be  found  of  use  and  comfort 
to  the  patient :  Cocaine  Hydrochlorate,  48  gr.  ;  Bismuth  Sub- 
nitrate,  15  gr.  ;  Lanoline,  1  oz.  This  should  be  applied  before  the 
bowels  act. 

Perhaps  the  best  and  most  useful  ointment  is  one  made  of  sub- 
chloride  of  mercury,  10  gr.  to  the  ounce  of  vaseline.  This  is  a 
palliative,  and  has  decided  antiseptic  qualities.  Injections  of  cold 
water  are  much  advocated,  especially  as  a  preventative ;  but 
although  this  treatment  has  an  astringent  effect,  especially  if  a 
little  hazeline  extract  is  added,  the  results  often  cause  a. consider- 
able amount  of  discomfort,  as  all  the  fluid  is  not  returned  at  the 
time  and  comes  away  later.  To  obviate  this  a  tube  should  be  kept 
in  the  rectum  for  a  few  minutes,  from  which  the  fluid  escapes. 

Pain. — Pain  is  not  such  a  common  symptom  in  haemorrhoids  as 
would  be  expected,  and  the  pain  of  an  external  haemorrhoid  is  far 
more  acute  than  from  any  form  of  internal  piles,  except  when  these 
are  prolapsed  and  strangulated.  If  a  pile  becomes  inflamed,  or 
if  it  is  associated  with  a  fissure  or  a  sub-mucous  pocket,  then  there 
will  be  acute  pain,  especially  after  defaecation,  but  these  latter  pains 
are  more  the  result  of  the  added  condition  than  of  the  pile  itself. 
The  ordinary  feeling  caused  by  these  internal  piles  is  one  of  weight 
and  a  dull  ache,  and  with  this  there  is  a  marked  state  of  mental 
depression. 

When  there  is  much  tenesmus  and  bearing-down  pain  after  the 
bowels  have  acted,  the  following  enema,  taken  from  St.  Mark's 
Hospital  pharmacopoeia,  is  of  use  :  Heroin,  £  gr. ;  Glycerine,  1  fluid 
drachm ;  Water,  to  %  fluid  ounce ;  but  a  hot  hip  bath  and  the  sub- 
sequent application  of  some  of  the  cocaine  and  bismuth  ointment 
will  be  found  more  helpful  than  anything  else. 


618  Haemorrhoids. 

A  certain  amount  of  relief  can  be  obtained  by  the  interstitial 
injection  of  any  pile  which  prolapses  and  can  be  reduced. 

From  5  to  8  min.  (dependent  upon  the  size  of  the  pile)  of  one 
or  other  of  the  following  prescriptions  is  injected  by  a  hypodermic 
needle  into  the  centre  of  the  pile,  after  which  the  pile  is  reduced  into 
the  bowel :  Liquified  Carbolic  Acid,  48  min. ;  Glycerine,  2  fluid 
drachms ;  Distilled  Water,  2  fluid  drachms  ;  or  Liquified  Carbolic 
Acid,  48  min. ;  Ponds'  Extract,  |  fluid  ounce  ;  Water,  ^  fluid  ounce. 

If  this  is  done  carefully  no  harm  will  happen ;  in  most  cases 
there  is  great  temporary  relief,  and  this  may  last  for  a  year  or 
more,  but  it  must  not  be  regarded  in  any  way  as  a  permanent  cure. 

OPERATIONS. 

Probably  the  best  operation  for  a  man  in  general  practice  is  that 
of  ligature.  It  is  an  operation  which  is  quite  simple  and  as  a  rule 
quite  effectual ;  but  at  the  same  time  it  cannot  be  said  that  it  is  free 
from  all  risks.  The  risks  are,  secondary  hemorrhage  and  post- 
operative infective  ulceration,  also  stricture  may  occur. 

The  operation  is  done  as  follows  : 

The  patient  is  either  on  the  side  or  in  the  lithotomy  position. 
The  sphincter  is  moderately  stretched  and  the  extent,  size  and 
number  of  the  piles  are  ascertained.  Forceps  are  applied  to  each 
pile  and  those  in  the  most  dependent  part  are  ligatured  first. 

The  pile  being  pulled  down,  a  pair  of  pile  scissors  held  parallel 
to  the  line  of  the  bowel  divides  the  skin  £  inch  from  the  anal 
margin,  and  then  cuts  steadily  up  to  the  upper  end  of  the  pile,  and 
when  once  the  pile  area  is  passed  the  cut  segment  of  mucous 
membrane  is  narrowed  considerably  so  that  it  only  contains  the 
mucous  membrane  and  the  blood-vessels.  The  pile  so  separated  is 
now  pulled  down  and  held  down  by  an  assistant,  whilst  a  stout  silk 
ligature  is  passed  round  the  base  of  the  pile  and  tied  tightly.  This 
ligature  must  be  tied  close  up  to  the  end  of  the  cut,  otherwise  the 
knot  may  be  just  below  a  divided  vessel,  and  when  the  ligature  is 
returned  to  the  bowel  haemorrhage  will  continue.  This  is  troublesome 
to  control,  as  the  whole  process  of  applying  the  ligature  has  to  be  done 
over  again,  without  most  of  the  facilities  for  doing  it,  but  this  must 
absolutely  be  persevered  in  until  all  the  haemorrhage  has  stopped. 

After  the  ligature  has  been  tied  some  operators  leave  the  pile 
mass  and  return  it  back  into  the  rectum,  with  the  object  of  prevent- 
ing secondary  haemorrhage,  and  no  doubt  as  far  as  this  goes  there 
is  some  definite  object  gained.  The  best  way,  however,  to  treat  the 
ligatured  pile  is  to  remove  the  bulk  of  it,  leaving  just  sufficient  of 


Haemorrhoids.  619 

the  pile  mass  to  prevent  the  slipping  of  the  ligature  and  only  a 
small  amount  of  the  tissue  need  be  left  to  ensure  the  safety  of  this. 
The  ligatures  are  now  cut,  leaving  about  2  inches  of  each  ligature 
outside  the  anus.  Four  inches  of  a  i-inch  rubber  tube  are  inserted 
into  the  bowel,  and  between  it  and  the  bowel  some  narrow  plain 
sterilised  gauze,  steeped  in  hazeline  solution,  is  packed  in  between 
the  tube  and  the  operation  area;  some  more  gauze  and  cotton- 
wool kept  in  place  with  a  T-bandage  complete  the  operation. 

The  bowels  are  opened  on  the  third  day  and  the  ligatures  come 
away  on  the  seventh  or  eighth  clay.  After  the  bowels  are  opened 
the  patient  sits  in  a  warm  bath  twice  daily,  and  the  wound  itself  is 
further  irrigated  with  some  antiseptic  solution,  such  as  1  in  1,000 
perchloride  of  mercury,  and  some  wool  soaked  in  this  lotion  is 
introduced  into  the  bowel.  The  patient  is  sufficiently  well  to  leave 
the  hospital  or  home  in  about  fourteen  days,  and  the  wound  is 
usually  healed  in  three  weeks  or  a  month.  After  the  first  ten  days 
the  introduction  of  the  cotton-wool  can  be  discontinued  and  the 
subchloride  of  mercury  ointment  introduced  into  the  bowel.  At 
the  end  of  three  weeks  a  digital  examination  of  the  bowel  should 
be  made  to  ensure  that  there  is  no  commencing  stenosis,  and  this  is 
particularly  necessary  when  four  or  five  large  piles  have  been  tied 
and  a  large  area  has  to  granulate.  Any  such  tendency  is  easily 
dealt  with  when  it  is  discovered  at  this  stage,  and  it  is  a  detail 
which  should  never  be  omitted  in  the  after-treatment. 

Secondary  Hemorrhage. — This  may  occur  during  the  first  twenty- 
four  hours  after  the  operation,  or  at  the  time  when  the  ligatures 
come  away,  although  at  either  time  hemorrhage  is  quite  unusual. 
The  indications  are  pallor,  extreme  faintness,  sweating  and  yawning, 
and  a  typical  pulse  of  haemorrhage.  The  patient  should  be  at  once 
examined  by  the  bowel,  and  as  the  finger  is  passed  through  the 
sphincter  a  gush  of  blood  will  come  and  the  rectum  will  be  found 
to  be  filled  with  blood  and  clots.  The  patient,  when  possible, 
should  at  once  be  anaesthetised — the  open  ether  method  being  the 
best  possible — and  the  rectum  should  be  washed  out  with  some  hot 
hazeline  solution  and  the  bleeding  point  sought  for  and  dealt  with. 
Should  it  not  be  possible  to  find  the  bleeding  point,  then  the  rectum 
should  be  packed  firmly  round  a  "  petticoated "  tube  with  some 
gauze  steeped  in  hazeline  solution.  This  should  be  left  for  two  days 
and  then  should  be  carefully  removed.  The  case  is  treated  as 
already  indicated,  but  these  patients  want  careful  handling  for  some 
days  after,  and  as  a  rule  their  recovery  is  considerably  delayed. 

The  operation  by  clamp  and  cautery  is  probably  simpler  than 
that  by  ligature,  and  is  done  to  best  advantage  when  there  are 


620  Haemorrhoids. 

three  or  four  piles  with  a,  narrow  base.  When  this  operation  is 
undertaken  it  is  better  that  the  patient  should  be  in  the  lithotomy 
position.  Each  pile  is  brought  out  and  held  apart  from  the  others, 
the  clamp  is  applied  to  the  base  of  the  pile,  and  after  the  surround- 
ing tissues  have  been  covered  with  vaseline  the  cautery  is  applied 
to  the  pile,  which  is  removed  by  this  means,  leaving  \  inch  of 
tissue  above  the  clamp.  The  next  pile  is  now  treated  in  the  same 
manner,  whilst  the  first  clamp  is  left  in  position.  After  the  second 
pile  has  been  removed  the  first  clamp  is  removed  quietly  and  with 
as  little  disturbance  of  the  burnt  margin  as  possible.  The  next 
pile  is  removed  and  then  number  two  clamp  is  released,  and  so  on 
until  all  the  piles  have  been  removed.  The  mucous  membrane  is 
allowed  to  return  to  the  bowel  and  no  further  dressing  or  applica- 
tion is  necessary,  unless  there  is  some  haemorrhage,  when  a  tube  is 
inserted  into  the  rectum  and  a  dressing  applied  outside.  A 
purge  is  given  on  the  third  day,  after  which  the  bowel  is  irrigated 
with  perchloride  of  mercury  solution  (strength  1  in  1,000). 
Some  ointment  of  the  same  salt  is  introduced  into  the  bowel  twice 
a  day. 

The  patient  is  well  enough  to  get  about  at  the  end  of  ten  days, 
and  the  wound  is  probably  healed  in  three  weeks. 

A  great  deal  has  been  said  for  and  against  this  operation,  but 
under  the  circumstances  just  suggested  the  operation  is  a  good  one, 
and  has  the  advantage  of  simplicity.  The  post-operative  sequelae 
are  the  same  as  in  the  last  operation  ;  but  haemorrhage  appears  to 
be  more  frequent,  after  the  clamp  and  cautery. 

These  two  operations  are  the  best  for  general  practice  ;  but  in 
giving  a  prognosis  it  is  as  well  not  to  suggest  that  anything  in  the 
shape  of  a  radical  operation  has  been  done. 

The  only  radical  operation  is  one  which  removes  the  whole  pile- 
bearing  area,  and  for  the  description  of  this  operation  I  must  refer 
my  readers  to  my  book  on  "Surgery  of  the  Rectum,"  where  it  is 
set  out  in  detail.  The  advantage  of  this  operation  is  that  in 
addition  to  removing  the  existing  haemorrhoids  and  the  rest  of  the 
pile-bearing  tissue  it  is  a  preventive  to  the  occurrence  of  abscess, 
fistula,  pruritus,  and  those  other  maladies  which  originate  in  the 
ano-rectal  area. 

F.  C.  WALLIS. 


621 


PROLAPSE  AND  PROCIDENTIA  OF  THE  RECTUM. 

PROLAPSE  of  the  mucous  membrane  of  the  rectum  occasional!}" 
occurs  in  children  and  is  usually  the  result  of  constipation, 
diarrhoea,  or  bad  habits  of  children's  nurses  in  making  children  sit 
and  strain  until  the  bowels  act. 

These  cases  are,  except  when  due  to  diarrhoea,  which  is  usually 


FIG.  1. — Prolapsed  bowel,  showing  lines  for  actual  cautery. 

produced  by  bad  feeding,  best  treated  with  some  gentle  laxative  and 
getting  the  bowels  to  act  whilst  the  child  is  lying  down ;  after  this 
the  protruding  mucous  membrane  is  bathed  with  some  alum  lotion 
and  then  returned.  A  few  weeks  of  this  treatment  usually  cure 
these  patients,  audit  is  rare  that  any  kind  of  operation  is  necessary; 
it  certainly  is  never  desirable  in  children. 

In  adults  the  application  of  the  actual  cautery  is  certainly  well 
worth  trying  in  a  large  number  of  cases,  and  this  is  done  in  the 
following  manner  :  The  patient  being  anaesthetised  and  placed  in 
the  lithotomy  position,  the  prolapse  is  pulled  down  to  its  fullest 
extent  and  a  cautery  is  applied  to  the  mucous  membrane  anteriorly, 
posteriorly  and  each  side,  from  the  highest  part  of  the  prolapse 


622  Prolapse  and  Procidentia  of  the  Rectum. 


FIG.  2. — Complete  prolapse  of  the  rectum. 
(From  Wallis's  Surgery  of  tne  Rectum,  Bailliere.) 

down  to  the  skin  edge,  and  the  mucous  membrane  is  burned  well 
through  three-quarters  of  its  depth.     The  bowel  is  then  returned, 


FIG.  3. — -The  folding  up  of  the  muscular  coat  of 
that  part  of  the  bowel  from  which  the 
mucous  membrane  has  been  removed. 

(From  Wallis's  Surgery  of  the  Rectum,  Bailliere.) 

and  the  patient  put  to  bed  and  kept  there  for  between  two  and 
three  weeks,  the  diet  and  bowels  being  during  this  period  carefully 


Prolapse  and  Procidentia  of  the  Rectum.  623 

regulated.  This  treatment  is  often  effective  after  one  application ; 
but  if  some  prolapse  still  remains  there  is  no  reason  why  the 
process  should  not  be  repeated. 

Operations. — There  are  many  operations  which  have  been  from 
time  to  time  invented  for  the  cure  of  what  is  certainly  a  most 
troublesome  complaint ;  but  it  must  be  said  of  some  of  them  that 
much  ingenuity  has  been  displayed  to  create  an  elaborate  operation 
for  a  trouble  that  can  be  cured  by  much  simpler  measures. 

When  the  prolapse  does  not  extend  beyond  2£  to  3  inches,  it  can 
be  treated  by  dissecting  off  the  prolapsed  part  of  the  mucous 
membrane,  sewing  the  cut  edge  of  the  mucous  membrane  to 
the  skin  edge,  and  treating  the  case  as  an  ordinary  excision  for 
haemorrhoids. 

When  the  prolapse  is  considerable  the  best  treatment  is  a 
tigmoidoptxy,  and  this  is  best  done  by  opening  the  abdomen  in  the 
left  semilunar  line  about  1^  inches  from  the  iliac  spine.  The  colon 
is  then  pulled  up  until  the  prolapse  has  completely  disappeared, 
and  an  assistant's  finger  in  the  bowel'  can  tell  when  this  has 
occurred ;  four  to  six  sutures  are  now  passed  through  the  muscular 
band  on  the  colon,  and  tied  up  to  the  anterior  parietes ;  the 
abdominal  wound  is  closed  in  the  ordinary  way.  The  patient  is  kept 
more  or  less  flat  in  bed  for  at  least  six  weeks,  and  during  this  time 
the  bowels  are  carefully  regulated. 

The  results  of  this  operation  are,  in  my  experience,  so  good  that  I 
have  never  understood  the  necessity  of  resorting  to  any  of  the  com- 
plicated operations  which  render  the  rectum  a  rigid  tube,  and  are 
full  of  the  possibilities  of  suppuration. 

F.  C.  WALLIS. 


624 


SIMPLE  TUMOURS  OF  THE  RECTUM. 

THE  simple  tumours  of  the  rectum  are  :  (1)  Single  pedunculated 
polypi,  (2)  multiple  polypi,  and  (3)  adenomata. 

The  treatment  of  single  polypi  is  quite  simple ;  they  are  usually 
situated  low  down  in  the  rectum  and  can  be  pulled  outside  the  anus ; 
as  they  are  always  pedunculated,  a  ligature  can  be  tied  round 
the  pedicle  and  the  polypus  removed  with  scissors.  No  further 
treatment  is  necessary. 

Multiple  polypi  are  best  left  alone  unless  some  urgent  symptom 
such  as  haemorrhage  arises,  which  may  necessitate  a  serious  opera- 
tion ;  but  this  is  rarely,  if  ever,  necessary,  as  any  excessive 
haemorrhage  can  usuallybe  controlled  by  injections  of  hot  water 
and  hazeline. 

If  an  adenoma  is  pedunculated  it  can  be  treated  as  a  simple 
polypus,  but  if  it  is  sessile,  and  they  mostly  are,  it  is  necessary  to 
remove  an  elliptical  piece  of  mucous  membrane  with  the  base  of  the 
tumour.  This  is  a  simple  matter  when  the  tumour  is  low  down  in 
the  bowel,  but  quite  the  reverse  when  it  is  high  up,  and  the 
operation  should  not  be  lightly  undertaken. 

It  must  always  be  remembered  that  these  innocent  tumours,  if 
left,  are  apt  to  become  malignant,  and  so  much  is  this  my  experience 
that  I  have  no  hesitation  in  saying  that  when  these  tumours  are 
known  to  exist  it  is  a  positive  duty  to  have  them  removed. 

Villous  tumours,  although  they  may  originally  have  no  malignant 
microscopical  elements  in  their  structure,  are  yet  so  peculiarly  apt 
to  become  malignant,  if  not  thoroughly  removed,  that  it  is  essential 
that  these  growths  should  be  treated  as  malignant. 

F.  C.  WALLIS. 


625 


MALIGNANT  GROWTHS  OF  THE  RECTUM. 

THE  operative  treatment  of  malignant  growths  of  the  rectum  is 
now  in  an  interesting  process  of  transition,  and  there  is  no  doubt 
from  the  recent  pathological  progress  which  has  been  made  that  the 
operation  known  as  the  abdomino-anal  operation  will  be  much 
more  often  performed  than  heretofore  ;  but  here,  again,  each  case 
must  be  treated  on  its  own  merit  and  upon  the  strength,  constitu- 
tion and  build  of  the  particular  patient,  always  supposing  that  the 
growth  is  a  removable  one,  and  in  many  cases  this  cannot  be 
decided  one  way  or  another  until  the  abdomen  has  been  opened 
and  a  thorough  examination  made.  It  is  not  within  the  scope  of- 
this  work  to  discuss  these,  the  most  difficult  operations  in  surgery, 
in  detail ;  but  it  may  be  briefly  said  that  although  the  future 
operative  measures  for  these  growths  may  be  even  of  a  greater 
magnitude  than  in  the  past,  yet  it  is  certain  that  far  better  results 
will  be  obtained  by  these  means  than  by  most  of  those  at  present 
employed. 

A  polypus  or  adenoma  which  has  become  malignant  may  be 
removed  through  the  anal  opening,  and  a  villous  tumour  may  be 
removed  by  the  ano-coccygeal  route;  but  nearly  all  malignant 
growths  originating  in  the  mucous  membrane  of  the  bowel  are  best 
dealt  with  by  the  abdomino-anal  method,  unless  the  patient  is  too 
fat.  And  in  almost  all  cases  the  abdomen  should  be  opened  as  a 
routine  so  that  the  extent  of  the  growth  may  be  thoroughly  made  out. 

Growths  involving  the  anus  and  also  probably  the  sphincter 
muscle  must  be  removed  quite  freely,  and  at  the  same  time  the 
inguinal  glands  on  both  sides  are  removed.  These  cases  do  well, 
and  it  is  extraordinary  what  a  small  amount  of  discomfort  arises  if 
the  bowels  are  thoroughly  emptied  with  an  enema  each  morning. 


F.  C.  WALLIS. 


COLOTOMY. 
Se<>  Cancer  of  the  Colon,  p.  578. 


S.T.  — VOL.    II.  40 


626 


DISEASES  AND  AFFECTIONS  OF  THE 
PERITONEUM. 

ASCITES. 

As  free  fluid  in  the  abdominal  cavity  may  be  due  to  many  causes, 
the  treatment  necessarily  varies  to  some  extent  with  the  underlying 
factor  in  each  case.  Thus,  when  the  cause  is  known  and  is  amen- 
able to  treatment,  as  in  syphilitic  disease  of  the  liver,  the  backward 
pressure  of  heart  disease,  ovarian  papilloma  with  implantation 
growths  on  the  peritoneum,  and  tuberculosis  of  the  peritoneum,  it 
should  be  thoroughly  treated.  In  many  cases,  however,  as  in 
simple  chronic  peritonitis,  malignant  disease  and  hepatic  cirrhosis, 
the  treatment  of  ascites  is  mainly  symptomatic  or  palliative.  It 
will  be  most  convenient  to  describe  in  the  first  place  the  general 
treatment  of  ascites  and  then  to  deal  with  special  forms. 

General  Treatment. — The  patient  should  be  kept  at  rest  and 
mainly  in  bed,  the  head  and  shoulders  being  somewhat  raised  so 
as  to  obviate  upward  pressure  on  the  diaphragm  ;  chill  and 
exposure  to  draughts  should  be  avoided.  In  the  chronic  cases 
in  which  the  patient  is  not  entirely  in  bed,  some  relief  to  the 
feeling  of  weight  in  the  distended  abdomen  may  be  obtained 
by  wearing  a  binder  or  belt.  By  strapping  the  abdomen  firmly 
with  adhesive  plaster  an  attempt  is  sometimes  made  to  prevent 
recurrence  of  ascites,  but  a  careful  watch  must  be  kept  to  see  that 
it  does  not  give  rise  to  pulmonary  embarrassment. 

The  method  of  restriction  of  the  fluid  intake  is  chiefly  of  use 
in  ascites  due  to  cardiac  failure  and  to  renal  disease.  When 
this  plan  is  adopted,  the  amount  of  fluid  should  be  gradually 
diminished,  the  quantity  being  progressively  curtailed  day  by  day 
until  20  to  30  oz.  only  are  taken,  and  care  must  be  taken  to  avoid 
constipation  and  discomfort  from  thirst.  A  salt-free  diet  should 
be  tried  in  order  to  diminish  the  effusion  of  fluid  into  the 
peritoneum  due  to  the  retention  of  chlorides,  but  the  results 
are  somewhat  disappointing. 

The  diet  should  be  as  nourishing  as  is  possible  in  the 
circumstances,  and  generally  speaking  should  consist  of  eggs, 
fresh  fish,  mutton,  chicken,  junket,  milk  puddings,  bread,  butter, 
cream  and  some  fresh  fruit.  Much  farinaceous  food,  potatoes 
and  cabbage  must  be  avoided  on  account  of  their  liability  to 


Ascites.  627 

produce  fermentation  and  flatulence.  Irritating  articles,  such 
as  spices  and  pickles,  and  alcoholic  stimulants  should  be  prohibited 
or  reduced  to  a  minimum.  The  diet  necessarily  varies  in  different 
cases  and  according  to  the  patient's  powers  of  digestion  and  other 
factors;  in  secondary  malignant  disease  of  the  peritoneum  the 
patient's  own  wishes  may  largely  dictate  the  diet,  whilst  in  hepatic 
cirrhosis  a  simple  diet,  mainly  of  milk,  should  be  enforced . 

Pain  and  discomfort  due  to  abdominal  distension  are  aggra- 
vated by  tympanitic  distension,  and  may  to  some  extent  be  relieved 
by  minimising  fermentation  and  the  production  of  gas  in  the 
intestines  by  careful  dieting  with  restriction  of  carbohydrates, 
by  the  administration  of  drugs  which  prevent  fermentation,  such 
as  guaiacol  carbonate  (5  gr.,  in  a  cachet  three  times  a  day),  naph- 
thalin  tetrachloride  (7  gr.,  three  times  a  day),  calomel  (^  gr., 
three  times  a  day)  taken  with  food,  and  by  carminatives,  such 
as  a  mixture  of  spiritus  chloroformi  10  rnin.,  spiritus  ammoniae 
arornat.  30  min.,  aquae  menth.  pip.  5  ss.,  infusum  caryo- 
phylli  ad  2  oz.,  or  tablets  of  peppermint  or  powdered 
charcoal.  Purgation  by  blue  pill  at  night,  followed  next  morning 
by  magnesium  sulphate  (5  ss.)  in  hot  water,  will  also  diminish 
flatulent  distension.  For  the  pain  and  discomfort  due  solely  to 
the  ascitic  accumulation,  tapping  is  the  proper  remedy. 

MEASURES  FOR  THE  REMOVAL  OF  THE  ASCITES. 
If,  with  rest  in  bed  and  the  appropriate'  treatment  of  the  cause, 
the  amount  of  ascites  remains  small  or  diminishes,  treatment 
by  other  means  is  unnecessary.  But  when  the  ascites  is  con- 
siderable or  increasing  progressively,  measures  for  its  removal 
must  be  taken;  these  may  be  considered  under  the  following 
heads,  but  more  than  one  ma}'  be  employed  at  the  same  time. 

(1)  Purgatives. — Moderate  purgation  may  do  good  not  only  by 
abstracting  fluid  but  also  by  preventing  intestinal  auto-intoxication 
and   flatulent   distension.     Drastic   purgatives,  such   as  gamboge 
or  elateriurn,  should  be  avoided,  as  the  patient's  resistance    and 
nutrition   may  suffer  from  excessive  purging.     Pilula  hydrargyri 
[U.S.P.    Massa     hydrargyri]    (5    gr.)    overnight,    followed     next 
morning  by  \  oz.  of  magnesium  sulphate  in  as  small  a  quantity 
of  hot  water  as  is  necessary  to  dissolve  it,  may  be  given  twice  or 
three  times  a  week.     Compound  jalap  powder  (30  gr.)  may  also  be 
given,  or  repeated  doses  at  three-hourly  intervals  of  magnesium 
sulphate  and  sodium  sulphate,  2  drachms  of  each  in  water,  until  a 
free  action  is  obtained. 

(2)  Diuretics  are  most  likely  to  be  useful  in  cases  in  which  the 

40—2 


628  Ascites. 

ascites  is  not  excessive  ;  for  in  the  presence  of  a  large  peritoneal 
effusion  pressure  on  the  renal  veins  may  interfere  with  the  action 
of  these  drugs.  The  choice  of  a  diuretic  will  depend  on  whether 
the  cause  is  known  or  not ;  thus,  in  heart  disease  digitalis  alone 
or  in  combination  should  be  given,  a  good  combination  being  a 
pill  of  powdered  digitalis  leaves  (|  gr.,  squill  1  gr.,  blue  pill 
[U.S.P.  mass  of  mercury]  2  gr.).  Digitalis,  in  the  form  of 
a  physiologically  standardised  solution,  may  be  combined  with 
diuretin  (5  to  10  gr.)  or  with  citrate  of  caffeine  (5  gr.),  or 
with  theocin  (3  gr.),  and  given  three  times  a  day.  In  cases  in 
which  the  cause  is  not  clear,  and  the  kidneys  are  not  obviously 
affected,  a  mixture  containing  liquor  ammonii  acetatis  1  drachm, 
spiritus  aetheris  nitrosi  20  mmv  spiritus  juniperi  20  min.,  infusuni 
scoparii  ad  1  oz.,  may  be  given  three  times  a  day.  Copaiba 
resin  (7  \  gr.)  in  keratin  capsules,  so  as  to  avoid  gastric  irrita- 
tion, may  be  given  three  times  a  day  after  food,  and  sometimes 
acts  extremely  well,  but  care  must  be  taken  to  see  that  it  does  not 
disturb  digestion.  Tincture  of  apocynum  (20, rnin.),  given  with 
tincture  of  cannabis  indica  (2  £  min.)  to  counteract  its  irritating 
effect  on  the  gastric  mucosa,  sometimes  has  a  good  effect.  Urea 
(10  gr.)  has  also  been  recommended. 

(3)  Diaphoresis. — The  use  of  hot-air  or  hot-water  baths,  the 
internal  use  of  liquor  ammonii  acetatis  and  spiritus  aetheris  nitrosi, 
and  the  hypodermic  injection  of  pilocarpine  (^  gr.),  though  useful 
in  the  treatment  of  general  dropsy  due  to  renal  disease,  have 
comparatively  little  effect  on  ascites  alone. 

Indications  for  Paracentesis. — When  the  mechanical  dis- 
tension gives  rise  to  abdominal  pain  and  this  is  not  relieved  by 
the  administration  of  carminatives  and  the  other  remedies  for 
flatulence  already  mentioned  (p.  627),  the  abdomen  should  be  tapped 
without  delay.  Eespiratory  embarrassment,  as  shown  by  dyspnrea, 
by  oedema  and  crepitations  at  the  bases  of  the  lungs,  and,  in 
extreme  cases,  by  haemoptysis  due  to  congestion,  demands  para- 
centesis.  The  presence  of  other  thoracic  complications,  such  as 
pleural  effusion  or  general  bronchitis,  also  renders  this  procedure 
desirable.  Abdominal  distension,  especially  when  repeated,  may 
give  rise  to  eversion  of  the  umbilicus,  which  becomes  so  thin  that, 
if  the  condition  is  allowed  to  persist,  rupture  may  eventually  occur; 
this,  of  course,  should  be  anticipated  by  removal  of  the  ascites. 
Another  indication  for  paracentesis  is  a  considerable  diminution 
in  the  urinary  excretion.  The  occurrence  of  hsematemesis  in 
a  patient  with  cirrhosis  is  a  signal  for  paracentesis  of  concomitant 
ascites.  In  alcoholic  patients  signs  of  incipient  delirium  tremens 


Ascites.  629 

make  it  advisable  to  tap  a  moderate  ascites  before  the  mental 
symptoms  advance  further.  As  a  general  rule,  an  ascitic  abdomen 
should  not  be  tapped  merely  because  it  contains  fluid,  but  only  for 
one  of  the  indications  stated  above.  The  reason  for  this  caution 
is  that  tapping  may  initiate  or  perpetuate  a  low  grade  of  peritonitis. 

Method  of  Tapping  the  Abdomen. — The  site  of  the  tapping  is 
usually  in  the  middle  line  midway  between  the  umbilicus  and  the 
pubes.  When  on  account  of  adhesions  no  fluid  is  withdrawn  in  this 
region,  the  puncture  must  be  made  elsewhere,  for  example  at  a 
point  halfway  along  a  line  drawn  from  the  anterior  superior  spine 
of  the  ilium  to  the  umbilicus.  In  order  to  avoid  the  danger  of 
wounding  the  caecum,  the  left  side  is  chosen  rather  than  the  right. 
In  very  rare  instances  the  trunk  or  a  branch  of  the  deep  epigastric 
artery  has  been  wounded  by  the  trocar,  and  severe  or  even  fatal 
haemorrhage  has  resulted.  This  accident  should  be  suspected  if 
arterial  blood  comes  in  spurts.  In  such  cases  the  artery  must  be 
cut  down  upon  and  ligatured. 

The  patient  should  be  propped  up  in  a  sitting  position  in  bed  or 
if  weak  should  lie  on  his  back  in  bed  with  the  head  and  shoulders 
raised.  The  urinary  bladder  should  be  emptied,  if  necessary  by  a 
catheter ;  and  the  site  of  the  proposed  puncture,  which  has  been 
found  to  be  dull  on  percussion,  should  be  washed  and  rendered 
aseptic.  A  many-tailed  flannel  bandage  should  be  placed  in  posi- 
tion behind  the  back,  so  that  it  can  be  tightened  directly  the 
puncture  is  made.  It  is  advisable  to  remove  the  fluid  slowly  by 
means  of  a  Southey's  trocar  and  cannula  rather  than  to  use  a  larger 
trocar  which  empties  the  peritoneal  cavity  more  rapidly,  as  rapid 
evacuation  occasionally  leads  to  faintness,  though  this  should  be 
prevented  by  keeping  up  the  intra-abdommal  pressure  by  a  bandage 
or  binder  which  is  progressively  tightened.  The  Southey's  cannula 
has  a  shield  fixed  on  it  close  to  its  head  by  means  of  a  screwed  top ; 
the  object  of  the  shield  is  to  enable  the  cannula  to  be  kept  in 
position  by  pieces  of  plaster.  A  piece  of  rubber  tubing  several  feet 
long  is  tied  with  thread  over  the  screw  top  of  the  cannula  ;  the 
tubing  is  then  pulled  tight  over  the  top  of  the  cannula,  and  the 
trocar  pushed  through  so  that  its  point  just  emerges  at  the 
end  of  the  cannula.  It  is  important  that  the  pointed  end  of 
the  trocar  and  enclosing  cannula  should  fit  smoothly  and  accu- 
rately, as  any  projection  of  the  margin  of  the  cannula  will 
interfere  with  the  clean  puncture  of  the  skin  and  hurt  the  patient. 
The  skin  is  sometimes  incised  before  the  trocar  is  introduced,  but 
this  is  not  necessary.  In  nervous  patients  the  pain  of  the  puncture 
may  be  minimised  by  freezing  the  skin  by  a  chloride  of  ethyl  spray 


630  Ascites. 

or,  less  conveniently,  by  the  application  of  a  piece  of  ice  ;  or  as  an 
alternative  local  infiltration  anaesthesia  of  the  skin  with  a  solution 
of  jS-eucaine  (1  in  500)  can  be  employed. 

The  trocar  and  cannula,  previously  sterilised,  are  sharply  plunged 
through  the  abdominal  wall  at  the  selected  spot,  care  of  course  being 
taken  to  avoid  any  obvious  veins  ;  the  trocar  is  then  withdrawn, 
the  cannula  being  left  in  position.  The  puncture  in  the  elastic 
rubber  tube  closes  by  retraction  and  should  not  leak.  The  shield  is 
kept  in  contact  with  the  abdominal  wall  by  two  slips  of  adherent 
plaster,  in  which  little  nicks  are  make  to  correspond  with  the 
cannula.  The  many-tailed  bandage  is  then  tightened  so  as  to  main- 
tain uniform  pressure  over  the  abdomen,  and  as  it  gets  loose  is 
readjusted.  The  rubber  tube  is  carried  into  a  receptacle  under 
the  bed  and  the  abdomen  is  protected  by  a  cradle.  It  usually 
takes  six  to  twelve  hours  for  the  fluid  to  run  away  ;  if  the  flow 
stops  before  the  abdomen  is  properly  emptied  the  indiarubber  tube 
should  be  "  milked,"  starting  from  the  cannula,  so  as  to  dislodge 
any  clot  or  other  obstruction.  In  extremely  fat  women  a  special 
trocar  and  cannula  or  even  the  trocar  and  cannula  of  an  aspirator 
must  be  used  in  order  to  get  through  the  abdominal  wall.  When 
the  fluid  has  finally  ceased  to  run,  the  cannula  should  be  withdrawn 
and  the  small  wound  covered  with  a  pad  of  absorbent  cotton-wool 
soaked  in  collodion.  The  abdomen  should  then  be  compressed  by 
the  many-tailed  bandage,  by  a  binder  firmly  pinned,  or  by  strapping. 
A  saline  purge  should  be  given  to  prevent  flatulence,  and  one 
of  the  diuretics  previously  mentioned.  In  some  instances  of 
recurrent  ascites  and  in  blood-stained  ascites  due  to  malignant 
disease  the  re-accumulation  has  been  obviated  or  delayed  by  the 
injection  through  the  cannula,  before  it  is  removed,  of  a  drachm  of 
a  1  in  1,000  solution  of  adrenalin  chloride  in  an  ounce  of  water. 

Bad  results  from  paracentesis  are  rare.  In  exceptional  instances 
acute  pulmonary  O3dema,  similar  to  that  seen  after  paracentesis  of 
the  chest,  has  occurred.  The  most  valuable  remedies  for  this  grave 
accident  are  prompt  bleeding  or  dry  cupping,  and  cardiac  stimu- 
lants. Wounding  of  an  artery  in  the  abdominal  wall  and  the  fact 
that  repeated  tappings  may  favour  chronic  peritonitis  have  already 
been  mentioned.  With  due  care  perforation  of  an  abdominal  viscus 
should  not  occur.  A  little  local  pain  for  two  or  three  days  is  not 
uncommon. 

SPECIAL    FORMS    OF    ASCITES. 

Cardiac  Ascites. — It  is  important  to  restrict  the  intake  of  fluid 
to  20  or  30  oz.  only  in  the  twenty-four  hours  ;  this,  as  already 
mentioned,  should  be  carried  out  gradually,  a  progressive  daily 


Ascites.  631 

reduction  of  a  few  ounces  being  made.  If  the  amount  is  greatly 
reduced  suddenly,  the  patient  may  suffer  from  thirst  and  from  con- 
stipation. The  condition  of  the  heart  should  be  treated  by  digitalis 
in  cases  of  mitral  regurgitation  or  by  strophanthus  in  mitral  stenosis. 
Digitalis  is  best  given  in  the  form  of  a  physiologically  standardised 
solution,  such  as  Parke,  Davis  &  Co.'s  fluid  extract,  1  min.  of  which 
is  equal  to  8  min.  of  the  Pharmacopoeial  tincture  ;  the  equivalent  of 
10  to  20  min.  of  the  B.P.  tincture  should  be  given  four  times  a  day 
and  may  advantageously  be  combined  with  citrate  of  caffeine  (gr.  5), 
diuretin  (gr.  5  to  10),  or  theocin  (gr.  3).  A  well-tried  combination  of 
digitalis  is  that  with  squill  and  mercury,  in  the  following  form : 
Digitalis  leaves  powdered,  gr.  ^ ;  squill,  gr.  1  ;  blue  pill  [U.S.P. 
mass  of  mercury],  gr.  2  (Matthew  Baillie's  pill)  ;  or  digitalis  leaves 
powdered,  gr.  1  ;  squill,  gr.  1  ;  calomel,  gr.  1  ;  ext.  hyocyam.,  gr.  If 
(Addison's  pill,  or  pil.  diuretica  of  Guy's  Hospital).  Nativelle's 
granules  of  digitaline  are  a  convenient  and  trustworthy  preparation 
dose  2i5o  to  ^o  gr.  in  a  pill.  In  mitral  stenosis  or  in  cases  in  which 
digitalis  does  not  agree,  tincture  of  strophanthus  should  be  given 
in  doses  of  5  to  10  min.  [U.S.P.  1  to  2J  min.]  three  times  a  day. 

In  order  to  reduce  the  hepatic  engorgement  a  blue  pill  (5  gr.) 
should  be  given  once  or  twice  a  week  at  night,  followed  early  next 
morning  by  a  Seidlitz  powder  (pulvis  sodae  tartratis  effervescens)  in 
8  oz.  of  water  or  by  2  to  4  drachms  of  magnesium  sulphate  in  as 
small  a  quantity  of  hot  water  as  will  dissolve  it  (Matthew  Hay). 

Operative  Measures  may  be  employed  with  different  objects  in 
different  conditions.  In  tuberculous  peritonitis  laparotomy  with 
removal  of  the  fluid  and  no  further  procedure  may  be  followed  by 
recovery ;  but  in  cases  which  relapse  after  this  simple  operation 
subsequent  laparotomy  with  removal  of  a  tuberculous  focus  which 
is  responsible  for  reinfection  may  lead  to  permanent  cure  (see 
also  article  on  Tuberculous  Peritonitis). 

In  hepatic  cirrhosis  laparotomy  and  the  formation  of  artificial 
adhesions  (Talma-Morison  operation)  has  been  extensively  performed 
in  order  to  increase  the  collateral  circulation. 

In  chronic  and  recurrent  ascites,  the  peritoneal  cavity  has  been 
drained  into  the  subcutaneous  tissues  of  the  abdominal  wall  or 
through  the  femoral  ring  into  the  thigh.  Permanent  drainage 
through  the  abdominal  wall  is  dangerous  from  the  risk  of  peritoneal 
infection. 

H.  D.  ROLLESTON. 

REFERENCE. 

Art.  "Ascites"  in  Nothnugel's  "Encyclopedia  of  Practical  Medicine,"  2nd 
English  edition,  1907,  Vol.  "  I»isi>:i«-s  <>i  Intestines  ;md  Peritoneum,"  p.  717. 


632 


ACUTE    PERITONITIS. 

THE  peritoneum  is  a  membrane  of  very  great  extent  which 
has  evolved  for  the  physical  purpose  of  allowing  free  movement 
of  the  abdominal  viscera  and  for  the  physiological  purpose  of 
protecting  the  body  from  the  hosts  of  micro-organisms  which  have 
been  introduced  into  the  alimentary  tract.  As  the  alimentary  tract 
is  the  most  septic  and  dangerous  region  in  the  human  body,  the 
functions  of  the  peritoneum  have  become  the  most  important,  as 
regards  life,  of  almost  any  serous  membrane  in  the  body,  and  its 
inflammation,  peritonitis,  one  of  the  most  serious  conditions. 

At  the  present  time  it  is  not  known  what  are  the  precise 
conditions  which  are  necessary  for  the  migration  of  micro- 
organisms from  the  intestinal  tract  through  the  tissues  to  the 
peritoneum.  But  there  is  reason  to  believe  that  such  a  diapedesis 
is  far  more  frequent  than  it  is  ordinarily  thought  to  be,  and 
that  peritonitis  is  really  a  superlative  exaggeration  of  events, 
then  clinically  recognisable,  which  are  of  daily  occurrence  in  all 
the  higher  races  of  animals  ;  hence  the  object  of  its  treatment 
must  be  to  aid  the  processes  of  natural  cure,  by  the  resources 
of  the  body,  by  destroying  the  storehouse  or  factory  base  of 
the  micro-organisms  and  by  removing  as  much  of  them  and 
their  poisonous  products  as  is  possible,  so  as  to  enable  the 
patient  to  withstand  the  continuance  of  the  struggle  between  the 
peritoneal  resources  and  the  hostile  micro-organisms. 

Peritonitis  is  a  disease  due  to  the  action  of  the  micro-organisms, 
endangering  the  life  of  the  patient  and  perhaps  producing  death 
by  poisoning  the  heart  and  nervous  system  with  the  toxines 
absorbed.  The  power  of  absorption  by  the  peritoneum  is  enor- 
mous. And  it  is  this  absorption  which  kills  the  patient;  it 
stands  to  reason  that  the  greater  the  virulence  of  the  organisms 
present  and  the  longer  time  the  patient  is  allowed  to  absorb  their 
toxines,  the  less  chance  of  recovery  from  the  disease  ;  hence  it 
is  of  utmost  importance  to  commence  treatment  at  the  earliest 
moment  and  to  ascertain  the  organisms  present.  The  peritoneum 
naturally  has  the  best  chances  of  overcoming  the  organism  with 
which  it  is  already  familiar,  e.g.,  the  bacillus  coli  communis  ; 
whilst  it  has  little  chance  of  overcoming  strange  and  powerful 
infections,  such  as  are  produced  by  the  pneumococcus  or  the 
streptococcus. 


Acute  Peritonitis.  633 

Table  of  Cases  of  Acute  Peritonitis  at  St.  Thomas'  Hospital. 


Due  to  Appendicitis 


Intestinal  Obstruction 

Intussusception 

Perforations  of  the  Alimentary  Tract 

Affections  of  the  Pelvic  Viscera    . 


37  per  cent. 
24 
15 
11 
6 


Peritonitis  of  Unknown  Origin     ....       2 
Unclassifiable  Causes 5 


It  is  seen  that  inflammation  of  the  appendix  is  by  far  the 
most  frequent  cause  of  peritonitis,  and  between  the  ages  of  five 
and  twenty  it  may  be  said  practically  to  be  almost  the  only 
cause.  This  is  an  important  point  to  remember  in  advising  treat- 
ment in  such  eases.  Clinically  and  pathologically  it  is  impossible 
to  separate  intestinal  obstruction  from  peritonitis,  the  paralysed 
bowel  in  peritonitis  causing  intestinal  obstruction,  and  the  diapedesis 
of  organisms,  ulceration,  etc.,  in  intestinal  obstruction  causing  peri- 
tonitis. Perforations  of  the  alimentary  tract  occur  clinically  in 
frequence  in  the  following  order  :  (1)  Perforations  of  the  appendix ; 
(2)  perforations  of  the  stomach  ;  (3)  perforations  of  the  duodenum ; 
(4)  perforations  of  the  rectum  ;  (5)  perforations  of  the  caecum. 

The  treatment  of  acute  peritonitis  is  surgical  and  should  be 
undertaken  at  the  earliest  possible  moment.  No  delay  in  carrying 
this  out  should  be  allowed. 

Before  Operation. — (1)  Put  the  patient  in  the  Fowler  or  semi- 
sitting  position,  which  keeps  the  infective  process  to  the  lower  and 
less  absorptive  part  of  the  peritoneal  cavity  ;  (2)  avoid  giving 
food  by  mouth,  and  so  to  cause  peristaltic  rest  and  prevent  the 
diffusion  of  the  infection  by  vermicular  movements ;  give  saline  per 
rectum  (with  a  tube  and  funnel)  in  J-pint  doses  every  two  or 
four  hours;  (8)  avoid  morphia,  as  it  gives  a  false  sense  of 
security  and  improvement,  and  it  lowers  the  patient's  powers 
of  combating  the  infection  ;  if  its  use  cannot  be  avoided  give 
the  smallest  doses  which  ease  the  patient,  combined  with  atropine 
sulphate;  (4)  wash  the  stomach  out  with  a  tube  and  funnel  and 
bicarbonate  of  soda  solution  (20  gr.  to  the  ounce). 

Operation. — The  less  delay  in  performing  this  the  better  for  the 
patient.  It  is  often  possible  to  diagnose  the  cause  of  the  peritonitis 
before  operation.  But  no  one  who  has  had  much  experience  of 
these  cases  can  have  failed  to  convince  himself  that  his  diagnosis  in 
acute  abdominal  cases  is  not  infrequently  wrong.  This  unavoidable 
uncertainty  is  an  additional  spur  to  operation. 

A  general  amesthetic,  ether  or  chloroform,  is  better  than  spinal 
or  local  anaesthesia,  except  perhaps  in  very  young  children. 


634  Acute  Peritonitis. 

The  abdomen  is  opened  through  the  middle  and  lower  part  of 
the  right  rectus  muscle,  for  the  following  reasons :  (a)  It  enables 
the  appendix,  by  far  the  most  frequent  cause  of  peritonitis,  to 
be  examined  ;  (b)  it  enables  the  pelvis  to  be  explored,  in  which 
region  catastrophes  in  the  upper  abdomen  indicate  their  existence 
by  free  gas,  food,  blood,  etc. ;  (c)  this  incision  will  be  wanted  to 
remove  food,  blood  or  pus  from  the  pelvis. 

In  almost  every  case  the  pus  of  appendicitis  declares  itself  by 
its  smell;  whilst  perforated  gastric  and  duodenal  ulcers  permit 
the  escape  of  gas,  and  more  or  less  odourless  material,  with  perhaps 
recognisable  particles  of  food.  Thus,  the  lower  incision  will  enable 
the  diagnosis  to  be  made  in  the  great  majority  of  cases. 

The  next  step  is  to  deal  with  the  cause  of  the  peritonitis,  e.g., 
the  appendix  or  a  pyo-salpinx  should  be  removed.  A  perforated 
ulcer  should  be  sutured.  If  there  is  so  much  induration  round 
a  perforation  that  it  cannot  be  sutured,  do  not  waste  time  ;  it 
must  be  sealed  by  stitching  the  omentum  over  it.  In  the  vast 
majority  of  cases  of  perforated  gastric  and  -duodenal  ulcers  a 
primary  gastro-enterostomy  is  unnecessary,  and  from  the  patient's 
point  of  view  a  mischievous  exhibition  of  surgical  gymnastics.  In 
a  few  cases  it  can  be  done  with  advantage. 

The.abdomen  is  wiped  out  with  gauze  and  closed  except  where  a 
drain  in  the  pelvis  comes  out  of  the  lower  wound. 

The  anaesthetist  then  washes  out  the  stomach  and  leaves  in 
it  some  bicarbonate  of  soda  solution  (20  gr.  to  the  ounce). 

The  surgeon's  object  is  to  do  the  operation  in  the  least  time 
possible  and  with  the  least  manipulation  possible.  He  must  not 
waste  time  and  make  manipulations  in  the  attempt  to  remove 
all  infective  material  from  the  peritoneal  cavity.  That  is  impossible. 
The  surgeon  removes  as  much  as  he  can  easily  and  quickly  ;  and 
the  patient  must  overcome  what  is  left  behind,  if  he  is  to  recover. 

The  following  figures,  derived  from  the  cases  at  St.  Thomas' 
Hospital,  emphasise  the  points  made  : 


Mortality. 

Operation  for  appendicitis  within  the  first  twelve  hours  of 
illness  ..........  Nil. 

Operation  for  appendicitis  between  twelve  and  twenty-four 

hours  since  the  onset  of  the  illness 9  per  cent. 

Operation  for  appendicitis  between  twenty-four  and  thirty- 
six  hours  since  the  onset  of  the  illness  .  .  .  .6  ,,  ,, 

Operation  for  appendicitis  between  thirty-six  and  forty  eight 

hours  since  the  onset  of  the  illness  .  .  .  .  23  ,,  ,, 

Appendicitis  with  local  and  spreading  peritonitis  .     18 '5    ,,       ,, 

Appendicitis  with  diffuse  generalising  peritonitis  .     66'6     ,,       ,, 

Perforated  gastric  and  duodenal  ulcers         .  .     51        ,,      ,, 


Acute  Peritonitis. 


635 


After  operation  the  patient  is  returned  to  a  warmed  bed,  placed 
in  the  Fowler  position,  and  the  continuous  rectal  administration 
of  normal  saline  commenced.  This  administration  of  saline  per 
rectum  is  the  most  important  item  in  the  treatment  of  acute 
abdominal  disease  which  has  been  introduced  of  recent  years. 
It  requires  considerable  attention,  skill  and  care  for  its  proper 
administration,  and  its  failure  should  be  construed  to  mean  its 
improper  administration. 

The  Continuous  Administration  of  Fluids  per  Rectum. — 
Proctoclysis. — As  the  patient  is  usually  propped  up,  a  solid 
tube  must  be  used  to  introduce  the  fluid,  otherwise  it  will  get 
kinked.  A  tube  answers  well  which  is  1  foot  in  length  and 
J  inch  in  diameter,  made  of  pewter,  with  a  slightly  bulbous 


FIG.  1. — Fowler's  position  and  rectal  irrigation. 

extremity,  which  is  introduced  into  the  rectum.  At  the  end  and  • 
on  all  sides  of  this  bulb  holes  are  pierced  so  that  fluid  can 
easily  pass  through  them  and  at  the  same  time  flatus  can  escape, 
and  can  be  seen  bubbling  through  the  supply  tank  or  funnel.  If 
only  a  single  aperture  is  present  in  the  tube,  it  is  apt  to  be  blocked 
by  faecal  matter  ;  but  when  there  are  many  openings  the  rectum 
is  equally  distended  above  the  sphincter  and  the  obstruction  of 
the  flow  of  fluid  by  faces  does  not  occur.  The  tube  is  intro- 
duced into  the  rectum  for  about  2  to  3  inches,  and  is 
bent  sharply  at  th'e  anus  so  as  to  lie  easily  on  the  bed.  To  the 
outside  end  a  long  rubber  tube  is  attached,  which  leads  to  the 
source  of  supply  at  the  bedside.  The  most  convenient  vessel  to 
hold  the  saline  solution  is  an  "infusion  flask"  (Sahli's  pattern). 
This  is  triangular  in  shape  and  has  a  large  base,  and  holds 


636  Acute  Peritonitis. 

from  3  to  4  pints ;  its  neck  is  closed  by  a  rubber  stopper, 
through  which  there  are  three  openings  ;  the  one  admits  a  glass 
tube,  which  at  one  end  reaches  to  the  bottom  of  the  flask,  and 
at  the  other  is  attached  to  the  rubber  tube  leading  to  the  rectum ; 
a  second  admits  a  thermometer  and  a  third  a  tube,  which  acts  as 
an  inlet  for  air.  The  whole  flask  is  immersed  in  a  bath  of  hot 
water,  beneath  which  a  spirit  lamp  burns,  so  securing  a  constant 
temperature  of  the  saline  solution.  The  best  temperature  is  from 
100°  to  102°  F. ;  if  the  fluid  is  hotter  than  this  it  is  not  retained 
well.  Its  temperature,  when  it  reaches  the  rectum,  is  probably 
3  or  4  degrees  lower  than  that  shown  by  the  thermometer. 
When  the  tube  has  been  introduced  into  the  rectum  and  the  flask 
attached,  the  latter  should  be  elevated  so  that  its  base  is  from  3 
to  6  inches  higher  than  the  rectum.  The  saline  begins  to  flow, 
and  continues  flowing,  at  the  rate  of  about  1  pint  an  hour.  It  is 
not  desirable  to  introduce  more  than  1J  pints,  or  at  the  most 
2  pints  during  the  first  hour ;  subsequently,  a  rate  of  1  pint  in  the 
hour  should  be  maintained.  The  rapidity  of  the  flow  is  altered  by 
raising  or  lowering  the  flask,  and  should  be  regulated  by  the 
patient's  comfort.  If  a  feeling  of  tightness  or  distress  is  caused, 
the  flow  is  too  rapid.  As  a  rule,  no  uneasiness  is  caused  till  about 
5  pints  have  been  introduced,  but  then  it  may  be  necessary  to  retard 
the  flow  for  half  an  hour  or  an  hour,  or  sometimes  it  is  sufficient  to 
stop  it  for  a  few  minutes.  If  the  rate  of  flow  is  regulated  properly, 
and  the  temperature  of  the  fluid  not  altered,  from  7  to  10  pints  can 
be  introduced  without  interruption.  If  flatus  reaches  the  rectum,  it 
can  escape  by  the  tube.  If,  as  rarely  happens,  the  fluid  introduced 
acts  as  an  enema,  the  tube  may  be  replaced  as  soon  as  the  bowels 
have  acted.  Care  and  almost  constant  attention  on  the  part  of  the 
nurse  are  necessary  to  ensure  a  successful  administration. 

The  largest  quantity  of  fluid  taken  by  any  patient  during  the 
first  twenty-four  hours  was  16  pints  ;  the  largest  quantity  adminis- 
tered was  29  pints,  extending  over  three  days.  These  quantities 
were  borne  quite  easily,  without  any  distress  whatever.  The  change 
in  the  appearance  of  a  patient  who  is  absorbing  fluid  so  rapidly  is 
very  remarkable.  If  the  case  is  one  of  acute  general  peritonitis,  the 
patient,  who  looks  livid,  whose  eyes  are  sunken,  whose  skin  is  moist 
and  cold,  whose  mouth  is  so  parched  that  his  tongue  can  hardly 
move,  begins  in  a  few  hours  to  look  ruddy  and  clean,  his  mouth  is 
moist,  his  eyes  are  bright,  and  all  his  aspect  is  one  of  comfort  and 
contentment.  The  pulse  gains  volume  and  improves  steadily  in 
character,  urine  is  passed  in  large  quantities,  and  the  skin  keeps 
moist.  Not  a  few  patients  say  that  they  feel  very  hot,  and  some  of 


Acute  Peritonitis. 


637 


them  perspire  freely.  It  is  a  question,  perhaps,  as  to  how  far  one 
is  justified  in  carrying  this  treatment. in  patients  whose  kidneys  are 
defective. 

Dr.  Murphy,  of  Chicago,  is  of  the  opinion  that  in  cases  of  acute 
peritonitis  the  fluid  causes  a  reverse  current  of  the  lymph  in  the 
peritoneal  lymphatics,  so  that  instead  of  absorption  taking  place 
from  the  peritoneal  surface  the  mouths  of  the  lymphatics  pour  out 
fluid,  bathing  the  peritoneum  with  this 
free  discharge,  which  then  escapes  by  the 
tubes  ;  that,  in  fact,  the  peritoneal  cavity 
is  flushed  out  by  the  fluid. 

Various  devices  have  been  tried  to 
obviate  the  care  and  trouble  required  to 
maintain  the  saline  at  the  right  tempera- 
ture, such  as  Paterson's,  which  requires 
that  electricity  is  available,  or  Dewar's 
flask.  The  latter  is  small  and  has  been 
found  experimentally  to  lose  2  degrees  of 
heat  in  half  an  hour. 

Vaccine  Treatment. — :Vaccine  treat- 
ment is  probably  useless  in  this  acute 
condition,  but  apparently  does  no  harm. 

Serum  Treatment.  --  The  serum  is 
best  given  hypodermically.  No  serum 
can  be  trusted  to  give  a  reliable  result. 
Anti-colon  serum  in  25  cubic  centimetre 
doses  has  certainly  improved  the  con- 
ditions of  some  patients.  It  may  be 
given  at  the  time  of  operation,  and  daily 
afterwards,  should  disquieting  symptoms 
remain  or  arise.  This  action  is  readily 

understood  as  the  colon  bacillus  is  by  far  the  most  numerous  and 
frequent  organism  in  peritonitis. 

Anti-streptococcus  and  anti-staphylococcus  sera  have  done  less 
obvious  good. 

Artificial  Leucocytosis. — To  increase  the  number  of  leucocytes 
would  appear  to  increase  the  numbers  of  the  patient's  army  resist- 
ing the  organisms ;  hence,  it  should  do  good.  Clinically,  this  is 
difficult  to  prove,  though  such  p,  leucocytosis  is  easily  produced  by 
a  hypodermic  injection  of  a  nuclein,  such  as  that  sold  commercially 
as  phagocytin. 

The  dressings  should  be  changed  as  often  as  necessary,  and  the 
drains  withdrawn  and  replaced  in  twenty-four  hours,  an  anaesthetic 


FIG.  2. — Electrical  apparatus 
for  proctoclysis. 


638 


Acute  Peritonitis. 


being  given  if  necessary.  A  many-tail  bandage,  the  tails  of  which 
are  long,  holds  the  dressing  in  position. 

Morphia  and  Opium  are  to  be  avoided  if  possible  for  the  reasons 
already  given.  If  they  must  be  given,  let  small  doses  be  used  and 
repeated  if  necessary.  Pain  and  anxiety  do  more  harm  to  the 
patient  than  a  small  dose  of  morphia. 

Stimulants,  such  as  adrenalin  (10  min.)  and  strychnine  solution 
(10  min.),  [U.S.P.  strychnines  hydrochloridi  gr.  ^j] ,  should  be 
given  without  hesitation.  One  often  repents  not  giving  them  when, 
after  a  temporary  improvement  on  the  first  day  after  operation, 
the  heart  "falls  to  pieces"  on  the  next  day.  I  have  repeatedly 
given  10  min.  of  strychnine  solution  every  four  hours  for  a  day 
or  two.  An  ill  patient  can  take  an  enormous  dose  without  harm. 

A  simple  (or  turpentine)  enema 
may  be  given  on  the  same  day 
or  the  next  day  after  operation, 
or  a  long  rectal  tube  can  be 
passed  to  relieve  abdominal 
distension. 

Purgatives  are  better  with- 
held, if  possible,  until  all 
sickness  has  ceased,  when  they 
are  given  repeatedly  in  small 
doses,  e.g.,  i  gr.  of  calomel 

*  IG.  3. — Ileostomy  tube.  y  ° 

every  hour  until  the  bowels 

act.  After  2  gr.  have  been  given  it  is  better  to  administer  an 
enema  to  commence  the  action  of  the  bowels.  An  enema  in  acute 
abdominal  disease  should  always  be  given  with  a  tube  and  a  funnel ; 
never  with  a  syringe. 

Repeated  Sickness  is  best  treated  by  washing  the  stomach  out 
with  a  tube  and  a  funnel,  or  making  the  patient  wash  it  out  by 
drinking  glasses  of  hot  bicarbonate  of  soda  solutions  (20  gr.  to  the 
ounce) . 

Abdominal  Distension  is  best  treated  with  hot  dry  flannels,  an 
enema  (or  rectal  tube),  and  gastric  lavage  if  necessary.  Only  two 
drugs  are  of  use  in  relieving  it,  both  given  hypodermically,  eserine 
salicylate,  every  two  hours  in  doses  of  •$$  gr.,  and  atropine  sulphate, 
in  doses  of  -^  gr.  every  three  hours.  The  injections  are  discon- 
tinued if  the  patient  is  relieved  and  shows  constitutional  signs  of 
their  action. 

In  severe  and  intractable  cases  where  the  distension  is  embarrass- 
ing the  heart's  action,  it  is  sometimes  necessary  to  open  part  of 
the  wound  and  do  a  temporary  ileostomy  on  a  distended  coil  of- 


Acute  Peritonitis. 


639 


small  bowel.     For  this  purpose  I  would  recommend  the  glass  tubes 
made  for  this  purpose  and  illustrated  by  Fig.  3. 

Hiccough  is  one  of  the  most  distressing  symptoms  which  one 
may  be  called  upon  to  treat  in  cases  of  peritonitis.  The  patho- 
logy of  the  condition  is  obscure  and  composite.  It  is  often 
associated  with  a  dilated  stomach ;  hence,  it  is  best  treated  by 
gastric  lavage,  bicarbonate  of  soda  (20  grs.  to  the  ounce),  and  a 


FlG.  1. — Vaginal  drainage. 

mustard  leaf  to  the  epigastrium.  Massage  to  the  epigastrium  and 
neck  may  also  help.  Other  drugs,  such  as  cocaine,  nitroglycerine, 
bromides,  turpentine,  musk,  etc.,  may  be  given,  and  at  times  seem 
to  do  a  little  good,  and  it  is  true  that  the  symptom  may  wear  itself 
out,  cease  or  ameliorate  when  they  are  being  used.  At  times 
morphia  must  be  given  to  give  the  patient  sleep  and  temporary  rest 
from  the  hiccough. 

Before  saline  was  administered  per  rectum,  either  ^  pint  to  1  pint 


640 


Acute  Peritonitis. 


every  hour  or  two  with  a  tube  and  a  funnel,  or  by  continuous 
irrigation,  it  was  needful  to  treat,  after  operation,  restlessness, 
thirst,  toilet  of  the  mouth,  and  similar  clinical  features  ;  now  the 
need  has  entirely  disappeared.  Such  points  resolve  themselves 
and  do  not  require  special  attention. 

In  a  similar  way  the  feeding  of  the  patient  merely  demands  the 
use  of  ordinary  intelligence.     Very  great  importance  is  attached  by 

the  patient's  friends,  and 
sometimes  by  the  patient, 
to  the  amount  of  food 
given.  It  is  useless  to 
attempt  to  give  much  in 
the  first  twenty-four  or 
forty  -  eight  hours  after 
operation.  Liquid  and 
easily  digestible  food  is 
given  in  small  doses,  e.g., 
milk  and  water,  milk  and 
soda,  in  doses  of  1  oz. 
every  hour  whilst  the 
patient  is  awake.  Food 
in  the  stomach  often  dis- 
tresses the  patient  unless 
relief  is  found  by  vomit- 
ing ;  hence,  it  is  better  to 
give  the  patient  very  little 
by  mouth  and  to  rely  on 

rectal  infusion  to  maintain 
Jjjg  strength 

After  the  bowels  have 
acfce(J  ft  ^  desirable  to  in- 
Crease  the  amount  of  food 

taken   by  mouth  ;   and  this 

» 
is   particularly    so   as  the 

rectal  infusion  is  discontinued.  In  some  patients  the  stomach 
remains  dilated  and  irritable  ;  if  so,  it  is  harmful  to  press  the  increase 
of  food,  and  it  is  better  to  avoid  altogether  "  made  up  "  or  seasoned 
foods,  champagne,  etc.,  on  account  of  their  containing  elements 
which  will  irritate  the  stomach  and  increase  the  patient's  distress. 
The  desire  to  suck  ice  is  frequently  met  with  in  this  disease.  It  is 
almost  invariably  associated  with  a  dilated  and  irritable  stomach, 
which  conditions  are  wrongly  attributed  to  the  ice.  Ice  is  certainly 
an  uneconomical  method  of  taking  water,  but  it  is  certainly  not 


FIG.  5.—  Paths  of  peritoneal  infection  in  appen- 
dicitis.  1.  Situation  of  a  right  subdiaphrag- 
matic  abscess.  2.  Situation  of  a  subhepatic 
abscess.  3.  Situation  of  a  right  ante-renal 
abscess.  4  Situation  of  a  left  ante-renal 
abscess.  5.  Situation  ot  a  pelvic  abscess. 
6.  Situation  of  an  abscess  in  the  left  iliac 
fossa.  7.  Situation  of  a  left  subdiaphrag- 
matic  abscess. 


Acute  Peritonitis. 


641 


responsible  for  the  harmful  results  attributed  to  it ;  still,  it  should 
be  checked  and  discontinued  as  soon  as  possible. 

Appendicostomy  has  been  done  instead  of  appendicectomy  in 
certain  cases  of  appendix  peritonitis,  the  appendicostomy  offering  a 
simple  means  of  administering  saline  solution. 

SPECIAL  FORMS  OF  PERITONITIS. 

Pneumococcus  Peritonitis. — Peritonitis  due  to  a  pneumococcus 
is  a  very  fatal  form  of  infection.  The  peritonitis  is  practically  an 
incident  in  pneumococcus  septicaemia. 
In  over  half  the  cases  there  is  another 
gross  pneumococcic  lesion  ;  in  some 
cases,  a  general  involvement  of  serous 
membranes,  such  as  the  pleura,  peri- 
cardium, peritoneum  and  dura  mater ; 
hence,  the  mortality  is  very  high. 
Pneumococcus  peritonitis  is  more 
common  in  children  than  in  adults,  in 
boys  than  in  girls.  It  is  seldom  diag- 
nosed before  operation,  when  it  is 
suggested  by  the  greenish  pus,  the 
widespread  distribution,  and  the 
absence  of  any  recognisable  cause  of 
the  peritonitis.  Except  in  the  locu- 
lated  and  more  chronic  forms  the 
prognosis  is  bad.  The  treatment 
follows  the  general  lines  laid  down 
under  the  treatment  of  peritonitis. 

Special  treatment  by  a  serum  or  vaccine  has  not  led  as  yet  to  hopes 
of  improved  results. 

Streptococcus  Peritonitis. — In  streptococcus  peritonitis  the 
peritonitis  is  an  incident  in  streptococcus  septicaemia ;  hence  it  is 
a  very  fatal  form. 

Staphylococcus  Peritonitis. — The  Staphylococcus  pyogenes 
albus  has  often  been  isolated  from  cases  of  peritonitis,  and  seems 
to  be  an  auto-infection  on  the  part  of  the  patient.  Its  presence  is 
by  no  means  a  forerunner  of  a  fatal  termination. 

The  Staphylococcus  aureus  gives  rise  to  a  very  serious  form  of 
peritonitis,  but  not  so  fatal  a  form  as  that  due  to  the  Streptococcus 
pyogenes. 

Colon  Bacillus  Peritonitis. — This  is  the  ordinary  infection  in 
cases  of  appendix  peritonitis  ;  hence  it  is  to  the  anti-colon  serum 
that  we  look  to  give  improved  results  in  these  cases. 

S.T. — VOL.  ii.  41 


FIG.  6.— Left  Empyema  from 
Disease  of  the  Appendix. 


642  Acute  Peritonitis. 

Gonorrhoeal  Peritonitis. — Gonorrhceal  peritonitis  is  in  reality 
a  name  given  to  peritonitis  arising  from  the  genital  organs. 
Naturally,  it  is  more  frequent  in  women  than  in  men.  It  is  most 
often  found  in  young  women,  but  may  be  found  in  young  girls  and 
even  in  female  babies. 

The  diagnosis  is  made  by  the  presence  of  peritonitis  without 
obvious  cause  and  the  presence  of  a  .vaginal  discharge.  The  treat- 
ment consists  of  laparotomy,  sponging  away  the  fluid  and  draining 
the  pelvis,  by  the  vagina  or  by  the  rectum  for  preference. 

The  prognosis  to  a  great  extent  depends  on  the  organisms  present, 
and  has  already  been  discussed. 

Puerperal  Peritonitis  (see  Puerperal  Sepsis,  Vol.  IV.). 

Tuberculous  Peritonitis  (see  p.  645). 

Thanks  are  due  to  Messrs.  Constable  &  Co.  for  the  use  of  many 
blocks. 


EDRED  M.  CORNER. 


KEFERENCE. 


"  Clinical   and    Pathological    Observations  on  Acute  Abdominal  Diseases," 
(Constable  &  Co.). 


^43 


SUBPHRENIC  ABSCESS. 

BY  the  term  "  subphrenic  or  subdiaphragmatic  abscess  "  is  meant 
a  collection  of  pus  immediately  under  the  diaphragm.  On  the  right 
side  it  lies  between  the  liver  and  the  diaphragm ;  on  the  left  side 
between  the  spleen  and  the  diaphragm.  That  on  the  right  side  is 
most  frequently  the  result  of  appendicitis ;  that  on  the  left  side  of 
a  perforated  gastric  ulcer.  A  subdiaphragmatic  abscess  is  practically 
never  primary.  It  is  always  secondary  to  some  intra-peritoneal 


FIG.  1.— Right  Subphrenic 
Abscess. 


FIG.  2.— Left  Subphrenic 
Abscess. 


infection,  such  as  those  already  mentioned,  or  to  pelvic  suppura- 
tion. After  a  suppurative  peritonitis  has  been  operated  upon,  the 
temperature,  pulse  rate  and  respiration  rate  subside  ;  when  a  sub- 
diaphragmatic  abscess  is  forming  they  begin  to  rise  again,  usually, 
in  the  second  week.  The  other  physical  signs  are  those  of  fluid, 
dulness,  absence  of  breath  and  voice  sounds  at  the  base  of  the  lung 
behind.  Later  the  liver  becomes  pushed  down  below  the  costal 
margin.  Thus  the  bases  of  the  lungs  behind  should  be  inspected 
carefully  if  the  temperature  rises  during  the  convalescence  of  intra- 
peritoneal  suppuration.  The  diagnosis  being  made,  the  treatment 
is  surgical.  It  consists  of  the  anaesthetisation  of  the  patient, 
making  an  incision  over  the  eighth  rib  as  in  Fig.  3,  resecting 
the  eighth  rib,  incising  the  pleura,  allowing  the  lung  to  retract, 
suturing  the  parietal  to  the  diaphragmatic  pleura,  incising  the 

41—2 


644 


Subphrenic  Abscess. 


diaphragm  and  exploring  the  space  above  the  liver.  In  doing  this 
operation  care  must  be  taken  to  resect  no  rib  above  the  eighth, 
as  then  the  movements  of  the  diaphragm  are  too  great  to  allow 
of  easy  manipulation.  Further,  about  4  inches  of  rib  should  be 
resected.  Do  not  rely  on  the  stitching  of  the  parietal  to  the  diaphrag- 
matic pleura  to  prevent  the  infection  of  the  pleural  cavity  ;  reinforce 
the  stitching  with  a  barrier  of  gauze. 

The  space  above  the  liver  is  too  large  to  be  always  explored 
successfully  through  this  costal  incision,  and  it  may  be  necessary 
to  combine  with  this  operation  an  intra-peritoneal  one  made  by 


FIG.  3. — Incision. 


FIG.  4. — Left  Subphreuic  Abscess 
Discharging  by  the  Lung. 


making  an  incision  over  the  upper  part  of  the  right  rectus,  as  in 
Fig.  3. 

At  the  conclusion  of  the  operation  drain  the  abscess  with  a 
rubber  tube.  A  gauze  "  drain "  more  frequently  acts  as  a  cork 
than  a  drain. 

The  mortality  consequent  upon  the  operation  is  high,  being 
somewhere  about  30  to  40  per  cent.  But  the  mortality  of  cases  of 
subdiaphragmatic  abscess  which  are  not  operated  upon  is  far 
higher.  From  time  to  time  such  an  abscess  discharges  through  the 
lung  without  causing  a  septic  broncho-pneumonia. 


EDRED  M.  CORNER. 


645 


TUBERCULOUS    PERITONITIS. 

THE  results  of  treatment  in  this  condition  when  unassociated 
with  tuberculosis  elsewhere  are  much  more  favourable  when  a 
considerable  amount  of  ascitic  fluid  is  present.  When  little  fluid  is 
present,  and  especially  in  the  dry  form  with  marked  caseation  of 
the  glands,  the  treatment  has  to  be  much  more  prolonged,  and 
the  results  obtained  are  less  satisfactory. 

General  Measures. — The  patient  should  be  kept  under  fresh- 
air  conditions.  So  long  as  fever  is  present,  that  is,  so .  long  as 
auto-inoculation  is  occurring,  rigid  and  absolute  rest  should  be 
enforced.  As  in  other  tuberculous  conditions,  the  diet  should  be 
abundant  and,  if  possible,  solid.  There  should  be  a  slight  excess  of 
fatty  foods  in  the  diet,  such  as  butter,  cream,  sterilised  milk  and 
bacon  fat.  If  indigestion  or  diarrhoea  occur,  suitable  changes  must 
be  made,  and  in  both  instances  the  fatty  constituents  of  the  diet 
should  be  reduced  to  a  minimum. 

Medicinal  Measures. — In  my  experience  it  is  seldom  of  value 
to  give  medicines  in  the  acute  stage.  Some  authorities  speak  well 
of  sodium  salicylate  (gr.  5  to  15  thrice  daily).  Dr.  Burney  Yeo  has 
recorded  satisfactory  results,  which  he  ascribes  to  the  use  of 
iodoform  internally  in  £-gr.  doses  after  food  three  times  a  day.  In 
addition  Dr.  Yeo  recommends  that  an  ointment  composed  of  equal 
parts  of  iodoform  ointment  and  cod-liver  oil  be  rubbed  into  the 
surface  of  the  abdomen  twice  daily.  There  is  no  question  that 
iodine  and  its  preparations  have  a  favourable  effect  in  many  cases 
of  tuberculosis,  and  such  preparations  from  time  to  time  are 
regarded  by  some  authors  as  being  almost  specific.  The  failures 
under  their  use,  however,  are  numerous.  Older  authorities  spoke  well 
of  the  practice  of  rubbing  J  drachm  of  unguentum  hydrargyri  into 
the  abdomen,  and  the  application  then  of  a  flannel  binder.  The  above 
measures  are  objectionable  to  the  patient,  and  in  my  experience  are 
seldom  necessary  ;  their  use  should  be  reserved  until  other  measures, 
and  especially  the  administration  of  tuberculin  (see  below),  has  failed. 

Certain  complications  may  require  treatment.  If  diarrhoea  is 
present  the  diet  should  consist  of  milk,  with  10  gr.  of  sodium 
citrate  to  the  £  pint.  The  best  drug  is  opium ;  in  children 
£  minim  [U.S. P.  \  minim]  of  tincture  of  opium  may  be  given  thrice 
daily  for  each  year  of  the  child's  age.  If  this  fails,  tannalbin  may 


646  Tuberculous  Peritonitis. 

be  given  in  5  to  15  gr.  doses  thrice  daily,  or  more  frequently  if 
necessary,  until  the  diarrhoea  is  under  control.  Pain  is  best  met  by 
the  use  of  Dover's  powder.  In  the  case  of  a  child  £  gr.  may  be  given 
for  each  year  of  its  age  thrice  daily.  If  drowsiness  is  induced,  the 
dose  of  opium  or  of  Dover's  powder  must  be  reduced.  The  anemia 
usually  improves  rapidly  under  good  hygienic  conditions,  rest  and 
careful  nourishment,  together  with  the  administration  of  tuberculin. 
If  it  is  a  troublesome  feature,  iron  and  arsenic  may  be  prescribed, 
with  or  without  cod-liver  oil.  A  useful  pill  is :  Acid.  Arseniosi, 
gr.  4*8  ;  Aloini,  gr.  J ;  Strychnini,  gr.  T^g  ;  Pil.  Feme,  gr.  2,  twice 
a  day  after  food.  A  change  to  the  sea  or  mountains  is  an  advan- 
tage when  convalescence  has  commenced. 

The  Administration  of  Tuberculin. — It  is  my  experience  that 
tuberculin  (T.R.  or  B.E.)  properly  administered  is  practically  a  specific 
in  cases  of  tuberculous  peritonitis  in  which  there  is,  or  has  recently 
been,  a  considerable  collection  of  ascitic  fluid.  Opinions  are  divided 
on  this  subject,  as  indeed  they  are  with  regard  to  the  effect  of 
tuberculin  in  other  forms  of  tuberculosis.  I  can  only  say  that  in 
the  last  three  years  I  have  had  a  consecutive  series  of  sixteen  cases 
with  the  presence  of  fluid,  in  all  of  which  tuberculin  has  reduced 
the  temperature  to  normal  and  caused  the  absorption  of  the  fluid, 
and  restored  the  patient  to  satisfactory  health.  The  ages  of  these 
patients  varied  from  eighteen  months  to  sixteen  years.  Six  of  them 
had  had  a  previous  attack,  for  which  they  had  laparotomy  per- 
formed ;  three  of  them  had  had  a  previous  attack  without  laparotomy. 
Three  of  them  were  transferred  to  me  from  the  obstetric  wards 
after  the  abdomen  had  been  opened  and  extensive  miliary  tuber- 
culosis discovered.  In  only  two  of  these  sixteen  cases  has  there 
been  a  relapse,  and  in  each  case  the  further  use  of  tuberculin  has 
given  good  results.  In  one  case  a  fatal  issue  occurred  four  months 
after  discharge  from  the  hospital  owing  to  perforation.  In  this  case 
there  was  extensive  matting  of  the  intestines  when  the  patient  first 
came  under  my  care. 

It  is  necessary  to  give  the  tuberculin  cautiously,  and  to  avoid 
reaction  (see  Tuberculin  Therapy,  Yol.  III.).  The  initial  dose 
should  not  be  larger  than  Too100o  mg.  T.E.  or  B.E.  The  dose 
should  be  gradually  increased  until  the  temperature  is  subnormal. 
When  this  has  happened  it  is  possible  to  proceed,  as  a  rule,  more 
rapidly.  It  may  take  five  or  six  weeks  or  longer  to  reduce 
the  temperature,  but  in  many  cases  the  response  to  tuberculin  is 
more  rapid.  It  must,  however,  be  understood  that  here,  as  in  other 
cases  of  tuberculosis,  too  large  doses  of  tuberculin  will  do  more 
harm  than  good.  In  all  cases  it  is  wise  to  continue  the  use  of 


Tuberculous  Peritonitis.  647 

tuberculin  for  at  least  six  months  after  apparent  restoration  to 
health. 

In  those  cases  in  which  fluid  is  scanty  or  absent  tuberculin  does 
not  yield  such  satisfactory  results.  In  such  the  initial  dose  should 
not  be  more  than  ^QOCJOO  m'g-  T.R.  or  B.E.,  and  the  increase  in  the 
size  of  the  doses  must  be  very  gradual.  If  the  use  of  tuberculin  leads 
to  an  increase  of  fever  or  to  pain,  it  must  be  discontinued.  In  such 
cases  we  probably  have  considerable  caseation  of  the  glands,  and  it 
is  possible  that  surgical  measures  might  be  of  service  if,  after  the 
laparotomy  and  such  measures  as  might  be  possible  for  the  removal 
of  the  caseating  glands  had  been  carried  out,  irrigation  of  the 
peritoneal  cavity  with  normal  saline  were  systematically  carried 
out,  and  tuberculin  subsequently  administered. 

The  Removal  of  the  Ascitic  Fluid. — At  one  time  laparotomy 
was  extensively  performed  for  this  purpose,  and  with  considerable 
success  at  any  rate  for  a  time.  Subsequent  relapses,  and  the 
improved  results  from  purely  medical  treatment,  have  led  to  this 
measure  being  utilised  much  less  frequently.  The  good  results 
were  no  doubt  due  to  the  fact  that  the  ascitic  fluid,  as  has  been 
proved  in  the  laboratory,  of  tuberculous  peritonitis  is  more 
deficient  in  opsonic  power  than  the  blood.  As  soon  as  this  fluid  is 
removed  from  the  abdomen,  it  is  replaced  by  lymph  with  a 
sufficiently  higher  opsonic  power  to  overcome  the  bacilli,  which  in 
these  cases  has  a  comparatively  low  virulence.  In  my  experience 
it  is  rare  for  the  fluid  not  to  be  absorbed  during  the  administration 
of  tuberculin.  If  the  case  is  a  chronic  one  and  absorption  is 
delayed,  removal  by  tapping  is  probably  all  that  is  required. 

ARTHUR  LATHAM. 


648 


DISEASES  AND  AFFECTIONS  OF  THE  LIVER. 

THE   SURGICAL   TREATMENT   OF  ABSCESS   OF 
THE   LIVER. 

Pus  may  be  found  in  connection  with  the  liver  in  several 
positions.  For  surgical  purposes  and  also  with  some  clinical  and 
pathological  significance  the  following  classification  of  collections  of 
hepatic  pus  is  expedient:  (1)  Supra-hepatic  abscess;  (2)  Intra- 
hepatic  abscess  ;  (3)  sub-  (or  infra-)  hepatic  abscess. 

(1)  Supra-hepatic  abscess  is  not  a  sub-diaphragmatic  abscess. 
The  latter  has  a  well-understood  signification,  and  is    altogether 
distinct  from  the  abscess  here  indicated.    The  pus  in  supra-hepatic 
abscess  accumulates  between  the  layers  of  the  broad  ligament  of 
the  liver,  having  the  diaphragm  above,  the  liver  (which  is  here 
destitute  of  peritoneum)  below,  and  the  folds  of  the  peritoneum  of 
the  great  and   lesser  sac  constituting   its    anterior  and  posterior 
boundaries  respectively.      This  abscess  is,  or  may  be,  independent 
of  dysenteric  infection. 

It  arises  primarily  in  the  tissues  (probably  in  the  lymphatics- 
lymphangitis),  between  the  layers  of  the  broad  ligament,  usually 
from  the  effects  of  "  chill"  alone.  On  the  other  hand,  if  the  focus 
of  hepatitis  which  breaks  down  into  pus  is  situated  near  the 
posterior  aspect  of  the  liver,  the  contents  of  this  abscess  may  find 
its  way  backwards  and  upwards  into  the  area  between  the  folds  oi 
the  broad  ligament  of  the  liver.  Whatever  its  origin  or  cause,  the 
surgical  treatment  is  the  same. 

(2)  Intra-hepatic  abscess  is  almost  invariably  associated  with 
dysentery,  and  owing  to  its  frequent  occurrence  in  tropical  countries 
is  often  referred  to  as  a  "  tropical  abscess."     As  a  rule  the  abscess 
is  single,  but  not  invariably  so,  and  two  abscesses  may  co -exist  with 
a  thin  piece   of  liver  tissue   between.     An   intra-hepatic   abscess, 
be  it  ever  so  large,  is  invariably  confined  to  one  half  of  the  liver. 
There  can  be  no  extension  of  pus  from  the  right  to  the  left  half,  for, 
as  the  writer  has  shown,  there  is  no  communication  between  the 
right  and  left  sides  of  the  liver ;  neither  the  arteries   nor  veins, 
neither  the  hepatic  bile-ducts  nor  the  lymphatcis  of  the  right  and 
left   halves   communicate  or   anastomose.      This   anatomical   fact 
explains  why  a  primary  cancer  of  the  liver  is  confined  to  one  half, 
why  a  hydatid  of  one  side  does  not  directly  extend  to  the  other, 


Abscess  of  the  Liver.  649 

and  why  pus  does  not  find  its  way  from  one  side  to  the  other. 
There  are  practically  two  livers  in  juxtaposition  as  distinct  in  their 
blood  and  bile  circulation  as  are  the  kidneys  ;  and,  as  the  writer 
has  demonstrated,  one  half  of  the  liver  is  sufficient,  as  in  the  case 
of  one  kidney,  to  carry  on  the  work  assigned  to  the  liver  when  the 
other  half  is  destroyed. 

(3)  Sub-hepatic  abscess  is  met  with  on  the  under  surface  of 
the  right  half  of  the  liver,  parallel  to,  and  to  the  right  of,  the  gall- 
bladder. Four  cases  only  of  this  abscess  have  been  recorded.  It  exists 
as  a  sausage-shaped  mass  extending  from  the  anterior  border  of 
the  liver  to  near  the  posterior  aspect  of  the  under  surface. 

THE  SIGNS  AND  SYMPTOMS  WHICH  SUGGEST  THE  NECESSITY 
FOR  OPERATION  IN  A  CASE  OF  LIVER  ABSCESS.- 

These  are  seldom  definite,  not  in  fact  unless  the  pus  has  been 
allowed  to  accumulate  to  an  unjustifiable  extent.  Short  of  gross 
clinical  evidence,  the  presence  of  pus  in  the  liver  is  usually  arrived 
at  by  a  process  of  exclusion  combined  with  some  local  clinical 
evidence.  There  is,  however,  no  single  sign  by  which  one  can 
conclude  definitely  that  one  has  a  liver  abscess  to  deal  with. 
Night  sweats,  increase  of  temperature,  the  history  of  dysentery, 
pain  in  the  right  side  or  in  the  right  shoulder,  loss  of  weight, 
congestion  of  the  base  of  the  right  lung,  increase  of  area  of  hepatic 
dulness,  abnormal  outline  of  liver  dulness,  etc.,  collectively  suggest 
the  probability  of  pus  in  the  liver,  but  singly  they  are  of  little 
value.  Pus,  however,  may  exist  in  the  liver  without  symptoms, 
although  there  may  be  over  a  pint  of  pus  in  the  liver  requiring 
evacuation.  There  is  only  one  definite  proof  that  a  hepatic  abscess 
is  present,  and  that  is  finding  the  pus  by  the  hollow  needle  of  an 
aspirating  syringe  or  by  laparotomy. 

When  a  liver  abscess  is  suspected,  no  time  should  be  lost  in 
clearing  up  the  diagnosis  by  searching  for  the  pus,  but  it  is 
imperative  before  doing  so  that  preparations  should  be  made  to 
complete  the  operation  there  and  then  if  pus  is  found. 

SEARCHING   FOR   PUS   IN    THE   LIVER. 

When  an  abscess  in  the  liver  is  suspected,  the  pus  may  be  searched 
for  by  incision  or  by  a  hollow  needle.  If  the  evidence  points  to 
the  left  half  of  the  liver  being  involved  there  is  usually  a  pro- 
minence to  be  felt  on  the  liver  in  the  epigastric  region,  and  here  it 
is  unwise  to  insert  a  needle  to  clear  up  the  diagnosis,  but  it  is 
necessary  to  proceed  at  once  to  expose  the  liver  by  an  incision 
over  the  indicated  seat  of  the  trouble.  If,  on  the  other  hand,  the 


650  Abscess  of  the  Liver. 

pus  is  believed  to  be  in  the  substance  of  the  right  half  of  the  liver, 
and  especially  when  it  is  far  back  or  supra-hepatic,  search  should 
be  made  by  a  hollow  needle. 

It  must  be  remembered  that  pus  deeply  placed  in  the  substance 
of  the  liver  may  give  no  evidence  of  its  presence  when  the  liver  is 
exposed  by  abdominal  incision.  Time  and  again  the  liver  has  been 
exposed  and  examined,  and,  as  nothing  abnormal  was  apparent, 
the  abdominal  wound  has  been  closed,  while  subsequent  history 
demonstrated  the  fact  that  the  abscess  was  missed. 

Introducing  a  Needle  in  Search  of  Pus  in  the  Liver. — 
Owing  to  fatal  haemorrhage  having  occurred  in  several  recorded 
operations  by  competent  surgeons,  after  the  introduction  of  a  needle 
into  the  liver,  considerable  hesitation  has  arisen  in  following  this 
method'  of  exploring  the  liver  for  pus.  With  the  object  of  allaying 
so  alarming  a  possibility  the  writer  has  drawn  up  certain  rules  to 
be  followed,  whereby  the  danger  may  be  reduced  to  a  minimum,  if 
not  wholly  removed.  The  importance  of  getting  rid  of  the  dread 
of  such  a  calamity  becomes  at  once  apparent  when  it  is  considered 
that  by  the  needle  and  the  needle  alone  can  the  presence  of  pus 
in  the  liver  be  definitely  ascertained.  Do  away  with  this  method 
of  diagnosis  or  allow  the  danger  of  fatal  haemorrhage  occurring  to 
cause  delay  in  using  the  needle,  and  the  patient's  chances  of 
recovery  are  rendered  precarious  in  the  extreme.  That  needle 
punctures  in  the  liver  bleed,  it  may  be  freely,  into  the  cavity  of  the 
abdomen  has  been  proved  conclusively,  as  the  following  instance 
will  show.  After  tapping  a  man  for  ascites  the  writer  inserted  a 
needle  into  several  places  of  the  liver  whilst  yet  the  ascitic  fluid 
was  escaping  through  a  cannula  introduced  just  above  the  pubes. 
Almost  immediately  after  puncturing  the  liver  with  the  needle  the 
ascitic  fluid  became  tinged  with  blood  ;  the  tinge  grew  deeper  and 
deeper  until  there  seemed  to  be  only  blood  escaping  through  the 
cannula.  In  considerable  alarm  the  cannula  was  withdrawn,  the 
patient  placed  in  a  recumbent  position,  and  a  firm  bandage  applied 
over  the  abdomen.  No  untoward  symptoms  occurred  ;  in  fact,  the 
opposite  obtained,  for  the  patient  was  greatly  relieved,  more 
especially  as  the  liver  was  enlarged  and  congested.  Haemorrhage 
from  needle  punctures  made  into  the  liver  substance  is  not  fraught 
with  danger,  and  it  must  be  due  to  some  large  vessel  being  wounded 
that  fatal  haemorrhage  may  occur.  Without  entering  into  ana- 
tomical details,  it  will  be  evident  that  of  the  vessels  entering  or 
leaving  the  liver  the  blood  might  come  from  either  the  portal  vein 
or  the  inferior  vena  cava.  The  portal  vein  is  not  likely  to  be 
punctured  by  a  needle  unless  it  is  introduced  low  in  the  epigastrium 


Abscess  of  the  Liver. 


651 


and  pushed  deeply,  a  procedure  which  should  not  be  adopted.  The 
inferior  vena  cava  has  alone  to  be  considered,  and  it  is  probably 
this  vessel  which  has  been  punctured  when  fatal  haemorrhage 
occurs.  To  obviate  this  accident  occurring  the  writer  made  a 
study  of  the  exact  position  of  the  inferior  vena  cava  in  the  region 
of  the  liver,  its  relation  to  the  surface  of  the  body,  and  the  depth 
at  which  it  lies. 

The  summary  of  these  investigations  is  as  follows  : 
The  inferior  vena  cava  occupies  a  position  in  the  "  operable  area  " 
for  liver  abscess  equidistant  from  the  surface.      By  the  operable 
area  is  meant  the  region  over  the  liver  between  the  middle  line  of 


--c 


FlG.  1. — Diagram  of  a  section  of  a  body,  32  inches  in 
circumference,  through  the  hepatic  region,  showing 
the  inferior  vena  cava  to  be  equally  distant  from  the 
surface  of  the  body  in  the  "  operable  "  area  of  the 
liver.  I.V.C.  =  Inferior  vena  cava.  I.  =  Liver. 
A,  B,  0,  D  =  Radii  of  a  circle  having  the  inferior 
vena  cava  as  a  centre,  c.  =  Colon,  gf.  =  Stomach. 
sp.  =  Spleen,  k.  k.  =  Kidneys,  a.  =  Aorta. 

the  body  in  front  and  the  angles  of  the  right  ribs  behind.'  This 
fact  can  only  be  ascertained  by  a  study  of  transverse  frozen  sections 
of  the  body  made  in  the  hepatic  region.  These  show  that  the 
inferior  vena  cava  occupies  a  position  at  equal  distances  from  the 
surface  of  the  body  in  the  hepatic  region.  The  diagram  (Fig.  1) 
will  best  interpret  the  facts. 

The  usual  circumference  of  the  body  at  the  hepatic  level  (of  the 
sections  measured)  is  32  inches,  and  it  will  be  found  that  the 
distance  of  the  centre  of  the  inferior  vena  cava  from  the  surface  of 
the  body  in  a  body  of  32  inches  circumference  is  4 J  inches.  But  the 
cava  at  this  point  measures  1  inch  in  diameter,  so  that  it  is  not  safe 
to  use  a  needle  longer  than  3|  inches  at  most,  to  avoid  wounding 
the  cava. 


652  Abscess  of  the  Liver. 

OPERATIONS    FOR    LIVER    ABSCESS. 

(1)  "When  the  Pus  is  Supra-hepatic  or  Deep-seated 
in  the  Right  Lobe  of  the  Liver. — (a)  Trans  -thoracic  Operation 
by  Trocar  and  Cannula. — This  operation  was  devised  by  Sir 
Patrick  Manson ;  the  apparatus  here  described  was  devised  by  the 
writer. 

Special  instruments  required  :  Aspirating  syringe ;  trocar  and 
cannula  ;  hepatic  drainage  tubes  ;  stretching  rod,  with  piece  of  glass 
tube  and  5  feet  of  indiarubber  tubing. 

Chloroform  should  be  the  anaesthetic  administered.  The  patient 
should  be  placed  so  that  the  right  side  of  the  body  is  towards  the 
light.  The  skin  over  the  liver  is  prepared  in  the  usual  way ;  the 
area  in  which  the  operation  is  to  be  performed  is  painted  with 
tincture  of  iodine. 

Percuss  afresh  the  region  of  the  liver  and  select  the  spot  where 
abnormal  dulness  prevails  for  the  introduction  of  the  needle. 
Puncture  the  skin  with  a  knife  before  introducing  the  hollow 
needle  ;  this  tends  to  obviate  the  plugging  of  the  channel  of  the 
needle  by  a  wad  of  skin.  Wash  the  needle  out  with  sterilised  water 
(not  carbolic  or  other  disinfectant)  before  introducing  it.  See  that 
the  plunger  is  driven  home  before  introducing  the  needle.  Insert 
the  needle  at  the  puncture  in  the  skin  previously  made,  and  push  it 
onwards  horizontally  by  pulling  the  barrel  off  the  piston,  not  by 
pulling  the  piston  out  of  the  barrel.  The  piston-handle  is  steadied 
in  one  hand  whilst  the  barrel  is  moved  onwards  ;  in  this  way  the 
moment  the  hollow  hi  the  needle  reaches  the  pus  it  is  sucked  into 
the  syringe. 

If  pus  is  not  found  with  the  first  stab  the  needle  is  withdrawn, 
sterilised  water  drawn  into  and  ejected  thrice  from  the  syringe, 
and  the  liver  punctured  in  another  likely  place.  This  may  be 
repeated  six  to  eight,  even  to  ten,  times  before  concluding  that 
further  search  is  useless.  The  punctures  may  be  made  anywhere 
from  between  the  angles  of  the  ribs  behind,  to  as  far  forwards  as 
2  inches  from  the  edge  of  the  sternum. 

Where  pus  has  been  found  introduce  the  trocar  and  cannula 
along  the  tract  followed  by  the  needle.  The  skin  over  the  spot  is 
cut  to  the  extent  of  about  |  inch,  and  through  this  the  point  of  the 
trocar  is  inserted  and  pushed  onwards  between  the  ribs  until  no 
resistance  is  felt,  or  to  the  depth  from  the  surface  at  which  pus  was 
struck  by  the  needle.  The  trocar  is  now  withdrawn,  and  through 
the  cannula  an  indiarubber  tube  12  inches  long  stretched  on  a  metal 
rod  with  forked  end  is  introduced  until  it  is  stopped  deeply  by  the 
abscess  wall.  The  cannula  is  now  withdrawn  by  pulling  it  over  the 


Abscess  of  the  Liver.  653 

stretched  rubber  tubing  whilst  the  metal  rod  is  held  steadily  in 
place.  On  the  cannula  being  removed  the  indiarubber  is  allowed 
to  slacken,  when  it  contracts  towards  the  bottom  of  the  wound  on 
the  stretched  rod.  The  rod  is  now  withdrawn  and  the  tube  stitched 
to  the  skin  at  the  edge  of  the  wound.  Into  the  projecting  end  of 
the  indiarubber  tube  a  glass  tube  some  4  inches  long  (of  a  diameter 
to  fit  the  tube)  is  inserted,  and  to  the  distal  end  of  the  glass  tube  a 
piece  of  indiarubber  tube  long  enough  to  reach  from  the  bed  to  a 
bucket  or  basin  on  the  floor.  In  the  basin  a  few  pints  of  water  are 
placed,  and  the  distal  end  of  the  rubber  held  beneath  the  surface  of 
the  water  by  a  weight ;  a  Spencer- Wells  forceps  clipped  on  one 
side  of  the  mouth  of  the  lower  end  of  the  tube  suffices  to  keep  the 
tube  under  the  surface  of  the  water.  A  syphon  is  now  created  of 
great  potency,  and  the  pus  is  speedily  drawn  into  the  water  in  the 
basin. 

If  after  a  time  blood  is  passing  too  freely,  the  basin  must  be 
raised  off  the  floor  by  a  stool  or  low  chair,  so  that  it  is  only  just 
below  the  level  of  the  exit  of  the  tube  from  the  patient's  side.  The 
syphonage  is  kept  up  until  pus  ceases  to  ,flow  and  the  fluid  coming 
away  is  seen  to  be  deeply  tinged  with  bile — a  period  varying  from 
a  few  days  to  a  few  weeks — when  the  large  rubber  tube  in  the  side 
is  withdrawn  and  a  smaller  one  inserted  in  its  place.  From  day  to 
day  this  tube  is  shortened  and  reduced  in  size  until  the  track 
gradually  closes. 

This  operation  is  simple  in  the  extreme.  It  can  be  performed 
single-handed,  a  point  of  much  importance,  seeing  that  operation 
for  liver  abscess  has  often  to  be  performed  in  out-of-the-way  parts 
of  the  tropics,  where  help  cannot  be  had.  The  operation  involves 
no  such  serious  undertaking  as  opening  the  abdominal  cavity,  or  of 
cutting  down  and  removing  a  piece  of  a  rib  or  two,  opening  the 
pleura,  cutting  the  diaphragm  and  traversing  the  peritoneum  to 
reach  deep-seated  pus  in  the  liver — a  procedure  which  may  be 
undertaken  in  a  well-appointed  hospital,  but  when  attempted  in  an 
improvised  hospital  "  in  the  wilds,"  where  asepsis  is  impossible,  is 
one  that  can  only  end  in  disaster. 

Under  any  and  every  condition,  however,  be  it  in  a  completely 
equipped  general  hospital  with  skilled  surgeons  and  trained  nurses, 
the  operation  by  trocar  and  cannula  and  a  stretched  indiarubber 
tube  and  syphonage  is  the  operation  par  excellence,  for  it  is  by  far 
the  most  successful  for  deep-seated  hepatic  abscesses,  as  the 
published  cases  of  the  writer  have  shown  (22  deaths  in  123  cases) ; 
it  yields,  moreover,  by  far  the  best  drainage,  which  is,  after  all,  the 
chief  aim  when  operating  for  liver  abscess. 


654  Abscess  of  the  Liver. 

(b)  Trans-thoracic  Operation  by  Incision  and  Removal  of  a  Piece  of 
Rib. — With  the  patient  prepared  as  described  above,  an  incision 
some  3|  to  4  inches  in  length  is  made  parallel  to  a  rib  over  the 
seat  of  the  abscess.  The  outer  surface  of  one  or  two  ribs  is  exposed, 
the  periosteum  incised  and  raised  from  the  rib  (or  ribs)  all 
round  the  circumference.  The  bone  is  then  cut  through  by  forceps 
in  two  places,  some  2  or  more  inches  apart,  and  the  detached 
piece  raised  carefully  and  removed.  Should  intercostal  vessels 
bleed,  they  are  tied.  If  the  pleura  is  exposed,  an  attempt  is  made 
to  stitch  its  two  layers  to  the  diaphragm,  leaving  an  area  of  exposed 
diaphragm  through  which  the  operation  can  be  continued.  The 
diaphragm  is  now  cut  or  split,  the  margins  of  the  wound  made  in  it 
held  apart,  when,  if  the  pus  has  not  been  reached,  the  peritoneum 
has  to  be  traversed,  its  cavity  packed  off  by  gauze  around  the  tract 
of  the  operation  and  the  liver  incised  in  the  hope  of  reaching  the 
pus.  When  the  pus  is  reached  the  liver  substance  is  distended  by 
the  expanding  blades  of  a  forceps  and  a  large  rubber  tube  (or  two 
tubes)  inserted.  The  tube  is  stitched  to  the  skin,  the  wound  around 
the  tube  packed  by  gauze,  and  the  whole  covered  by  layers  of  gauze 
and  wool.  Fortunately  for  the  operator,  this  intricate  and  formid- 
able procedure,  owing  to  delay  or  hesitation  in  operating,  is  not 
often  required,  as  the  pus  is  usually  met  with  immediately  below 
the  piece  of  rib  removed,  when  the  operation  resolves  itself  into  one 
of  the  simplest  nature.  The  delay,  however,  is  not  conducive  to  the 
patient's  welfare. 

(2)  Operation  by  Abdominal  Incision.  --When  a  hepatic 
abscess  is  in  the  left  half  of  the  liver,  or  when  in  the  right  half  it 
presents  towards  the  abdominal  wall  in  front,  it  should  be  reached 
by  incision.  If  attempts  at  diagnosis  by  inserting  a  needle  are 
made  in  this  region,  it  is  necessary  to  employ  the  utmost  caution  to 
prevent  rupturing  the  abscess  cavity  by  the  pressure  employed 
whilst  inserting  the  needle,  and  also  to  beware  of  pushing  the 
needle  too  deeply,  otherwise  the  stomach,  the  gall-bladder,  or  even 
the  portal  vein  may  be  pricked. 

An  incision  is  made  over  the  most  prominent  point  of  the 
"  lump  "  to  be  felt.  It  is  preferable  always  to  go  through  a  rectus 
muscle  and  not  the  aponeurotic  tissue  at  its  outer  margin,  nor 
through  the  middle  line.  A  vertical  incision  3£  to  4  or  more  inches 
long  is  made  through  the  skin  and  subcutaneous  tissues,  the 
anterior  layer  of  the  aponeurotic  sheath  -of  the  rectus  is  incised 
vertically,  the  rectus  muscular  fibres  separated,  the  posterior  sheath 
of  rectus  incised  and  the  peritoneum  opened.  The  finger  is  now 
introduced  to  ascertain  the  presence  of  adhesions,  or  to  explore  the 


Abscess  of  the  Liver.  655 

surface  of  the  liver  if  no  adhesions  are  present-  If  the  abscess 
projection  conveys  the  sensation  of  fluctuation,  the  peritoneum  is 
packed  off  by  gauze  and  the  abscess  opened  and  evacuated.  The 
gauze  may  be  left  in  situ,  a  drainage  tube  inserted,  the  tube  stitched 
to  the  skin,  the  wound  partially  sutured,  and  dressings  applied. 
Instead  of  leaving  the  gauze  in  situ,  the  forefinger  may  be  intro- 
duced into  the  cavity  of  the  abscess  to  facilitate  stitching  the 
margins  of  the  wound  in  the  liver  to  the  peritoneum  as  the  gauze  is 
withdrawn.  Some  operators  before  opening  the  abscess  stitch  the 
cut  edges  of  the  parietal  peritoneum  to  the  peritoneum,  covering  the 
liver  around  the  site  of  the  abscess  by  a  continuous  suture.  An 
outer  row  of  interrupted  stitches  may,  in  addition,  be  inserted  £  inch 
beyond  the  inner  row,  so  as  more  completely  to  insure  that  the 
pus  may  not  reach  the  peritoneal  cavity  before  the  abscess  is 
opened.  In  the  exposed  area  the  liver  is  incised  and  the  pus 
evacuated,  or  the  opening  of  the  abscess  may  be  delayed  if  there  is 
no  urgency  for  twenty-four  hours. 

These  elaborate  precautions  are  not,  however,  necessary,  as  liver 
pus  is  almost  invariably  sterile,  and  seldom  causes  untoward 
symptoms  even  if  it  does  gain  access  to  the  peritoneal  cavity  in 
small  quantity. 

The  dressings  are  changed  as  required,  the  size  of  the  rubber  tube 
reduced,  and  the  wound  allowed  gradually  to  heal. 

(3)  Treatment  when  a  Hepatic  Abscess  has  Burst 
Upwards  through  the  Lung. — A  supra-hepatic  abscess  and  a 
deep-seated  abscess  on  the  right  half  of  the  liver  frequently  finds 
exit,  if  operation  has  been  delayed,  by  way  of  the  lung. 

The  pus  is  coughed  up,  and  it  is  possible  the  cavity  may  be 
satisfactorily  emptied  and  the  patient  forthwith  cured  of  his  ailment. 
This,  however,  is  not  the  rule.  After  the  primary  evacuation 
the  pus  coughed  up  gradually  lessens  in  quantity,  the  temperature 
subsides,  and  all  seems  well.  After  a  week  or  two  or  more  the 
expectoration  may  cease,  the  temperature  rises,  pain  supervenes,  and 
in  a  few  days  a  sudden  gush  of  pus  is  expectorated.  This  may  be 
repeated  at  intervals  of  weeks  or  months  for  a  year  or  two,  but  even 
at  so  remote  a  period  the  patient  may  get  well  without  operation. 
It  is  not,  however,  wise  to  allow  these  recurrences  to  go  on 
indefinitely.  If,  therefore,  a  recurrence  takes  place  more  than  once, 
operation  is  necessary. 

The  question  arises,  when  should  an  operation  be  performed  ? 
The  answer  is  :  During  the  period  when  the  expectoration  ceases, 
when  the  temperature  is  up  and  pain  present,  for  then  and  only 
then  is  it  possible  to  hit  the  cavity  in  the  liver.  If,  whilst  the 


656  Abscess  of  the  Liver. 

expectoration  is  free  and  the  temperature  normal,  an  attempt  is 
made  to  search  for  the  cavity  of  the  abscess  by  a  needle,  disappoint- 
ment is  almost  certain,  for  there  is  practically  no  cavity.  The 
evacuation  by  expectoration  being  free,  the  walls  of  the  abscess  are 
collapsed  and  in  contact,  and  to  hit  a  space  no  thicker  than  a  piece 
of  paper  is  well-nigh  an  impossibility.  When,  however,  the  fever 
recurs  and  the  cough  stops,  showing  that  pus  is  collecting  in  the 
cavity,  it  is  possible  to  ascertain  its  presence  by  a  needle  introduced 
at  this  period.  When  the  pus  is  reached,  the  trocar  and  cannula 
should  be  introduced  and  the  whole  steps  of  the  operation  gone 
through  as  above  described.  In  old- standing  cases  the  channel  of 
pus  through  the  chest  will  be  found  most  frequently  between  the 
lung  and  the  pericardium ;  the  walls  of  the  channel  become  thick 
and  fibrous,  and  to  reach  the  tract  from  the  right  side  of  the  chest 
is  fraught  with  difficulty.  The  writer  has  found  it  necessary,  on 
account  of  the  depth,  to  excise  a  portion  of  a  rib  or  ribs,  to  traverse 
a  portion  of  condensed  lung  and  puncture  the  thick-walled  channel 
whilst  in  contact  with  the  pericardium.  As  this  is  usually  some 
7  to  8  inches  from  the  surface  of  the  skin  in  the  axillary  line  it  is 
not  a  proceeding  that  can  be  lightly  attempted. 

To  allow  pus  to  find  exit  by  way  of  the  lung  should  be  prevented 
at  all  hazards.  It  means  either  that  the  abscess  has  not  been 
diagnosed — a  pardonable  error,  or  that  there  has  been  unjustifiable 
delay  in  operating— an  unpardonable  error.  Since  operation  by 
the  trocar  and  cannula  is  so  simple  that  it  can  be  undertaken  at 
once  wherever  the  patient  may  be,  and  however  unhygienic  the 
surroundings,  delay  in  operating  is  not  justified. 

JAMES  CANTLIE. 


657 


ACUTE   YELLOW   ATROPHY. 

As  it  is  now  known  that  this  disease  is  not  invariably  fatal,  it  is  im- 
portant to  take  prompt  prophylactic  measures  in  cases  of  jaundice  in 
which  acute  yellow  atrophy  may  possibly  follow.    Thus,  in  jaundice 
in  pregnant  women,  catarrhal  jaundice  associated  with  much  drowsi- 
ness or  toxaemic  symptoms,  and  jaundice  in  the  subjects  of  secondary 
syphilis,  an  attempt  should  be  made  to  dimmish  the  toxaemia.     In 
such  circumstances  the  patients  should   be  kept  in  bed  for  a  time 
in  a    well-ventilated    room,    and    the  diet   confined  to   milk   and 
carbohydrates.      The    milk  may  be  flavoured  with  coffee,    cocoa 
or  tea,  and  may  be    thickened    with    cornflour.      Three   to    four 
pints  may  be  given  daily.     When  there  is  difficulty  in  digestion 
peptonised    milk-gruel    or    Benger's    food    may   be    substituted 
in   part   or   entirely   for  milk.      Sugar   and   chocolate  are  of  use 
in  preventing   acidosis.      The   patients  should   be   encouraged  to 
drink  plenty   of  water   so   as    to   dilate  the   toxins   and  increase 
excretions  ;  for  this  purpose  alkaline  mineral  waters,  such  as  Vichy 
or  Vals,  are  especially  suitable.     The  bowels  should  be  kept  very 
freely  open  by  calomel   (3  to  5   gr.),   followed  by  salts  (magnesii 
sulphatis,  333,  or  sodii  sulphatis  2  drachms  and  sodii  phosphatis 
2  drachms  in   water)  next   morning   twice   a   week,   with  cascara 
sagrada  on  the  intervening  days.     The  degree  of  purgation  must 
be  regulated  by  the  progress  of  toxsemic  symptoms.     If  necessary, 
the  urinary  excretion   may   be   further   stimulated  by  citrate    of 
caffeine  (5  gr.)  or  diuretin  (7|  gr.)  combined  with  digitalis.     The 
jaundice  should  be  met  by  urotopin  (7£  gr.)  combined  with  sodium 
salicylate  (10  gr.),  and  bicarbonate  of  sodium  (15  gr.),  three  times  a 
day  before  food.     Acids  should  be  avoided.     Intestinal  antiseptics  in 
one  of  the  following   forms  may  be  tried :  Beta-naphthol  (5  gr.), 
naphthalin  tetrachloride   (7%  gr.),  calomel  (T\,  gr.),  salol  (5  gr.), 
rubbed  up  with  insoluble  powder    or  given   in  the   form   of   an 
emulsion  so  as  to  prevent  the  formation  of  calculi,  acetozone  (1  in 
2,000   parts   of   water)  sweetened    with    syrup   of   lemon  [U.S.P. 
syrup  of  citric  acid]  (2  oz.  to  1  pint),  \  to  1  pint  daily,  or  salicylate 
of  bismuth  (10  gr.).     In  jaundice  in  secondary  syphilis,  mercurial 
treatment  or  a  single  injection  of  Ehrlich's  dioxydiamido-arseno- 
benzol  ("  606  ")  is  essential. 

S.T. — VOL.    II.  42 


658  Acute  Yellow  Atrophy. 

In  cases  in  which,  from  the  presence  of  nervous  symptoms  and 
considerable  diminution  of  the  liver  dulness,  the  onset  of  acute 
yellow  atrophy  seems  fairly  certain  the  above  measures  should  be 
pushed,  and  in  addition  enemas  or  subcutaneous  or  intramuscular 
transfusions  of  saline  solution  should  be  carried  out  to  obviate  the 
toxaemia.  Sodium  bicarbonate  should  be  given  in  larger  quantities 
(1  drachm)  three  or  four  times  daily  by  the  mouth  or  in  the 
enemas  or  transfusions  (3  drachms  to  1  pint).  As  the  condition  is 
thought  to  depend  on  autolysis  of  the  liver,  I  gave  horse  serum, 
which  has  an  anti-autolytic  action,  in  one  case  in  which  recovery 
eventually  occurred. 

Vomiting  should  be  treated  by  careful  feeding,  small  doses  of 
cocaine  (^  gr.),  dilute  hydrocyanic  acid  (ij|2^),  or  small 
hypodermic  injections  of  morphine  (^  gr-)-  Sleeplessness  and 
delirium  should  be  met  by  tepid  sponging,  ice-bags  to  the  head, 
bromides,  morphine,  veronal  or  trional.  Chloral  and  its  allies 
should  be  avoided,  because  the  chloroform  which  is  formed  exerts  a 
toxic  action  on  the  liver  cells.  The  circulation  should  be  main- 
tained by  the  hypodermic  injection  of  liquor  strychnines  Ou3)  or 
digitalin  (^  gr.). 

H.  D.  ROLLESTON. 

REFERENCES. 

Legg,  J.  Wickham,  "  The  Bile,  Jaundice  and  Bilious  Diseases,"  1880,  London. 
H.  Quincke  Nothnagel's  "  Encyclopedia  of  Practical  Medicine,"  English  edition, 
1903,  Vol.  on  "  Diseases  of  the  Liver,"  p.  47.3.  Eolleston,  H.  A.,  "  Diseases  of 
the  Liver,  Gall-bladder  and  Bile-ducts,"  1905,  London.  Thomson,  J., 
"Jaundice  in  Newly-born  Children."  Allbutt  and  Eolleston,  "System  of 
Medicine,"  1908,  IV.,  Part  I.,  p.  98. 


659 


ANOMALIES    IN    FORM    AND    POSITION    OF    THE 

LIVER. 

DISPLACEMENT  of  the  liver  by  a  large  pleural  effusion,  pneumo- 
thorax,  or  subphrenic  abscess  on  the  right  side,  or  by  a  gigantic 
pericardial  effusion,  is  of  course  treated  by  relief  of  the  causal  factor. 

A  Wandering  Liver  (Total  Hepatoptosis)  is  nearly  always  a 
manifestation  of  visceroptosis  (Glenard's  disease),  and  the  treat- 
ment is  mainly  on  the  same  lines  as  in  that  disease.  As 
prophylactic  measures,  women  with  pendulous  abdomens  should 
be  specially  careful  about  getting  up  after  childbirth,  and  should 
wear  a  straight-fronted  corset  or  the  form  designed  by  Gallant. 
The  corset  should  be  carefully  fitted  and  moulded  in  the  first 
instance,  and  should  always  be  put  on  in  the  supine  position. 
Tight-lacing  and  all  ill-fitting  corsets  must  be  forbidden.  For  the 
pain  which  may  accompany  hepatoptosis  rest  in  the  horizontal 
position  with  the  foot  of  the  bed  raised  gives  relief.  The  abdominal 
muscles  should  be  strengthened  by  exercises  and,  if  necessary,  by 
massage.  The  patients  often  require  feeding  up,  but  care  must  be 
taken  to  avoid  flatulence.  In  cases  in  which  a  properly  fitted 
abdominal  support  fails  to  give  relief,  the  liver  has  been  fixed  in 
position  by  suturing  (hepatopexy).  This  may  be  necessary  in 
extreme  cases,  but  it  must  be  remembered  that  a  wandering  liver 
is  usually  part  of  general  visceroptosis,  and  that  relapses  may 
occur  after  hepatopexy. 

Linguiform  Lobe  (Riedel's  Lobe  ;  Partial  Hepatoptosis).— 
When  there  is  pain  in  connection  with  this  comparatively  common 
deformity,  treatment  must  in  the  first  place  be  directed  to  any 
underlying  condition  such  as  gall-stones,  cholecystitis,  or  distension 
of  the  gall-bladder.  Tight- lacing  and  badly-fitting  corsets  must  be 
avoided  and  a  straight-fronted  corset  should  be  worn.  Two  forms 
of  operative  treatment  have  been  advocated  :  (1)  Excision  of  the 
lobe ;  (2)  fixation  of  the  lobe  to  the  abdominal  wall. 

H.    D.   ROLLESTON. 

KEFERENCES. 

• 

F.,  "  Los  ptc>si><  viscerales,"  Paris,  1899.      Keith,   A.,   "  Hepato- 
Allbutt  and  Rolleston,  "  System  of  Medicine,"  1908,  IV.,  Part  L,  p.  11. 

42—2 


66o 


CIRRHOSIS  OF  THE  LIVER. 

PORTAL    OR    COMMON    CIRRHOSIS. 

Prophylactic  Treatment. — Portal  or  multilobular  cirrhosis  of 
the  liver  is  the  final  result  of  the  repeated  occurrence  of  small 
areas  of  necrosis  of  the  liver  cells  produced  by  toxins  reaching  it 
by  the  portal  vein.  The  toxins  are  absorbed  by  the  alimentary 
canal  and  are  mainly  the  result  of  indigestion,  most  commonly  of 
alcoholic  origin.  The  prophylactic  treatment  of  portal  cirrhosis, 
therefore,  includes  that  of  dyspepsia  (see  Vol.  I.)  and  chronic 
alcoholism  (see  Vol.  I.).  The  diet  should  be  carefully  regulated 
so  as  to  avoid  highly-spiced  food  containing  condiments  such  as 
curries  ;  alcohol  in  all  forms  and  even  medicinal  tinctures  should 
be  forbidden.  It  may  be  wise  for  the  patient  to  change  his 
occupation,  for  example,  to  give  up  work  as  a  barman. 

Early  Stages. — In  a  patient  suffering  from  dyspepsia  whose 
liver  is  found  to  be  enlarged,  but  who  has  no  other  symptoms  of 
cirrhosis,  these  restrictions  in  diet  may  advantageously  be  supple- 
mented by  a  course  at  a  spa  such  as  Harrogate,  Homburg,  Vichy, 
Karlsbad,  Kissingen  or  Marienbad.  In  this  stage  and  after  a 
single  attack  of  hfematemesis  strict  attention  to  diet,  abstinence 
from  alcoholic  stimulants,  and  freedom  from  dyspepsia  may  be 
followed  by  arrest  of  the  disease  and  the  patient  may  remain  well. 
But  it  is  important  that  he  should  realise  that  the  condition  is 
compensated  for,  not  cured,  and  that  he  should  maintain  the  life 
of  strict  moderation,  otherwise  the  symptoms  may  return.  Even 
when  the  disease  appears  latent,  copious  gastro-intestinal  haemor- 
rhage may  occur  with  little  or  no  warning  except  a  feeling  of 
faintness  and  nausea.  The  hgemateniesis  should  be  treated  by  rest 
in  bed  for  four  or  five  days,  and  nothing — not  even  water — should 
be  given  by  the  mouth  for  two  days ;  as  a  rule  it  is  unnecessary  to 
give  nutrient  enemas  during  this  short  period,  but  an  enema  of  a 
pint  of  water  should  be  given  three  or  four  times  daily  to  relieve 
thirst.  A  drachm  of  calcium  chloride  may  be  put  into  the  first 
water  enema  so  as  to  diminish  the  tendency  to  haemorrhage.  As 
the  bleeding  commonly  comes  from  dilated  and  ulcerated  veins  at 
the  lower  end  of  the  cesophagus,  20  min.  of  a  1  in  1,000  solution 
of  adrenalin  chloride  in  an  ounce  of  water  may  be  given  by  the 
mouth  for  its  local  action  on  the  bleeding  spot.  Tannic  and  gallic 


Portal  Cirrhosis  of  the  Liver.  66 1 

acids,  perchloride  of  iron,  and  turpentine  have  been  given  with  the 
same  object,  but  are  somewhat  irritating  and  rarely  necessary.  If 
the  patient  is  anxious  and  nervous  a  hypodermic  injection  of 
morphine  (J  gr.)  may  be  given.  In  rare  cases  in  which  there  is 
serious  collapse  as  a  result  of  the  haemorrhage,  subcutaneous, 
intramuscular,  or  intravenous  transfusion  of  1  to  2  pints  of 
saline  solution  should  be  given  at  blood  heat.  On  the  evening  of 
the  second  day  a  blue  pill  [U.S.P.  mass  of  mercury]  should  be  given 
followed  next  morning  by  magnesium  sulphate  (jss  in  4  oz.  of 
water),  so  as  to  get  the  bowels  freely  open.  On  the  third  day,  pro- 
vided there  has  been  no  recurrence,  feeding  by  the  mouth  may  be 
started  with  peptonised  milk,  peptonised  milk  gruel,  and  gradually 
improved.  For  a  week  or  so  milk  up  to  4  pints  a  day  should  be  taken  ; 
it  can  be  flavoured  with  coffee  or  tea,  or  given  in  the  form  of  junket 
or  Benger's  food.  The  after-treatment  is  of  importance,  for  it  is 
often  only  after  an  attack  of  haematernesis  that  the  existence  of 
cirrhosis  is  suspected  and  that  the  patient  can  be  sufficiently 
impressed  with  the  need  for  temperance.  As  the  patient  improves, 
the  dietary  should  be  extended  ;  soft  and  easily  digested  fish, 
pounded  fish  and  rice,  eggs  lightly  boiled,  minced  chicken, 
mashed  potatoes,  butter  and  stale  bread,  milky  puddings  and 
vegetable  soups  may  be  given.  Meat  soups  and  extracts,  highly 
spiced  foods  and  irritating  articles  must  be  avoided.  Iodide  of 
potassium  should  be  given  in  10-gr.,  increasing  to  15-gr.,  doses 
three  times  a  day,  unless  syphilis  can  be  excluded.  Constipation 
must  be  prevented  by  simple  waters  such  as  Apenta,  Hunyadi  Janos, 
Karlsbad  or  Epsom  salts,  or  a  mixture  of  rhubarb  and  soda, 
compound  jalap  powder  (30  gr.),  cream  of  tartar  (jss),  or 
calomel  (3  gr.),  followed  by  magnesium  sulphate  (^ss)  next 
morning.  Undue  looseness  of  the  stools,  which,  by  abstracting 
food,  would  impair  the  patient's  nutrition,  should  be  prevented  by 
salicylate  of  bismuth  (15  gr.),  aromatic  chalk  mixture,  or  tannigen. 
Intestinal  fermentation  and  putrefaction  should  be  prevented  by 
diet,  and  if  necessary,  by  calomel  (^  gr-)>  guaiacol  carbonate 
(5  gr.),  or  naphthalin  tetrachloride  (7  gr.)  three  times  a  day. 
No  drug  will  remove  the  fibrous  tissue  in  the  liver,  but  some 
patients  improve  while  taking  ammonium  chloride  (10  to  15  gr.) 
three  times  a  day. 

Tonics,  such  as  tincture  of  nux  vornica  (5min.)  [U.S.P.  (12  min.)] 
in  combination  with  sodium  bicarbonate  (10  gr.)  and  infusion  of 
gentian  (jss)  twice  or  three  times  a  day  before  food,  may  be 
required  at  intervals.  Arsenic  is  best  avoided,  as  it  appears  to  be 
capable  of  inducing  cirrhosis. 


662  Portal  Cirrhosis  of  the  Liver. 

The  course  of  portal  cirrhosis  may  be  conveniently  divided  into 

(1)  the  pre-ascitic  stage  in  which  hsematemesis  may  occur,  and 

(2)  the  stage  of  ascites  accompanied  by  coxic  symptoms.    The  onset  of 
ascites  is  sometimes  preceded  by  the  rapid  appearance  of  ti/nipanitic 
distension,  which  may  be  so  excessive  as  to  be  dangerous.     This 
should  be  met  by  the  remedies  mentioned  above  in  connection  with 
the  prevention  of   intestinal    fermentation    and  putrefaction,  and 
also  as  it  is  probably  toxic  in  origin  by  diuretics,  such  as  caffeine 
citrate  (5  gr.)  with  tincture  of  digitalis  (15  min.)  three  times  a  day, 
and  also  by  purgatives.     The  treatment  of  ascites  and  the  indica- 
tions for  tapping  have  been  considered  elsewhere  {see  article  on 
Ascites,  Vol.  I.),  but  reference  must  be  made  here  to  the  surgical  treat- 
ment of  the  ascites  of  hepatic  cirrhosis  by  producing  vascular  peritoneal 
adhesions.     This  method,  first  suggested    by  Talma  and  carried 
out   in   this    country   by   Morison,    is    often   called    the    Talma- 
Morison   operation.      Its   object   is   to  increase   the   anastomoses 
between  the  portal  and  the  general  systemic  veins,  and  thus  to  lead 
to  absorption  of  the  ascites  ;  but  it  may  also  act  by  improving  the 
nutrition  of  the  liver  cells  and  so  enabling  them  to  exert  their 
antitoxic  function  more  effectually.     The  operation  should  not  be 
undertaken   in  an   advanced  stage   of   the   disease,  as   shown  by 
marked  debility,  wasting  and  toxaemia ;    when  there  is  consider- 
able jaundice ;    or   in    the    presence    of   definite   cardiac  or  renal 
disease.     The  really   suitable  cases,  which  are  not  very  common, 
are   those  in  which  the  general  condition  is  good    and  in  which 
the  symptoms  are  those   of  obstruction  rather  than  of  toxaemia. 
The  details    of   the    operative    procedure  vary,  but  the  essentials 
are    to    scrape    the    adjacent  peritoneal  surfaces  of  the  liver  and 
diaphragm  so  as  to  favour  adhesive  peritonitis.     Some  surgeons 
turn   the   omentum    up    and    fix    it   between    the    liver    and    the 
diaphragm ;  others,  again,  scrape  the  surfaces  of  the  spleen  and 
adjacent  peritoneum.    Omentopexy,  or  suturing  the  great  omentum 
to  the  abdominal  wall,  has  also  been  carried  out.     According  to 
Sinclair  White's  analysis  of  227  cases,  87  per  cent,  were  cured  and 
13  per  cent,  improved  as  the  result  of  the  Talma-Morison  operation. 
Ascites  has  also  been  treated  surgically  by  fixing  the  great  omentum 
under   the   abdominal    muscles    and    externally    to    the   parietal 
peritoneum  (Schiassi);    by  introducing  the  omentum  into  a  sub- 
cutaneous pocket  in  the  abdominal  wall  (Narath) ;  by  permanent 
drainage  into  the  tissues  of  the  thigh  through  the  femoral  ring 
(Wynter  and  Handley) ;  and  even  by  anastomosing  the  peritoneal 
cavity  with  the  saphenous  vein  (Soyesima). 

Late    stages. — As   tox&mia   is   a   prominent   feature,    the   diet 


Hypertrophic  Cirrhosis  of  the  Liver.       663 

should  consist  of  milk  (3  to  4  pints  in  the  twenty-four  hours) ; 
to  avoid  monotony  it  may  be  flavoured  with  coffee,  tea  or 
cocoa,  or  given  in  the  form  of  junket.  When  milk  or  milk  diluted 
with  barley  water  sets  up  nausea,  skimmed  milk  or  koumiss  may 
be  tried.  If  the  patient  improves,  the  milk  diet  should  be  supple- 
mented by  the  cautious  addition  of  Benger's  food,  peptonised  milk 
gruel,  milk  puddings,  eggs,  and  eventually  pounded  fish. 

The  hamorrkagic  tnulciicy  should  be  met  by  the  administration 
of  calcium  salts.  For  example :  Calcii  Lactatis,  gr.  10 ;  Magnesii 
Lactatis,  gr.  7^ ;  Syrupi,  53 ;  Aquam,  ad  jj,  t.d.,  for  six  doses. 
Acidosis,  as  shown  by  a  purple  colour  on  adding  a  few  drops  of 
liquor  ferri  perchloridi  to  the  urine,  should  be  treated  by  Sodii 
Bicarbonatis,  gr.  30  ;  Syrupi,  533  ;  Aquam,  ad  gj,  three  times  a 
day.  For  drowsiness  due  to  toxemia,  purgatives  and  diuretics 
should  first  be  tried,  then  hot  water  or  hot-air  baths,  copious 
enemas  of  water  at  blood  heat,  and  lastly,  transfusion  of  saline 
solution  (1  to  3  pints).  If  there  is  evidence  of  acidosis,  bicarbonate 
of  sodium  (2  drachms  to  I  pint)  should  be  added  to  the  saline  solu- 
tion. Medicinally,  besides  iodide  of  potassium,  which,  as  already 
mentioned,  should  always  be  tried  unless  syphilis  can  be  excluded, 
a  tonic  such  as  Tinct.  Nucis  Vom.,  iti7£ ;  Sodii  Bicarbonatis, 
gr.  15  ;  Aquam  Menth.  Pip.,  ad  ^j  [U.S. P.  Tinct.  Nucis  Vom.,  irilS  ; 
Sodii  Bicarbonat.,  gr.  15  ;  Aquam  Menth.  Pip.,  ad  jj],  may  be  given. 
Arsenic  should  not  be  given.  The  patient's  general  health  should 
be  maintained  by  fresh  air  and  sun  when  the  weather  is  suitable, 
but  exertion,  cold,  damp  and  east  winds  must  be  avoided. 

Extract  of  liver  substance  has  been  recommended,  and  the  daily 
administration  of  3£  oz.  of  pulped  pig's  liver  has  been  stated  to 
have  been  beneficial  (Widal).  A  grape  cure,  in  which  as  much  as 
5  Ibs.  of  ripe  grapes  are  taken  daily,  has  also  been  advocated 
(Cavazzini). 

REFERENCES. 

Kelly,  A.  O.  J.,  in  "  Osier  and  McCrae's  System  of  Medicine,"  1908,  Vol.  V., 
]).  7S(i.  Rollrston,  H.  D.,  "  Diseases  of  the  Liver,  Gall-bladder,  and  Bile-ducts," 
London,  1905.  White,  W.  Hale,  "  Common  Affections  of  the  Liver,"  London, 
.1908.  White,  Sinclair,  "Brit.  Med.  Journ.,"  1906,  II.,  p.  1287. 


HYPERTROPHIC    BILIARY    CIRRHOSIS    (HANOT'S   DISEASE). 

As  this  somewhat  rare  disease  may  depend  on  infection  by  means 
of  water,  special  attention  should  be  paid  to  this  point,  and  if  the 
residence  is  damp  and  low  lying  the  patient  should  move  to  a  drier, 


664          Syphilitic  Cirrhosis  of  the  Liver. 

more  elevated  and  sunnier  spot.  Every  effort  to  improve  the  general 
health  should  be  made.  Fresh  air  and  regulated  exercise  are 
desirable;  cold  and  damp,  exposure  to  east  winds,  and  over- 
fatigue  must  be  avoided.  The  diet  should  be  more  generous  than 
in  portal  cirrhosis,  but  stimulating  and  spicy  food  and  alcohol 
should  be  forbidden.  During  the  attacks  of  fever  and  increased 
jaundice  a  milk  diet  should  be  enjoined.  In  the  early  stages 
benefit  may  result  from  treatment  at  Harrogate,  Ems,  Vichy, 
Homburg,  Neuenahr,  or  a  mild  course  at  Karlsbad. 

Constipation  should  be  prevented  by  mineral  waters,  such  as 
Hunyadi  Janos,  Condal,  Karlsbad.  As  the  disease  may  be  infective 
a  mixture  of  Urotropin,  gr.  5  ;  Sodii  Salicylatis,  gr.  7ss  ;  Sodii 
Bicarbonat.,  gr.  10 ;  Aquam  Menth.  Pip.,  ad  §j,  may  be  given 
twice  a  day  before  food  every  alternate  week.  Calomel,  T\y  to 
\  gr.  every  four  hours  for  three  days  in  each  week  for  a  month,  has 
been  stated  to  do  more  good  than  any  other  drug.  Pruritus  should 
be  treated  on  the  lines  indicated  on  p.  670. 

Surgical  treatment  in  the  form  of  drainage  of  the  gall-bladder  for 
periods  up  to  three  months  has  been  followed  by  good  results  in  a 
number  of  cases,  but  the  diagnosis  in  these  cases  is  perhaps  open 
to  criticism. 

REFERENCES. 

Fletcher,  H.  Morley,  Allbuttand  Rolleston,  "  System  of  Medicine,"  1908,  IV., 
Part  I.,  p.  194.  L6r6boullet,  "  Les  Maladies  du  foie  et  leur  Traiteinent,"  Paris, 
1910,  p.  315. 


SYPHILITIC   CIRRHOSIS   OF    THE   LPVER. 

IN  Tertiary  Syphilis  of  the  liver,  mercury  and  its  compounds 
should  be  given  either  by  the  mouth,  by  intramuscular  injection, 
or  by  inunction.  The  choice  of  the  method  must  depend  on 
circumstances  ;  usually  the  oral  administration  of  the  green  iodide 
(|  to  1  gr.)  in  the  form  of  a  pill  made  up  with  sugar  of  milk,  or  of 
a  mixture  of  perchloride  of  mercury  solution  On  30  to  5J)  [U.S. P. 
corrosive  mercuric  chloride,  gr.  ^  to  gr.  Tv]  in  combination 
with  iodides  (see  below)  is  the  most  convenient  form.  But  if 
salivation  or  gastro-intestinal  irritation  is  set  up,  or  in  the  case 
of  patients  who  cannot  be  relied  upon  to  take  their  medicine, 
the  intramuscular  injection  of  mercurial  salts,  either  soluble,  such 
as  the  perchloride  (£  gr.),  the  cyanide  (T^  gr.),  or  succinimide  (j^gr.), 
or  the  insoluble  salts,  such  as  the  salicylate(|  gr.),  calomel  (^  gr.) 


Syphilitic  Cirrhosis  of  »the  Liver.          665 

should  be  employed.  The  injection  is  made  deeply  into  the 
substance  of  muscles,  such  as  the  gluteal,  once  a  week.  Inunction 
and  fumigation  are  most  commonly  given  at  spas  such  as  Aix-la- 
Chapelle  and  Luchon.  Iodides  should  be  given  at  the  same  time 
as  mercury.  Beginning  with  10  gr.  three  times  a  day  before  food, 
the  amount  should  be  increased,  provided  severe  symptoms  of 
iodism  do.  not  appear,  until  30  gr.  three  times  a  day  are  given. 
It  is  probably  best  to  give  the  iodides  of  potassium,  sodium  and 
ammonium  in  equal  doses.  In  cachectic  patients  large  doses  of 
decoction  of  sarsaparilla  (up  to  a  pint  in  the  day)  have  been 
recommended.  It  must  be  remembered  that  symptoms  due  to  a 
gumma  will  be  relieved,  whilst  those  due  to  a  syphilitic  cicatrix  will 
not  be  influenced  by  treatment.  In  some  large  gurnmas  incision 
and  scraping  out  the  caseous  contents  has  hastened  a  cure  by  drug 
treatment.  The  reports  of  the  effects  of  injections,  intramuscular 
or  intravenous,  of  dioxydiamido-arsenobenzol  (Ehrlich's  606),  point 
to  a  rapid  and  easy  cure  of  tertiary  lesions. 

For  the  treatment  of  congenital  syphilis  of  the  liver  see  Article 
on  Syphilis  (Vol.  I.). 

H.  D.  ROLLESTON. 


666 


DISEASES  OF  THE  BLOOD-VESSELS  OF  THE  LIVER. 

Thrombosis  of  the  Portal  Vein  is  usually  associated  with 
cirrhosis  or  with  some  other  grave  affection  of  the  liver,  such  as 
new  growth  or  syphilis.  Symptoms  suggesting  its  presence  are 
sudden  and  considerable  ascites,  which  rapidly  recurs  after  removal 
and  gastro- intestinal  haemorrhages  ;  these  should  be  treated  as  in 
cirrhosis.  When  pylethrombosis  is  suspected,  citric  acid  (30  gr.  in 
water  every  four  hours  for  four  days)  may  be  tried  in  order  to 
reduce  the  excessive  coagulability  of  the  blood  and  so  to  prevent 
the  extension  of  the  thrombosis ;  but  it  must  not  be  given  in  the 
presence  of  a  general  haemorrhagic  tendency,  which  it  would  tend 
to  increase.  If  there  is  evidence  of  past  syphilis  this  should  be 
treated.  In  cases  of  obliteration  of  the  portal  vein  as  a  result  of 
past  thrombosis,  shown  clinically  by  splenic  enlargement  and 
recurrent  haematemesis,  it  would  appear  reasonable  to  perform 
the  Talma-Morison  operation  for  promoting  vascular  anastomoses 
around  the  liver  (see  p.  662).  But  this  procedure  has  not  often 
been  carried  out,  and  when  done  has  not  been  successful. 

Suppurative  Pylephlebitis.— As  the  blood  is  usually  sterile  and 
the  causal  organism  cannot  be  determined,  vaccine  therapy  must 
be  hypothetical ;  a  streptococcus  vaccine  or  a  polyvalent  anti-strep- 
tococcus serum  may  be  tried.  Apart  from  any  attempt  of  this  kind, 
the  treatment  must  be  directed  to  relief  of  the  symptoms ;  thus, 
the  alleviation  of  local  pain  should  be  effected  by  soothing  applica- 
tions, and  if  necessary  by  morphine  hypodermically.  The  general 
symptoms  are  those  of  septicaemia  and  should  be  treated  on 
those  lines.  Surgical  treatment  can  hardly  be  expected  to  do 
good  ;  but  in  a  few  instances  recovery  has  followed  opening  a 
small  hepatic  abscess  in  cases  resembling,  if  they  were  not, 
pylephlebitis ;  so  that  if  the  condition  of  things  be  explained  to  the 
patient  and  he  wishes  the  risk  to  be  taken  an  exploratory  operation 
may  be  performed. 

The  prophylactic  treatment,  namely,  the  removal  of  a  cause 
likely  to  produce  pylephlebitis,  for  example,  an  inflamed  appendix, 
is  all-important. 

Obstruction  of  the  Hepatic  Veins  may  be  due  to  thrombosis, 
stricture  by  fibrosis  in  the  neighbouring  parts  of  the  liver,  or 


Obstruction  of  the  Hepatic  Veins.         667 

chronic  periphlebitis  and  endophlebitis.  The  symptoms  are  very 
much  the  same  as  those  of  thrombosis  of  the  portal  vein,  and  the 
treatment  should  be  on  the  same  lines. 

Aneurysm  of  the  Hepatic  Artery  is  very  rare  and  has  hardly 
ever  been  diagnosed.  When  found  at  an  exploratory  laparotomy 
the  treatment  is  ligature,  but  even  then  the  outlook  is  bad ;  out  of 
six  cases  thus  operated  upon  recovery  occurred  in  one  (Kehr).  The 
symptoms,  usually  simulating  those  of  biliary  colic  or  duodenal 
ulcer,  must  be  treated  by  anodynes. 


H.  D.  ROLLESTON. 


BEFERENCES. 


Disease*  of  the  Portal  and  Hepatic  Veins:  Brown,  W.  Langdon,  "St.  Bart. 
Hos.  Rep.,"  Lond.,  1901,  X  XX  V  11.,  p.  62.  Hess,  A.  F.,  "  Amer.  Journ.  Med. 
Sciences,"  1'hilad.,  1905, '  CXXX.,  p.  986.  Herringham,  W.  P.,  Allbutt  and 
Rolleston,  "  System  of  Medicine,"  IV.,  Part  I.,  p.  153. 

Ant'ui -ysms "of  the  Hepatic  Artery  :  Kehr,  H.,  "Miinchen.  Med.  Wchnschr.," 
903,  L.,  p.  1861.  W.  Holland  (abstract  of  forty  cases),  "  Glasgow  Med.  Journ.," 
90S,  LXIX.,  p.  342. 


668 


DEGENERATIONS    OF    THE    LIVER. 

FATTY    LIVER. 

UNDER  this  heading  will  be  included  the  conditions  formerly 
spoken  of  as  fatty  infiltration  and  fatty  degeneration  of  the  liver. 
An  excessive  quantity  of  fat  occurs  in  the  liver  in  a  large  number 
of  conditions,  such  as  obesity,  some  cases  of  cirrhosis,  alcoholism, 
poisoning  by  arsenic,  phosphorus  and  iodoform,  and  in  infective 
conditions  such  as  gastro-enteritis  and  pulmonary  tuberculosis. 
There  are  no  special  symptoms  referable  to  fatty  liver  apart  from 
those  due  to  the  causal  disease,  and  the  treatment  is  that  of  the 
primary  condition. 

Intense  fatty  change  in  the  liver  is  such  a  prominent  feature  in 
delayed  chloroform  poisoning  that  a  brief  reference  to  its  treatment 
should  be  made  here.  Prophylactic  measures  consist  in  feeding 
the  children  before  chloroform  narcosis,  especially  when  from 
vomiting,  diarrhea  or  other  causes,  the  liver  has  been  deprived  of 
food.  It  is  important  that  sugar  and  alkalies,  such  as  bicarbonate 
or  citrate  of  sodium,  should  be  given  both  before  and  after  opera- 
tions on  badly  nourished  children  in  order  to  obviate  acid  intoxica- 
tion. The  sugar  may  be  given  by  the  mouth  or  per  rectum,  and 
the  alkali  in  the  strength  of  2  drachms  to  the  pint  of  water,  either 
by  the  bowel  or  under  the  skin.  Beddard  advocates  intravenous 
transfusion  of  a  solution  of  6  per  cent,  of  dextrose  after  symptoms 
of  acid  intoxication  have  appeared. 

\ 

KEFERENCES. 

Beddard,  A.  P.,  Lancet,  1908,  I.,  p.  782.  Guthrie,  L.  G.,  "  Clin.  Journ.," 
Lond.,  1907,  XXX.,  p.  129.  Hunter,  W.,  Art.  "Delayed  Chloroform  Poison- 
ing," Allbutt  and  Eolleston,  "  System  of  Medicine,"  1908,  IV.r  Part  I.,  p.  136. 

FUNCTIONAL    DERANGEMENT. 

THIS  condition  of  the  liver  is  common  both  as  the  result  of  gross 
structural  change  and  of  poisons  reaching  it  from  the  alimentary 
canal.  The  conditions  popularly  described  as  "torpid  liver,"  "liver 
not  acting  "  and  "  biliousness,"  are  not  due  to  a  primary  functional 
insufficiency  of  that  organ,  and  these  titles  are  usually  euphemisms 
for  constipation,  indigestion  and  gastro-intestinal  catarrh,  and  over- 
indulgence in  food  and  drink.  The  appropriate  treatment  should 
be  directed  to  correct  constipation,  dyspepsia  and  dietetic  errors. 

H.  D.  ROLLESTON. 


669 


HYDATID  CYSTS  OF  THE  LIVER. 

THE  liver  is  the  commonest  seat  of  Hydatid  Cysts  which  in  the 
majority  of  cases  affect  the  right  lobe.  Active  treatment  is  almost 
always  indicated,  for  although  the  cysts  sometimes  die  and  dry  up 
or  calcify,  in  most  cases  they  continue  to  enlarge  and  ultimately 
rupture  or  suppurate. 

The  older  methods  of  treatment,  aspiration,  aspiration  followed 
by  injection,  and  electrolysis,  will  not  be  discussed,  for  they  are 
very  uncertain  in  their  action  and  involve  great  risks.  At  the 
present  time,  two  methods  of  treatment  are  available  :  (1)  Enuclea- 
tion,  and  (2)  Incision  and  drainage. 

Enucleation. — This  is  obviously  the  ideal  method  when  it 
is  practicable.  It  is  especially  suitable  for  cases  in  which  the  cyst 
is  small,  near  to  the  surface  of  the  liver,  and  not  suppurating. 

A  vertical  incision  is  made  over  the  cyst  and  the  surrounding 
peritoneal  cavity  is  carefully  packed  off.  The  endocyst  is  emptied 
as  far  as  possible  by  an  aspirator  or  by  incision,  and  is  then  care- 
fully separated  from  the  ectocyst.  The  resulting  cavity  is  obliterated 
by  catgut  sutures,  and  if  this  is  effected  satisfactorily,  the  abdominal 
wound  is  closed  without  drainage. 

Incision  and  Drainage. — This  procedure  is  the  one  more 
commonly  practised,  and  is  the  safer  for  large  cysts  and  for  those 
in  which  suppuration  has  occurred.  Some  authorities  recommend 
that  it  should  be  carried  out  in  two  stages ;  this  may  be  advisable 
for  suppurating  cysts  when  there  are  no  adhesions  to  the  anterior 
abdominal  wall,  but  as  a  rule  the  operation  may  safely  be  completed 
in  one  stage. 

The  cyst  is  exposed  and  thoroughly  isolated  by  gauze  packs. 
Some  of  its  fluid  is  withdrawn  by  an  aspirator,  and  a  small  incision 
is  made  into  it ;  a  finger  is  passed  into  the  cavity,  and  the  cyst  is 
emptied  as  far  as  possible.  The  edges  of  the  incision  are  then 
carefully  sutured  to  the  deeper  layers  of  the  abdominal  wall,  and  a 
large  drainage  tube  is  inserted.  Throughout  the  operation  every 
precaution  must  be  taken  to  protect  the  edges  of  the  wound,  owing 
to  the  risk  of  hydatid  infection  of  the  raw  surface. 

Occasionally  when  the  cyst  occupies  the  highest  part  of  the  right 
lobe  of  the  liver,  it  is  necessary  to  deal  with  it  through  the  thoracic 
wall,  portions  of  two  or  three  ribs  being  resected. 

T.   CRISP   ENGLISH. 


670 


JAUNDICE. 

THE  radical  treatment  of  jaundice  must,  of  course,  be  directed  to 
underlying  cause,  and  accurate  diagnosis  in  each  case  is  therefore 
essential.  But  before  considering  the  treatment  of  some  special 
forms  of  jaundice  it  will  save  time  to  deal  with  the  treatment  of  the 
symptoms  which  may  occur  in  jaundice,  however  caused. 

SYMPTOMATIC  TREATMENT  OF  JAUNDICE  GENERALLY. 

Constipation  should  be  prevented  by  drinking  plenty  of  water 
before  breakfast  and  at  bedtime ;  in  the  morning  the  patient  should 
walk  about  while  sipping  the  water  which,  when  necessary,  should 
contain  Karlsbad  salts  (5J  to  5iij),  or  sulphate  of  sodium  (5J)  and 
sulphate  of  magnesium  (5J),  or  sulphate  of  sodium  (5J)  and 
phosphate  of  sodium  (5J).  The  salts  may  be  made  more  palatable 
by  the  addition  of  a  little  infusion  of  quassia  or  cinchona.  Karlsbad, 
Marienbad,  Kissingen,  Condal,  Apenta,  Friedrichshall,  and  other 
waters  may  be  taken  instead  of  the  plain  water.  If  necessary, 
calomel  (gr.  2  to  4),  or  blue  pill  [U.S. P.  mass  of  mercury]  (gr.  3), 
may  be  taken  the  night  before.  Vigorous  purges  should  be  avoided. 
Benefit  often  follows  spa  treatment  at  Harrogate,  Karlsbad, 
Neuenahr,  Homburg,  Vichy.  For  flatulence,  guaiacol  carbonate 
(gr.  7),  in  cachets,  may  be  taken  three  times  a  day,  or  salicylate  of 
bismuth  (gr.  10),  naphthalin  tetrachloride  (gr.  7),  calomel  (gr.  ^o), 
or  salol  (gr.  5),  rubbed  up  with  carbonate  of  magnesium  in  order 
to  prevent  the  formation  of  salol  calculi.  Fresh  ox  or  pig's  bile 
(gr.  7|),  in  capsules  or  keratin-coated  pills,  are  sometimes  given. 

Pruritus  may  be  the  most  troublesome  symptom  and  may 
become  very  serious  from  the  sleeplessness  that  it  induces.  In  some 
instances  it  may  be  necessary  to  try  several  remedies  before  relief 
is  obtained,  and  sometimes  nothing  but  morphine  hypodermically  is 
effectual.  In  the  first  place,  the  local  application  of  carbolic  acid  to 
the  skin  should  be  tried  ;  it  may  be  employed  as  a  lotion  of  1  part 
in  40,  and  dabbed  on  the  skin  with  a  small  sponge,  or  by  means  of 
strips  of  lint  which  are  kept  moist  by  the  addition  of  the  lotion  from 
time  to  time.  A  2  per  cent,  solution  in  olive  oil  may  also  be 
employed  in  the  same  way.  These  applications  should  not  be  pre- 
scribed when  the  skin  is  excoriated  by  scratching,  as  there  is  the 
risk  of  toxic  results  from  absorption.  As  the  itching  is  often 


Jaundice.  671 

worse  at  night  a  warm  bath  containing  8  oz.  of  bicarbonate  of 
sodium  or  potassium  may  be  taken,  the  skin  being  afterwards 
rubbed  with  an  ointment  of  equal  parts  of  boracic  acid  ointment 
and  lanoline.  A  bath  containing  hydrochloric  acid  has  also  been 
recommended,  but  it  must  be  given  in  a  special  wooden  bath. 
When  these  local  measures  fail,  the  following  should  be  tried  : 
Menthol,  either  in  the  form  of  spirit  (menthol,  gr.  5  to  the  ounce), 
or  of  an  ointment  (menthol,  gr.  30,  olive  oil,  5Jss,  lanoline,  ^ij)  ; 
ichthyol  in  water  (1  to  4  per  cent.)  or  mixed  with  equal  parts  of 
alcohol  and  ether  (ichthyol,  5ijss,  alcohol  and  ether  equal  parts, 


Relief  may  sometimes  be  obtained  from  the  internal  administra- 
tion of  (1)  nervine  sedatives,  such  as  antipyrin,  aspirin,  bromides, 
and  chloral  ;  (2)  calcium  salts  ;  the  unpleasant  taste  of  calcium 
chloride  may  be  minimised  in  the  following  prescriptions  :  1^  . 
Calcii  chloridi,  gr.  15  ;  Ext.  Glycyrrhizse  liq.,  553  ;  Aquam 
Menth.  Pip.,  ad  3]  ;  or  1^.  Calcii  Chloridi,  gr.  15  ;  Syrupi  Aurant., 
588  ;  Aquam  Chloroformi,  ad  5J  [U.S.  P.  1^.  Calcii  Chloridi, 
gr.  15  ;  Fluid  Extract.  Glycyrrhizse,  5ss  ;  Aquam  Menth.  Pip.,  ad 
5J  ;  or  H.  Calcii  Chloridi,  gr.  15  ;  Syrupi  Aurant.,  588  ;  Aq.  Chloro- 
formi, jss;  Aquam,  ad  jj].  (3)  Thyroid  extract.  These  internal 
remedies  should  be  tried  in  conjunction  with  the  local  applica- 
tions and  in  the  order  given.  Pilocarpine  given  in  ^  to  J  gr. 
hypodermically  or  by  the  mouth  sometimes  gives  good  results.  As 
has  already  been  mentioned,  all  remedies  short  of  hypodermic 
injections  of  morphine  may  fail,  and  unfortunately  even  this  is  not 
infallible. 

In  cases  of  severe  jaundice  in  which  there  is  a  tendency  to 
cutaneous  and  mucous  haemorrhages  calcium  salts  should  be 
given  ;  a  suitable  prescription  is  :  1^  .  Calcii  Lactatis,  gr.  7%  ;  Magnesii 
Lactatis,  gr.  7^;  Aquam  Chloroformi,  ad  jj  [U.S.P.  1^.  Calcii 
Lactatis,  gr.  7$;  Magnesii  Lactatis,  gr.  1\  ;  Aq.  Chloroformi,  333  ; 
Aquam,  ad  ^j].  One  such  dose  to  be  taken  three  times  a  day  for 
three  days  every  ten  days.  Horse  serum  may  also  be  given  by  the 
mouth  in  doses  of  10  c.c.  twice  a  day  for  two  or  three  days. 

The  diet  will  necessarily  vary  to  some  extent  with  the  degree  of 
indigestion  and  the  patient's  appetite.  Fat  of  all  kinds  should  be 
avoided,  and  carbohydrates  and  proteins  given  in  an  easily  digested 
form,  for  example  bread,  rusks  or  biscuits  with  jam,  marmalade  or 
honey,  bread  and  milk,  gruel,  blancmange,  potatoes  —  preferably 
mashed,  and  rice  puddings.  Pounded  fish,  kedjeree,  pounded  chicken, 
chicken  cream,  lightly  curried  fish  or  chicken,  game  and  a  little 
meat  ;  fresh  fruit,  such  as  grapes,  bananas,  and  baked  apples  ; 


6j2  Jaundice. 

well-diluted  coffee  or  tea,  or  Vichy  water  are  suitable.  Alcoholic 
drinks  should  be  proscribed  in  ordinary  jaundice,  but  in  malig- 
nant disease  stimulants  are  usually  desirable.  In  cases  of  con- 
siderable wasting  sterilised  oil  (388  twice  a  day)  has  been  injected 
under  the  skin  (Hale  White). 


TREATMENT  OF  SPECIAL   FORMS  OF  JAUNDICE. 

(1)  Icterus  in  the  Newly-born  may  be  due  to  various  causes, 
and  the  treatment  must  be  determined  accordingly. 

In  the  Physiological  Jaundice  of  new-born  infants  which  occurs  in 
from  30  to  90  per  cent,  of  all  infants  no  special  treatment  is  neces- 
sary. In  rare  instances  successive  infants  become  jaundiced  and  die 
without  any  organic  cause ;  this  condition  has  been  regarded  as  an 
intense  form  of  the  jaundice  of  the  newly-born,  and  in  such  cases  it 
is  worth  while  to  treat  the  mother  during  pregnancy  with  urotropin 
and  salicylate  of  sodium  and  small  doses  of  calomel  (^  gr.)  three 
times  a  day,  in  order  to  counteract  any  intestinal  infection  or 
intoxication. 

Infective  Jaundice  of  Umbilical  Origin  has  a  very  high  mortality, 
as  it  is  extremely  likely  to  lead  to  septicaemia.  Since  the  infec- 
tion is  often  due  to  streptococci,  the  use  of  polyvalent  antistrepto- 
coccus  serum  or  of  vaccines  would  appear  to  be  reasonable.  Care 
and  aseptic  treatment  of  the  umbilicus  are  obviously  essential  as 
prophylactic  measures. 

Infective  Jaundice  of  Intestinal  Origin  may  occur  in  epidemics 
and  has  a  high  mortality ;  it  has  been  called  Winckel's  disease  and 
is  closely  related  to  Buhl's  disease.  Repeated  small  doses  of  calomel 
(^  gr.)  should  be  administered  and  plenty  of  water  by  the  mouth. 
Acetozone  (1  in  3,000  parts  of  water)  with  syrup  of  lemon  [U.S.P. 
syrup  of  citric  acid](l  drachm  to  1  oz.)  may  be  given  as  an  antiseptic, 
about  2  oz.  in  the  twenty-four  hours.  Enemas  of  saline  solution 
should  be  given,  and  subcutaneous  transfusion  of  saline  solution  is 
necessary.  The  stools  should  be  disinfected  and  burnt. 

Catarrhal  Jaundice  is  very  rare  in  babies,  and  no  hard  and  fast 
line  can  be  drawn  between  it  and  mild  infective  jaundice.  It 
should  be  treated  in  the  same  way  as  infective  jaundice  of 
intestinal  origin  except  that  transfusion  is  unnecessary. 

In  Congenital  Syphilis  jaundice  is  most  unusual,  except  in  the 
very  rare  instances  in  which  the  ducts  are  affected  ;  in  the  latter 
cases  the  condition  exactly  resembles  that  of  congenital  obliteration 
of  the  ducts.  The  treatment  of  congenital  syphilitic  disease  of 
the  liver  is  that  of  congenital  syphilis.  Syphilised  mothers  and 


Jaundice.  673 

those  who  have  had  stillbirths  or  miscarriages  thought  to  be  due  to 
this  cause  should  be  put  on  specific  treatment  during  pregnancy. 

In  Congenital  Obliteration  of  the  'Bile-ducts  no  benefit  can  be 
expected  from  operative  interference,  and  the  same  is  unfortu- 
nately true  with  regard  to  medical  treatment.  In  rare  instances 
syphilis  affects  the  larger  ducts  and  gives  rise  to  a  clinical  picture 
exactly  resembling  that  of  congenital  obliteration  of  the  ducts,  and 
moreover  cases  diagnosed  as  congenital  obliteration  of  the  ducts 
have  recovered  after  mercurial  treatment.  On  these  grounds  the 
infant  should  be  given  hydrargyrum  c  creta  (^  gr.)  three  times  a  day. 
Salol  (£  gr.)  or  guaiacol  carbonate  (1  gr.)  may  be  given  to  diminish 
intestinal  auto-intoxication.  In  the  later  stages  haemorrhages  are 
apt  to  occur  and  should  be  combated  by  calcium  lactate  (1  gr.)  three 
times  daily. 

(2)  Catarrhal  Jaundice.  In  the  early  stages,  when  there  is  still 
some  gastro-duodenitis,  it  is  important  to  treat  this  and  to  avoid 
further  irritation  of  the  stomach  by  food.  Gastric  irritability 
should  be  met  by  a  few  doses  (six  in  the  first  thirty-six  hours) 
of  a  mixture  such  as  1^.  Bismuthi  Carbonatis,  gr.  15;  Sodii 
Bicarbonatis,  gr.  10;  Tinct.  Cardamom.  Co.,  nj.15  ;  mucilaginis 
Tragacanth.,  q.s.  ;  Spiritus  Chloroformi,  irj.10  ;  Aquam,  ad  §j,  to 
which,  if  vomiting  is  persistent,  5  min.  of  chlorodyne  or 
10  min.  [U.S. P.  6  min.]  of  tincture  of  opium  may  be  added  for  a 
few  doses.  The  patient  should  be  in  bed,  and  for  the  first  day  or 
so  may  with  advantage  be  starved,  though  he  may  take  as  much 
water,  Vichy  water,  or  water  containing  bicarbonate  of  sodium  as 
he  feels  inclined.  Instead  of  absolute  starvation  diluted  whey, 
which  is  much  the  same,  may  be  allowed.  Rest  to  the  stomach  is 
extremely  important,  for  the  main  cause  of  an  early  relapse  is 
excessive  food  at  this  stage.  Epigastric  discomfort  may  be  relieved 
by  the  application  of  poultices  or  warm  compresses  frequently 
changed. 

As  the  gastric  irritability  subsides,  milk  containing  citrate  of 
sodium  (10  gr.  to  the  pint)  and  diluted  should  be  given,  beginning 
with  1^  pints  in  twenty-four  hours,  and  increased  gradually.  The 
bismuth  mixture  should  now  be  stopped  and  the  bowels  moved  by 
a  dose  of  calomel  (3  gr.),  followed  by  Karlsbad  salts  (2  drachms)  in 
water  early  the  next  morning ;  or  a  pill  of  hydrargyr.  c  creta  (1  gr.) 
may  be  taken  three  times  daily  ;  in  order  to  prevent  the  diarrhoea 
1  or  2  gr.  of  powdered  chalk  may  be  added  (Murray).  The 
following  mixture  may  then  be  taken :  fy.  Sodii  Salicylatis,  gr.  1\ ; 
Sodii  Bicarbonat.,  gr.  10  ;  Urotropin.,  gr.  7£  ;  Spiritus  Chloro- 
formi, in  10;  Infusum  Caryophylli,  ad  jj.  During  this  period  large 

S.T. — VOL.  n.  43 


674  Jaundice. 

rectal  injections  (Krull's  irrigations)  of  water  at  a  temperature  of 
60°  to  65°  F.,  or  even  cold,  have  been  recommended,  with  the  object  of 
producing  vigorous  peristaltic  contractions  of  the  gall-bladder  and 
bile  ducts,  and  so  driving  bile  through  into  the  intestine;  as  a 
rule,  however,  this  course  is  not  necessary.  Pruritus,  when  present, 
should  be  treated  on  the  lines  given  on  p.  670. 

As  the  appetite  returns,  cautious  additions  to  the  milk  diet 
should  be  made  in  the  form  of  thin  clear  soup,  gruel  made  with 
arrowroot,  toast,  eggs,  souffles,  pounded  fish,  kedjeree,  chicken 
cream  and  rice  puddings.  Fatty  food,  especially  liquid  fat  and 
melted  butter,  should  be  avoided.  Intestinal  fermentation  should 
be  prevented  by  keeping  the  bowels  open  with  compound  liquorice 
powder,  1  drachm  at  night,  and  if  necessary  a  Seidlitz  powder 
(pulvis  sodae  tartratis  effervescens)  the  next  morning  ;  or  by  ^  gr. 
doses  of  calomel  three  times  a  day,  or  salol  (5  gr.),  or  naphthaliu 
tetrachloride,  7  gr.  twice  a  day.  Convalescence  is  now  commencing 
and  the  patient  may  be  up  and,  provided  he  avoids  chills  and  expo- 
sure to  the  east  wind,  may  go  into  the  fresh  air.  As  a  safeguard 
against  chills  a  cholera  belt  may  be  worn.  The  medicine  contain-  • 
ing  urotropin  and  salicylate  of  sodium  should  be  taken  in  a  rather 
smaller  quantity  twice  a  day,  and  tincture  of  nux  vomica  (5  min.) 
[U.S.P.  12  min.]  should  be  added  to  each  dose.  A  mixture 
containing  acid  and  somewhat  of  the  following  composition  : 
1^.  Tinct.  Nucis  Vom.,  rn,5  ;  Acidi  Nitrohydrocblorici  Dil.,  iri.10  ; 
Infusum  Calumbae,  ad  ^j  [U.S.P.  1^.  Tinct.  Nucis  Vom.,  ir[12; 
Acidi  Nitrohydrochlorici  Dil.,  trilO;  Infusum  Calumbae,  ad  jj]  is 
often  given,  but  personally  I  prefer  an  alkaline  medicine.  In 
prolonged  cases  ammonium  chloride  (10  gr.),  with  syrup  of  lemons 
[U.S.P.  syrup  of  citric  acid]  (5  ss.),  may  be  given  three  times  a 
day.  Jaundice,  in  the  course  of  secondary  syphilis,  rapidly  yields 
to  mercurial  treatment  (hydrargyr.  c  creta,  1  gr.,  t.d.s.),  but  is  very 
resistant  to  the  ordinary  treatment  of  catarrhal  jaundice. 

In  cases  of  catarrhal  jaundice  which  do  not  clear  up  and  in  which 
there  is  no  other  reason  to  suspect  any  graver  condition,  benefit 
may  result  from  a  visit  to  a  spa  such^as  Harrogate,  Llandrindod 
Wells,  Vichy,  Evian,  Neuenahr,  Ems,  Homburg,  Karlsbad, 
Marienbad.  At  the  spa  the  water  should  be  sipped  slowly  when 
walking  about  before  breakfast. 

(8)  Chronic  Haemolytic  Jaundice. — This  condition  is  extremely 
resistant  to  treatment,  but  at  the  same  time  it  must  be  remembered 
that  in  many  instances,  especially  in  the  hereditary  and  congenital 
cases,  the  patients  suffer  little  or  no  inconvenience  from  it,  and 
that  it  may  persist  through  a  long  life  even  up  to  seventy  years  of 


Lardaceous  Disease  of  the  Liver.          675 

age.  The  anaemia,  which  is  more  prominent  in  the  acquired  than 
in  the  congenital  cases,  may  be  benefited  by  iron,  but  arsenic  is 
useless.  The  patient  should  lead  a  quiet  and  regular  life,  and 
avoid  factors  which  increase  the  symptoms,  such  as  fatigue, 
exposure  to  cold  and  excitement,  and  unsuitable  diet.  According 
to  Tileston  and  Griffin  the  attacks  of  abdominal  pain  are  not 
a  necessary  part  of  the  disease,  but  are  due  to  concomitant 
cholelithiasis,  arid  should  therefore  be  treated  on  appropriate  lines 
(see  p.  682). 

H.  D.  ROLLESTON. 


LARDACEOUS  OR  AMYLOID  DISEASE  OF  THE  LIVER. 

LIKE  fatty  change,  this  is  a  local  manifestation  of  a  general  cause 
and,  except  that  in  children  ascites  sometimes  seems  to  be  thus 
caused,  does  not  give  rise  to  any  symptoms  as  apart  from  signs. 
It  is  due  to  syphilis,  to  prolonged  suppuration,  for  example,  a  psoas 
abscess  or  a  chronic  empyema,  and  in  rare  instances  to  other 
cachexiae.  It  is  therefore  essential  to  treat  it  by  removing  the 
cause  if  it  be  still  present.  Thus  syphilis  should  be  energetically 
combated,  and  any  suppuration  brought  to  a  conclusion  by  surgical 
interference.  The  general  health  should  be  improved  by  residence 
at  the  seaside,  open-air,  good  nourishing  food  and  hygienic  sur- 
roundings. Tonics,  iron  and  dilute  nitro-hydrochloric  acid  should 
be  given  a  prolonged  trial.  Ammonium  chloride  has  also  been 
recommended. 

H.  D.  ROLLESTON. 


43—2 


676 


"  TROPICAL    LIVER." 

TROPICAL  LIVER  or  tropical  hepatitis,  as  it  may  be  more  correctly 
designated,  may  be  due  to  several  causes,  and  the  treatment  of  the 
condition  will  necessarily  depend  on  which  of  these  is  present.  The 
commonest  causes  of  the  condition  are  (1)  dysentery  (amoebic), 
(2)  malaria,  (3)  a  hot  climate,  and  (4)  over-eating  and  drinking  in 
the  tropics. 

Amoebic  hepatitis  may  coincide  with  the  acute  attack  of 
dysentery,  or  it  may  follow  it,  or  it  may  be  associated  with  a 
latent  phase  of  that  disease,  no  dysenteric  symptoms  being  present. 
In  his  book  "  Fevers  in  the  Tropics,"  Leonard  Eogers1  discusses 
this  question  in  a  chapter  entitled,  "  The  Pre-suppurative  Stage  of 
Amoebic  Hepatitis,"  clearly  showing  that  many  cases  of  hepatitis 
and  obscure  pyrexias  with  a  leucocytosis  are  due  to  infection  with 
amoebae,  and  that  dysenteric  symptoms  in  such  cases  are  often 
absent.  The  treatment  of  frank  attacks  of  amoebic  hepatitis,  or  of 
attacks  of  hepatitis  occurring  in  a  country  where  amcebiasis  is 
common,  should  always  be  by  ipecacuanha  in  large  doses  (sec  article 
on  Dysentery,  Vol.  III.).  Eogers  (loc.  cit.)  has  had  splendid  results  by 
the  use  of  this  drug,  and  lately  using  a  similar  treatment  in  several 
cases  of  hepatitis  in  England,  where  an  amoebic  influence  could  not 
be  absolutely  put  out  of  court,  I  have  also  been  successful.  The  drug 
should  be  administered  in  large  doses  (20  gr.  once  or  twice  aday, 
or  30  gr.  for  an  initial  dose)  this  being  reduced  by  5  gr.  a  night 
till  a  dose  equivalent  to  the  latter  figure  is  reached.  When  the 
temperature  is  high  and  the  condition  acute  the  patient  must  be 
kept  strictly  in  bed,  poultices  should  be  applied  and  a  very  low  diet 
prescribed.  If  there  is  any  evidence  of  an  abscess  having  formed, 
then  a  surgeon  should  be  called  in  to  operate  (see  Treatment  of 
Tropical  Liver  Abscess,  Vol.  III.). 

Malaria  has  been  given  as  one  of  the  principal  causes  of  tropical 
liver.  An  acute  hepatitis  due  to  the  malarial  parasite  is  by  no 
means  uncommon,  and  is  undoubtedly  responsible  for  a  certain 
number  of  cases.  Calomel  at  night,  followed  by  an  ample  dose  of 
salts  in  the  morning  and  then  appropriate  doses  of  quinine,  is  the 
treatment  to  adopt.  In  more  chronic  cases  with  an  old  history  of 
malaria  I  have  found  painting  the  skin  over  the  liver  with  linimentum 
iodi  beneficial. 


Tropical  Liver.  677 

The  treatment  of  cases  of  tropical  liver  arising  from  over-eating 
and  drinking  or  from  excessive  hea-t  is  largely  a  question  of  diet. 
Many  apply  the  term  tropical  liver  only  to  such  cases,  and  strictly 
speaking  this  is  correct  enough.  Our  first  step,  then,  in  dealing 
with  such  a  case  should  he  to  relieve  the  acute  congestion  of  the 
liver,  and  this  in  a  mild  case  can  readily  be  accomplished  by  the 
free  use  of  Carlsbad  salts.  A  strict  diet  must  be  prescribed  and  alcohol 
cut  down  to  its  narrowest  limits.  The  question  of  exercise  should 
not  be  forgotten,  and  the  patient  must  be  led  to  understand 
that  any  indiscretions  will  certainly  give  him  another  attack. 
In  severe  cases,  where  there  is  pain  and  tenderness  over  the 
liver  with  pyrexia,  the  patient  should  be  placed  in  bed,  and  hot 
poultices  or  turpentine  stupes  should  be  applied  over  the  region  of 
the  liver.  Very  little  in  the  way  of  food  should  then  be  given,  the 
diet  consisting  of  milk  alone  or  milk  and  water,  or  if  the  patient 
cannot  take  these,  barley-water  and  weak  beef-teas.  All  alcohol 
should  be  stopped,  and  a  sufficient  dose  of  salts  to  produce  a  free 
motion  of  the  bowels  every  morning  should  be  administered. 

Under  such  measures  improvement  rapidly  takes  place,  and  after 
the  temperature  has  become  normal  and  all  pain  disappeared  the 
patient  may  be  allowed  up  in  his  room  every  day.  If  all  goes  well, 
the  patient  may  return  to  ordinary  life,  say,  in  seven  days  or  less. 

Ammonium  chloride  (in  20  gr.  doses,  three  or  four  times  a  day) 
has  been  strongly  recommended  in  such  cases  by  some  authorities. 
As  Sir  Patrick  Manson2  says,  "  it  does  no  harm,"  but  I  am  inclined 
to  share  his  view  that  it  also  does  little  good.  Where  the  condition 
becomes  chronic,  the  patient  should  leave  the  tropics,  and  pay  a  visit 
to  Carlsbad3  or  Harrogate  if  possible  for  a  course  of  special  treatment. 
I  know  of  no  better  directions  for  treatment  than  those  given  by 
Sir  Patrick  Manson  (loc.  cit.)  for  this  class  of  case,  and  therefore  I  quote 
him  more  or  less  closely  in  the  following :  The  patient  should  start  the 
morning  by  sipping  1  pint  of  boiling  water  in  which  a  tablespoonf  ul 
or  more  of  Carlsbad  salts  (Sprudel  salts  in  powder)  have  been  dissolved. 
This  takes  from  fifteen  to  twenty  minutes  for  completion.  Gentle 
exercise  may  be  indulged  in  while  doing  this,  but  in  some  people  there 
is  a  tendency  to  sickness,  and  such  individuals  should  remain  quietly 
in  bed.  No  food  should  be  taken  till  from  half  an  hour  to  one  hour 
afterwards.  A  light  breakfast  is  then  permissible.  The  quantity  of 
the  salt  must  be  increased  if  the  bowels  do  not  move  freely ;  the  exact 
amount  required  will  soon  be  ascertained  by  the  patient  himself. 
The  salts  should  be  taken  for  two  or  three  weeks,  and  a  strict  diet  is 
to  be  rigidly  adhered  to.  Butter,  fat,  nuts,  fruits,  pastry,  preserves, 
tinned  foods,  cheese,  salads,  wines,  spirits  and  beer  are  all 


678  Tropical  Liver. 

contra-indicated,  and  meat  is  only  to  be  taken  once  a  day.  After  the 
cure  a  country  life  in  a  temperate  climate  with  its  active  pursuits 
is  best  for  the  patient,  precautions  in  the  shape  of  warm  clothing, 
avoidance  of  cold  baths,  alcohol  and  high  living  being  scrupulously 
observed  and  a  weekly  saline  purge  taken. 

Dyspepsia  may  be  troublesome  in  this  late  stage  of  tropical  liver. 
Davidson4  recommends  the  use  of  nitro-hydrochloric  acid  and  nux 
vomica  for  this.  In  cases  where  anaemia  is  present  I  have  found 
injections  of  arsenate  of  iron  very  serviceable.  If  mental  depression 
is  present,  frequent  change  of  scenery  is  best,  as  it  takes  the 
patient's  mind  off  himself,  and  tends  in  time  to  make  him  forget 
his  complaints. 

G.  C.  LOW. 

REEEKENCES. 

1  Rogers,  L.,  "Fevers  in  the  Tropics,"  Oxford  Medical  Publications,  p.  173. 

2  Manson,  Sir  P.,  "  Tropical  Diseases,"  4th  edit.,  Lond.,  1907,  p.  484. 

8  Young,  "  The  Carlsbad  Treatment  for  Tropical  Ailments "  (Calcutta, 
Thacker,  Spink  &  Co.). 

4  Davidson,  Andrew,  article  on  "  Tropical  Liver,"  Allbutt  and  Rolleston, 
"System  of  Medicine,"  1907,  II.  Pt.  II.,  p.  571. 


679 


TUMOURS   OF  THE   LIVER. 

Secondary  Malignant  Growths  are  much  commoner  than 
primary,  in  about  the  proportion  of  1  to  80.  The  treatment  of  the 
two  forms  is  the  same  except  for  two  points  :  (1)  In  some  cases  of 
primary  new  growth  it  may  be  possible  to  excise  the  tumour ; 
(2)  in  secondary  malignant  disease  of  the  liver  symptoms  due  to  the 
primary  growth,  for  example,  in  the  stomach  or  colon,  may  require 
treatment. 

Pain  may  be  relieved  by  local  applications,  such  as  belladonna 
plaster,  but  morphine  hypodermically  should  be  given  without 
scruple.  Dragging  and  a  feeling  of  weight  due  to  traction  exerted 
by  the  heavy  organ  when  the  patient  sits  up  or  stands  may  be 
mitigated  by  a  belt.  Ascites,  if  considerable,  should  be  tapped. 
For  pruritus,  sec  p.  670.  Constipation  must  receive  attention. 
Vomiting  may  be  treated  by  bismuth  subnitrate  (gr.  15),  with 
cerii  oxalat.  (gr.  10),  as  a  powder  repeated  three  times  in  the 
day;  or  chlorodyne  On.10),  in  an  ounce  of  water.  For  the  pro- 
gressive weakness,  Tinct.  Nucis  Vom.  Tit7£;  Nitrohydrochloric. 
Acid.  Dil.,  ir|.7J  ;  Syrup.  Limon.,  533;  Aquam  ad  5J  [U.S.P.  Tinct. 
Nucis  Vom.,  111 18;  Nitrohydrochloric.  Acid.  Dil.,  iil7£ ;  Syrup. 
Citric.  Acid.,  533 ;  Aquam  ad  £j],  should  be  given  three  times  a 
day  after  food.  Alcoholic  stimulants  are  generally  required.  The 
patient  should  be  allowed  to  take  as  generous  a  diet  as  possible. 

In  rare  instances  innocent  tumours  of  the  liver  such  as 
single  adenomas,  solid  or  more  rarely  cystic,  simple  cysts, 
and  angiomas  occur.  The  treatment  is  surgical.  Hydatid  cysts 
also  should,  when  large,  be  treated  surgically,  the  cyst  being  freely 
exposed  and  not  tapped  through  the  abdominal  wall  (see  p.  669). 

Lymphadenoma  when  it  attacks  the  liver  is  usually  rapidly  fatal. 
It  should  be  treated  by  arsenic  by  the  mouth  or  by  soamin  or 
other  arsenical  injections. 

For  actinomycosis  of  the  liver  large  doses  of  iodide  of  potassium, 
30  gr.  or  more,  three  times  a  day,  should  be  given. 

H.  D.  ROLLESTON. 


68o 


INJURIES    AND    DISEASES    OF    THE    GALL^ 
BLADDER    AND    BILE    DUCTS, 

INJURIES   OF   THE   BILE    PASSAGES. 

INJURIES  to  the  bile  passages  are,  as  might  be  expected,  much  less 
common  than  injuries  to  the  liver,  and  they  are  apt  to  be  con- 
founded with  the  latter,  though  in  reality  they  present  many  points 
of  difference. 

They  may  be  caused  by  stabs  or  gunshot  wounds,  or  by  violent 
blows  or  severe  compression  in  the  region  of  the  liver.  These 
injuries  appear  to  be  more  common  in  persons  who  have  already 
suffered  from  biliary  calculi  or  from  inflammatory  lesions  of  the 
gall-bladder  or  ducts. 

The  fundus  of  the  gall-bladder,  the  most  exposed  portion  of  the 
bile-excreting  apparatus,  is  the  part  most  frequently  injured,  both 
in  penetrating  wounds  and  in  subcutaneous  injuries. 

In  the  case  of  penetrating  wounds  the  neighbouring  organs  are 
frequently  injured,  e.g.,  the  liver,  stomach,  or  colon. 

Courvoisier  collected  forty-eight  cases,  of  which  three  were 
subcutaneous  ruptures  and  fourteen  penetrating  wounds  of  the  bile 
passages. 

In  all  the  museum  specimens  where  the  history  is  appended,  the 
fact  of  the  long  survival  after  so  serious  an  accident  is  notable,  and 
the  lesson  is  manifest  that  operation  would  in  each  case  have  given 
good  hopes  of  success.  As  a  result  of  a  wound  or  rupture  of  any 
part  of  the  biliary  secreting  apparatus,  extravasation  of  bile  occurs 
into  the  peritoneum.  As  a  rule  the  bile  occupies  the  right  half  of 
the  abdomen,  extending  down  to  the  iliac  fossa.  It  is  confined  to 
this  portion  of  the  abdomen  by  the  insertion  of  the  mesentery,  but 
occasionally  it  extends  to  the  pelvis,  or  even  into  the  left  loin. 
After  a  certain  time  the  collection  of  bile  becomes  encapsuled  by 
the  formation  of  a  false  membrane  on  the  surrounding  viscera. 
This  false  membrane  frequently  seals  the  opening  in  the  gall-bladder 
or  ducts,  preventing  the  further  escape  of  bile,  and  rendering  it 
difficult  at  an  operation  to  detect  the  actual  situation  of  the 
injury. 

If  the  bile  is  aseptic  there  may  be  no  peritonitis,  and  in  some 
cases  spontaneous  recovery  has  undoubtedly  occurred. 


Injuries  of  the  Bile  Passages.  68 1 

Recovery  has  also  occurred  after  the  spontaneous  formation  of  a 
biliary  fistula. 

As  a  rule,  even  in  cases  in  which  the  bile  is  aseptic,  gradual 
emaciation  occurs,  ending  in  death,  probably  owing  to  the  absorption 
of  some  toxic  matter  from  the  extravasated  bile. 

Septic  peritonitis  may  occur  at  any  time,  as  the  bile  may  be 
already  septic  from  previous  gall-bladder  disease,  or  infection  may 
arise  from  proximity  to  the  bowel,  or  after  exploration  or  aspiration. 
Courvoisier  collected  thirty-three  cases,  in  eighteen  of  which  the 
extravasated  bile  had  been  removed  by  aspiration.  In  eleven  of 
these  recovery  followed.  He  advocated  repeated  aspiration  before 
resort  to  laparotomy.  Occasionally  a  single  aspiration  has  been 
successful ;  more  usually  multiple  aspirations  are  required  before 
recovery  ensues. 

Terrier  and  Auvray  (Chimrgie  de  Foie)  collected  seventeen  cases 
in  which  aspiration  (in  most  cases  repeated)  had  been  performed. 
Of  these,  ten  recovered  and  seven  died. 

Laparotomy  may  be  performed  as  a  primary  or  a  secondary 
operation.  The  former  will  probably  be  restricted  to  cases  of 
penetrating  wounds,  while  the  latter  will  be  performed  in  cases  of 
subcutaneous  injury. 

Secondary  laparotomy  will  usually  be  performed  in  cases  of 
subcutaneous  rupture,  owing  to  the  difficulties  in  diagnosis  until 
jaundice  appears.  In  many  eases  it  will  be  impossible  to  detect 
the  wound  owing  to  the  formation  of  false  membrane.  In  these 
cases  the  bile  should  be  washed  out  with  saline  solution  and  the 
abdomen  drained,  or  drainage  may  be  adopted  without  irrigation. 

If  a  small  wound  is  found  in  the  gall-bladder,  it  may  be  sutured 
or  the  gall-bladder  may  be  drained  through  the  opening.  If  the 
gall-bladder  is  extensively  lacerated,  or  if  the  cystic  duct  is  injured, 
cholecystectomy  should  be  performed. 

If  a  wound  of  the  hepatic  duct  is  discovered,  it  may  be  possible 
to  close  the  opening  by  sutures,  but  as  a  rule  reliance  must  be 
placed  on  drainage. 

Terrier  collected  twelve  cases  of  secondary  laparotomy  for  injuries 
to  the  bile  ducts  and  gall-bladder,  with  six  recoveries.  If  rupture 
of  the  common  duct  is  discovered,  he  recommends  ligature  of  both 
ends  of  the  duct  and  cholecystenterostoray. 

A.  W.  MAYO-ROBSON. 


682 


CHOLELITHIASIS. 

Prophylaxis. — The  factors  responsible  for  cholelithiasis  are 
inflammation  of  the  gall-bladder  and  stagnation  of  bile.  According 
to  Naunyn,  bacterial  infection  of  the  gall-bladder  is  the  essential 
factor,  stagnation  of  bile  being  important  only  in  so  far  as  it  favours 
infection ;  but  more  recently  (Aschoff  and  Bacmeister)  evidence  has 
been  brought  forward  to  show  that  stagnation  of  bile  in  the  gall- 
bladder without  inflammation  may  give  rise  to  the  formation  of 
single  pure  cholesterol  calculi.  The  prophylactic  treatment  of  gall- 
stones, therefore,  concerns  the  prevention  of  cholecystitis  and  of 
stagnation  of  bile.  The  form  of  cholecystitis  that  gives  rise  to  gall- 
stones is  of  a  comparatively  mild  grade  and  is  mainly  due  to  infec- 
tion with  Bacillus  coli  and  B.  typhosus,  though  other  allied  bacteria, 
such  as  B.  paratyphosus,  may  play  a  causal  part.  In  typhoid  fever 
the  bile  constantly  contains  the  pathogenetic  organism,  and  it  is 
therefore  reasonable  during  the  course  of  this  fever  and  in  con- 
valescence to  give  short  courses  of  Urotropin,  gr.  7|  ;  Sodii  Salicylat., 
gr.  7£ ;  Sodii  Bicarbonat.,  gr.  10;  Infusum  Caryophylli,  ad  £j. 

In  fat  persons,  especially  women,  and  after  typhoid  fever, 
influenza  and  pregnancy,  measures  should  be  taken  to  diminish 
the  liability  to  stagnation  of  bile  ;  thus,  gentle  exercise  in  the  open- 
air  and  breathing  exercises  are  indicated.  For  a  flaccid  condition 
of  the  abdominal  wall  a  belt  and  graduated  exercises  are  useful. 
Tight-lacing  must  be  prohibited.  A  visit  to  a  spa,  such  as 
Harrogate,  Bath,  Homburg,  Neuenahr,  Karlsbad,  Marienbad, 
Kissingen,  Ems  or  Vichy,  is  a  valuable  precautionary  measure. 

The  medical  treatment  of  gall-stones  will  be  considered  under 
the  two  main  heads  of  (1)  the  general  treatment,  (2)  the  treatment 
of  certain  manifestations,  biliary  colic  and  intermittent  hepatic 
fever. 

(1)  General  treatment  should  be  directed:  (a)  To  prevent  stagna- 
tion of  bile.  Exercise  by  producing  contraction  of  the  diaphragm  and 
abdominal  muscles  leads  to  emptying  of  the  gall-bladder.  Breath- 
ing exercises  or  somewhat  active  exertion  which  necessitates  deep 
respirations  are  therefore  better  than  walking.  A  flaccid  condition 
of  the  abdomen  may  be  remedied  by  a  suitable  belt  and  by  massage, 
the  region  of  the  gall-bladder  being  avoided.  Intestinal  peristalsis, 
in  which  the  gall-bladder  shares,  should  be  maintained  by  meals 


Cholelithiasis.  683 

at  short  intervals  and  when  necessary  by  purgatives.  Of  the 
numerous  drugs  described  as  cholagogues  nearly  all  act  by  increas- 
ing the  output  of  bile  from  the  gall-bladder.  The  only  ones  which 
increase  the  secretion  of  bile  are  salicylate  of  sodium  and  bile. 
Salicylate  of  sodium  acts  not  only  as  a  cholagogue  but  as  an  anti- 
septic, and  may  conveniently  be  given  twice  a  day  for  ten  days  in 
every  month  in  the  following  combination  :  Sod.  Salicylat.,  gr.  7| ; 
Sod.  Benzoat.,  gr.  7^  ;  Urotropin,  gr.  5  ;  Spirit.  Chloroformi,  irtlO; 
Infusum  Caryophylli,  ad  jj.  Ox  or  pig's  bile  (gr.  7£)  in  capsules 
or  keratin-coated  pills,  may  be  taken  three  times  a  day  ;  or  sodium 
glycocholate  (gr.  10)  three  times  a  day. 

(/>)  To  prevent  and  remove  infection  oj  the  bile  passages. 
Dyspepsia  and  constipation  should  be  guarded  against  by  careful 
dieting  and  by  the  methods  recommended  in  the  symptomatic  treat- 
ment of  jaundice  (p.  670).  The  condition  of  the  teeth  should  be 
attended  to  and  food  should  be  thoroughly  masticated.  The 
abdomen  should  be  kept  warm  so  as  to  avoid  chills  ;  for  this  purpose 
a  cholera  belt  is  useful.  Infection  of  the  bile  passages  should  be 
treated  by  increasing  the  flow  of  bile  and  by  the  administration  of 
salicylate  of  sodium  and  urotropin  (see  above). 

(c)  To  attempt  to  dissolve  or  remove  calcidi  from  the  g all-bladder. 
Although  it  has  been  shown  experimentally  that  calculi  inserted 
into    the   healthy  gall-bladder   of  an  animal  dissolve  in  the  bile 
(Harley  and  Barrett,   Bain),    this   can  hardly   be  anticipated    in 
human  beings  with  symptoms  of  cholelithiasis,  as  the  gall-bladder 
almost  always  shows  morbid  change.    Although  gall-stones  dissolve 
slowly  in  olive  oil,  this  cannot   be   effected   by  the  ingestion   of 
oil.     This  agent,  however,  inhibits  hyperchlorhydria,  which  often 
accompanies  cholelithiasis,  and  so  relieves  pain  due  to  that  cause. 
The  attempt  to  massage  gall-stones  out  of  the  gall-bladder  is  too 
dangerous  to  be  employed. 

(d)  To  spa  treatment,  as  this  is  of  use  in  flushing  the  ducts  and  gall- 
bladder, and  thus  preventing  stagnation  and  infection.     The  most 
suitable  spas  are  Harrogate,  Bath,  Karlsbad,  Neuenahr,  Kissingen, 
Homburg,  Marienbad,  Ems,  Vichy.    The  Karlsbad  cure  can  be  carried 
out  at  home,  though  less  satisfactorily.     Hot  Karlsbad  water  should 
be  sipped  while  walking  up  and  down  an  hour  before  breakfast  and 
in  the  afternoon,  about  f  pint  being  taken  on  each  occasion  and 
three-quarters  of  an  hour  being  devoted  to  the  process.      The  taste 
of  the  salts  is  less  disagreeable   if   some  infusion  of  quassia   or 
cinchona  is  added.      No  food  should  be  taken  until  an  hour  after 
the  last  dose  of  water  is  taken. 

(e)  Diet.    The  meals  should  be  small  and  frequent  and  should  be 


684  Cholelithiasis. 

simple  and  easily  digestible.  A  mixed  diet  should  be  taken  with  a 
preponderance  of  protein  constituents.  Sugary  and  much  starchy 
food  should  be  avoided.  In  the  absence  of  jaundice,  butter  and  fats, 
such  as  cold  fat  bacon,  may  be  taken.  Alcohol  should  be  avoided 
or  only  taken  in  small  quantities  and  well  diluted. 

(6)  Biliary  Colic. — The  pain  is  often  so  severe  that  it  is  abso- 
lutely necessary  to  give  morphine  (-J  to  %  gr.)  combined  with  atropine 
(TOU  8r-)  subcutaneously.  In  such  cases  ihe  hypodermic  injection 
may  with  advantage  be  followed  by  the  inhalation  of  chloroform  in 
order  to  relieve  the  pain  until  the  morphine  acts.  The  hypodermic 
syringe  should  never  be  entrusted  to  the  patient. 

In  less  severe  cases  the  patient  may  be  put  in  a  hot  bath  (104°  F.) 
and  a  hot  sponge  applied  over  the  region  of  the  pain  ;  a  pint  of 
hot  water  may  be  taken  by  the  mouth.  The  following  draught 
may  be  given:  01.  Terebenth.,  it(,15;  Spiritus  Athens,  111 30; 
Tinct.  Belladonnas,  rn.20;  Spirit.  Chloroforrni,  n\_l5 ;  Aquam  ad  §j 
[U.S.P.  01.  Terebenth.,  in  15;  Spiritus  Athens,  m80;  Tinct.  Bella- 
donna Fol.,  ivi  28  ;  Spirit.  Chloroform.,  in  12;  Aquam  ad  §j],  and 
repeated  every  two  hours  for  three  doses  in  all.  Good  results  have 
also  been  ascribed  to  the  administration  of  sod.  salicylat.  (gr.  30  to 
45)  in  a  single  dose  ;  or  of  aspirin,  antipyrin,  or  exalgin  (1  gr.)  in  hot 
water  every  half -hour  for  three  or  four  doses  (Robson).  Relief  has 
also  been  ascribed  to  salicylate  of  methyl  (1  to  2  drachms)  painted 
over  the  painful  part  and  covered  with  gutta-percha  to  favour 
absorption. 

For  the  reflex  vomiting  draughts  of  water  containing  bicarbonate 
of  sodium  (5]  to  1  pint),  hot  applications  or  repeated  injections  of 
morphine  in  small  doses  (^  gr.)  may  be  employed. 

Surgical  interference  during  acute  biliary  colic  should  only  be 
undertaken  when  one  of  the  following  complications  is  believed 
to  have  supervened  :  (i.)  Rupture  of  the  gall-bladder  or  ducts  ; 
(ii.)  acute  suppurative  inflammation  of  the  biliary  passages  with 
peritonitis  ;  (iii.)  acute  intestinal  obstruction  due  to  volvulus. 

Intermittent  Hepatic  Fever. — This  condition,  due  to  a  gall- 
stone "  floating"  in  the  common  duct,  is  characterised  by  recurrent 
attacks  of  fever,  jaundice,  pain  and  vomiting,  with  periods  of 
quiescence.  Under  medical  treatment  the  recurrent  bouts  of  infec- 
tion may  be  diminished  in  frequency  and  in  rather  rare  instances  the 
calculus  is  passed.  In  order  to  combat  the  infection  Sodii  Salicylat., 
gr.  10;  Urotropin,  gr.  7| ;  Spirit.  Chloroformi,  inlO;  Infusum 
Caryophylli,  ad  33. ;  should  be  taken  three  times  daily  every  alternate 
week,  or  constantly  if  necessary.  The  other  methods  of  general 
treatment  of  gall-stones  should  be  carried  out.  For  the  troublesome 


Cholelithiasis.  685 

gastric  symptoms,  which  are  mainly  reflex,  the  effects  of  dieting 
are  disappointing.  Pain  should  be  treated  on  the  same  lines  as  in 
biliary  colic. 

Inasmuch  as  a  stone  in  the  common  duct  may  give  rise  to  grave 
complications,  such  as  various  forms  of  pancreatitis  and  suppurative 
cholangitis,  it  is  important  that  if  medical  treatment  fails  to  give 
relief  surgical  treatment  should  be  seriously  considered.  Generally 
speaking,  the  time  devoted  to  unsuccessful  medical  treatment 
should  not  exceed  two  months,  but  each  case  must  be  considered 
on  its  merits.  The  constitutional  condition  of  the  patient  is  a  most 
important  factor  in  considering  the  advisability  of  operation,  and  it 
must  be  borne  in  mind  that  the  results  of  the  operation,  which  is 
by  no  means  an  easy  one,  vary  much  with  the  experience  of  the 
surgeon  in  this  special  line  of  work.  If,  in  cases  in  which  opera- 
tion is  inadvisable  or  declined,  there  is  evidence  from  the  agglu- 
tination reaction  and  from  the  opsonic  index  that  there  is  infection 
of  the  ducts  with  B.  coli  or  other  micro-organism,  a  vaccine  should 
be  given. 

The  treatment  of  the  other  complications  of  gall-stones  is  mainly 
surgical. 

H.  D.  ROLLESTON. 

REFERENCES. 

Aschoff,  L.,  und  Bacmeister,  C.,  "  Die  Cholelithiasis,"  Jena,  1909.  Moynihan. 
B.  Q.  A.,  "  Gall-stones  and  their  Surgical  Treatment,"  Lond.,  1905.  Robson, 
A.  W.  Mayo,  "Diseases  of  the  Gall-bladder  and  Bile-ducts,"  3rd  ed.,  Lond., 
1904.  Rolleston,  H.  D.,  "Diseases  of  the  Liver,  Gall-bladder,  and  Bile-ducts," 
Lond.,  1905. 


686 


THE  SURGICAL  TREATMENT    OF   CHOLELITHIASIS. 

WHEN  gall-stones  have  once  formed,  no  medicine,  so  far  as  is 
known,  can  dissolve  them  or  produce  permanent  relief,  though  much 
may  be  done  by  medical  and  general  treatment  for  the  relief  of  the 
catarrh  so  regularly  associated  with  cholelithiasis,  which  may,  in 
fact,  bring  on  attacks  not  to  be  distinguished  from  true  gall-stone 
seizures. 

Medical  treatment  must  therefore  always  be  tried  fully  before 
surgical  measures  are  resorted  to ;  but  if  after  a  fair  trial  medical 
means  fails,  surgical  treatment  should  be  adopted  before  serious 
complications  supervene  and  before  the  patient  is  reduced  by 
jaundice,  suppuration,  or  other  untoward  manifestations. 

While  cholecystotomy  is  generally  recognised  as  the  operation 
to  be  aimed  at  in  the  treatment  of  affections  of  the  gall-bladder  and 
bile  ducts  due  to  gall-stones,  it  is  often  impossible  to  say  what 
operation  will  have  to  be  done  until  the  abdomen  is  opened  and  the 
exact  state  of  affairs  made  out,  for  a  contracted  or  dilated  gall- 
bladder, a  suppurating  or  merely  a  distended  viscus,  concretions  in 
the  gall-bladder  or  cystic  or  common  ducts,  the  condition  of  the 
surrounding  organs,  the  presence  or  absence  of  adhesions,  and  a 
host  of  other  conditions,  will  all  influence  the  subsequent  action  of 
the  surgeon,  who  always  begins  the  operation  as  an  exploratory  one, 
the  subsequent  steps  being  altered  according  to  the  circumstance 
mentioned. 

Operation  is  indicated  under  the  following  circumstances  : 

(1)  In  frequently  recurring  biliary  colic  without  jaundice,  with  or 
without  enlargement  of  the  gall-bladder. 

(2)  In  enlargement  of  the  gall-bladder  without  jaundice,  even  if 
unaccompanied  by  great  pain. 

(3)  In  persistent  jaundice  ushered  in  by  pain,  and  when  recurring 
pains,  with  or  without  ague-like  paroxysms,  render  it  probable  that 
the  cause  is  gall-stones  in  the  common  duct. 

(4)  In  empyema  of  the  gall-bladder. 

(5)  In  peritonitis,  starting  in  the  right  hypochondrium. 

(6)  In  abscess  around  the  gall-bladder  or  bile  ducts,  whether  in 
the  liver  or  under  or  over  it. 

(7)  In  some  cases  where,  although  gall-stones  may  have  passed, 
adhesions  remain  and  prove  a  source  of  pain  and  illness. 


The  Surgical  Treatment  of  Cholelithiasis.     687 

(8)  In  fistula  discharging  mucus  or  inuco-pus. 

(9)  In   certain   cases   of   chronic  jaundice  with  distended   gall- 
bladder  dependent    on    some   obstruction   in   the   common    duct, 
although   the   suspicion   of   malignancy  is  entertained.      In   such 
cases   the   increased   risk   must   be   borne  in  mind,  as  malignant 
disease  may  be  the  cause  of  the  obstruction,  and  operation  in  such 
cases  is  attended  with  greater  danger  than  ordinary. 

(10)  In  phlegmonous  cholecystitis  and  in  gangrene  of  the  gall- 
bladder. 

(11)  In  gunshot  injury  or  in  stab  wound  over  the  region  of  the 
gall-bladder. 

(12)  In  suspected  rupture  of  the  gall-bladder  without  external 
wound. 

(13)  In  some  cases  of  chronic  catarrh  of  the  gall-bladder  or  bile 
ducts. 

(14)  In  infective  and  in  suppurative  cholangitis. 

(15)  In  certain  solid  tumours  of  the  gall-bladder  where  there  is 
no  evidence  of  secondary  growths  in  the  liver. 

(16)  In  certain  cases  of  biliary  fistula,  if  it  is  thought  that  the 
cause  of  obstruction  may  possibly  be  removed. 

(17)  In  acute,  subacute,  or  chronic  pancreatitis  due  to  gall-stone 
obstruction  or  to  secondary  infection  from  the  biliary  passages. 

No  surgeon  should  attempt  the  removal  of  gall-stones  unless  he  is 
prepared  for  any  of  the  various  operations  on  the  biliary  passages, 
such  as  choledochotomy  or  cholecystectomy,  as  it  is  almost  impos- 
sible to  say  beforehand  what  may  be  required  until  the  ducts  have 
been  explored  by  the  fingers  and  the  condition  of  the  affected  viscera 
ascertained  ;  no  operation  should,  as  a  rule,  be  concluded  until  it  is 
clearly  made  out  that  the  ducts,  including  the  hepatic  and  common, 
are  free  from  concretions,  otherwise  disappointment  and  dissatisfac- 
tion are  certain  to  follow. 

Since  in  the  majority  of  cases,  then,  an  operation  for  gall-stones 
is  in  the  first  place  simply  exploratory,  the  actual  operation  on  the 
gall-bladder  or  bile  ducts  being  only  determined  by  the  condition 
found  when  the  abdomen  is  opened,  it  may  be  well  first  to  consider 
a  simple  abdominal  section  in  the  gall-bladder  region. 

With  regard  to  instruments,  a  gall-stone  scoop  is  the  only  special 
appliance  I  employ.  All  the  instruments  are  boiled  for  half  an  hour 
before  being  used. 

My  sutures  and  ligatures  are  of  iodised  catgut,  Nos.  1,  2  and 
3  ;  they  are  strong  and  reliably  aseptic.  For  stitching  the  incision 
in  the  duct  in  choledochotomy,  the  "  00  "  green  chromic  catgut 
prepared  by  the  iodine  process  answers  well,  as  it  does  not  become 


688     The  Surgical  Treatment  of  Cholelithiasis. 

absorbed  before  the  second  or  third  week.  As  showing  the  dis- 
advantage of  non-absorbable  sutures,  a  case  came  under  my  notice 
in  which  a  silk  suture  used  in  a  choledochotomy  formed  the  nucleus 
of  a  gall-stone,  which  fortunately  passed  without  further  operation. 
The  patient  is  prepared  by  having  an  aperient  given  so  as  to 
secure  the  bowels  being  moved  the  day  before  operation,  and  an 
enema  is  given  the  evening  before  if  the  operation  is  to  take  place 
early  the  next  morning.  If  there  is  any  feebleness  of  pulse,  5  min. 
of  liq.  strychninae  [U.S.P.  strychnin,  hydrochlor.,  gr.  ^]  are  given 
subcutaneously  on  the  afternoon  and  evening  of  the  day  before 
operation  and  5  min.  before  the  operation  is  finished.  Should  there 
be  chronic  jaundice  or  a  tendency  to  haemorrhage,  calcium  chloride 
or  lactate  is  given ;  for  although  there  is  a  greater  tendency  to 
bleeding  in  chronic  jaundice  from  pancreatic  disease  than  when 
jaundice  is  due  to  gall-stone  obstruction,  I  think  there  can  be  no 


FlG.  1. — Gall-stone  scoop  used  by  author. 

doubt  that  in  all  cholaemic  conditions  the  blood  becomes  so  altered 
that  the  coagulability  becomes  seriously  diminished,  and  that  these 
factors  demand  serious  attention  before  any  operation  is  undertaken 
in  cases  of  common  duct  cholelithiasis. 

The  skin  of  the  patient  over  the  operation  area  is  prepared  the 
day  before  by  thoroughly  washing  with  ether  soap  ;  if  needful, 
shaving  is  then  done.  A  dressing  of  lint,  wet  with  1  in  1,000 
biniodide  of  mercury  solution  in  methylated  spirit  diluted  with  one- 
third  of  water,  is  then  applied,  and  over  this  oilskin  or  gutta-percha 
tissue.  The  dressing  is  changed  early  the  next  morning  and  a 
similar  one  applied. 

If  the  patient  is  feeble,  a  pint  of  normal  saline  solution  with  1  oz. 
of  brandy  is  given  by  the  rectum  a  short  time  before  the  operation. 

As  shock  is  intensified  by  exposure  to  cold,  my  patients  are 
always  enveloped  in  cotton  wool,  which  is  conveniently  done  by 
making  a  suit  of  gamgee  tissue  that  can  be  readily  run  together  by 
the  nurses  in  a  hour  or  two  the  day  before  operation, 


The  Surgical  Treatment  of  Cholelithiasis.     689. 


LINt   OF  IHCISION 
NOH  ADOPTED 


The  operation  is  performed  on  a  special  table  that  can  be  raised 
at  the  level  of  the  liver  so  that  the  common  and  hepatic  ducts  are 
brought  several  inches  nearer  to  the  surface.  By  opening  out  the 
costal  angle  and  tending  to  make  the  intestines  slip  down  from 
the  liver  it  acts  like  the  Trendelenburg  position  in  pelvic  surgery. 

A  vertical  incision  is  made  over  the  inner  third  of  the  right  rectus 
in  a  line  parallel  with  its  fibres ;  the  sheath  of  the  rectus  is  then 
separated  by  the  fingers  aided  by  scissors  at  the  lineae  transversse  and 
the  rectus  muscle  is  retracted,  the  posterior  sheath  of  the  rectus  and 
peritoneum  being  divided  together.  When  the  gall-bladder  is 
distended  and  there  is  no  jaundice,  a  small  incision  of  2  or  3  inches 

only  may  be  required ; 
but  when  it  is  neces- 
sary to  explore  either 
the  hepatic,  common, 
or  deeper  part  of  the 
cystic  duct,  instead  of 
prolonging  the  in- 
cision downwards,  as 
was  formerly  done,  I 
now  carry  it  upwards 
in  the  interval  between 
the  ensiform  cartilage 
and  the  right  costal 
margin  as  high  as 
possible,  thus  expos- 
ing the  upper  surface 
of  the  liver  very  freely. 
It  will  be  found  that 
by  lifting  the  lower 

border  of  the  liver  in  bulk  (if  needful  first  drawing  the  organ 
downwards  from  under  cover  of  the  ribs),  the  whole  of  the  gall- 
bladder and  the  cystic  and  common  ducts  are  brought  close  to  the 
surface,  and  as  the  gall-bladder  is  usually  strong  enough,  my 
assistant  can  take  hold  of  it  with  his  fingers  or  forceps,  and  by  gentle 
traction  can  keep  the  parts  well  exposed  at  the  same  time  that,  by 
means  of  his  left  hand  with  a  flat  compress  under  it,  he  retracts  the 
left  side  of  the  wound  and  the  viscera,  which  would  otherwise  fall 
over  the  common  duct  and  impede  the  view. 

It  will  now  be  observed  that  instead  of  the  gall-bladder  and  cystic 

duct  taking  a  considerable  angle  with  the  common  duct,  an  almost 

straight  passage  is  found  from  the  fundus  of  the  gall-bladder  to  the 

entrance  of  the  bile  duct  into  the  duodenum,  and  if  adhesions  have 

S.T. — VOL.  ii.  44 


FIG.  2. 


,690     The  Surgical  Treatment  of  Cholelithiasis. 

been  thoroughly  separated  the  surgeon  has  immediately  under  his 
eye  the  whole  length  of  the  ducts  with  the  head  of  the  pancreas 
and  duodenum.  So  complete  is  the  exposure  that  if  needful  the 
peritoneum  can  be  incised  over  the  free  border  of  the  lesser  omentum 
and  the  common  duct  separated  from  the  hepatic  artery  and  portal 
vein,  but  this  is  not  necessary  except  when  a  growth  or  glands 
have  to  be  excised.  The  surgeon,  whose  hands  are  both  free,  can 
deal  with  the  gall-bladder,  cystic,  common,  or  hepatic  duct  quite 
easily:  for  example,  with  his  left  finger  and  thumb  he  can  so 
manipulate  the  common  or  cystic  duct  as  to  render  prominent  any 
concretions,  which  can  be  directly  cut  down  on,  the  edges  of  the 
opening  in  the  duct  being  caught  by  pressure  forceps.  The  assistant 
can  now  take  hold  of  the  forceps  with  his  left  hand,  as  they  with 
the  sponge  will  form  a  sufficient  retractor,  since  the  duct  is  so  near 
the  surface. 

When  the  duct  is  incised  there  is  usually  a  free  flow- of  bile,  which 
it  must  be  remembered  is  probably  infective,  but  by  packing  the 
kidney  pouch  with  a  gauze  pad  and  rapidly  mopping  up  the  bile  as 
it  flows,  any  soiling  of  surrounding  parts  is  avoided,  and  if  thought 
necessary  the  bulk  of  the  infected  bile  can  be  drawn  off  by  the 
aspirator  either  from  the  gall-bladder  or  from  the  common  duct 
above  the  obstruction  before  the  incision  into  the  bile  passage  is 
made. 

After  removing  all  obvious  concretions  the  fingers  are  passed 
behind  the  duodenum  and  along  the  course  of  the  hepatic  ducts 
to  feel  if  other  gall-stones  are  hidden  there,  and  when  the 
common  duct  has  been  incised  a  gall-stone  scoop  is  passed  into 
the  primary  division  of  the  hepatic  duct  in  the  liver  and  down  to 
the  duodenal  orifice  of  the  common  bile  duct,  and  if  thought 
necessary  to  ensure  the  opening  into  the  duodenum  being  patent, 
a  long  probe  is  passed  into  the  bowel. 

The  incision  into  the  bile  duct,  if  one  has  to  be  made,  is  now  closed 
by  an  ordinary  curved  round  needle  held  in  the  fingers  without  any 
needle-holder,  a  continuous  catgut  suture  being  used  for  the  margins 
of  the  duct  proper,  and  a  continuous  fine  green  catgut  thread  being 
employed  to  close  the  peritoneal  edges  of  the  duct. 

Where  the  gall-bladder  is  contracted  and  the  pancreas  is  in- 
durated and  swollen  from  chronic  pancreatitis,  and  likely  to  exert 
pressure  for  a  time  on  the  common  duct,  I  insert  a  drainage  tube 
directly  into  the  duct,  passing  it  upwards  into  the  hepatic  duct,  and 
closing  the  opening  around  it  by  a  purse-string  suture,  the  tube 
being  fixed  into  the  opening  by  a  catgut  stitch  which  will  hold  for 
about  a  week ;  but  when  this  is  not  done  and  the  size  of  the  gall- 


The  Surgical  Treatment  of  Cholelithiasis.     691 

bladder  will  permit  of  it,  I  usually  fix  a  drainage  tube  into  the 
fundus  of  the  gall-bladder  in  the  same  way,  as  this  drains  away  all 
infected  bile  and  avoids  pressure  on  the  newly  sutured  opening  in  the 
duct. 

So  easy  is  it  to  remove  impacted  stones  after  this  method  of 
exposure  that  I  now  never  spend  a  long  time  in  manipulating 
stones  impacted  deeply  even  in  the  cystic  duct,  but  at  once  incise 
the  duct,  remove  the  concretions,  and  close  the  opening  without 
damaging  the  duct  by  much  pressure  and  prolonged  manipulation. 

Although  there  is  seldom  any  fear  of  leakage  or  infection,  yet 
where  the  ducts  have  been  incised  and  extensive  adhesions  separated, 
there  is  usually  some  tendency  to  pouring  out  of  fluid  in  the  first 
few  hours.  I  therefore  generally  insert  a  gauze  drain  through  a 
split  drainage  tube,  bringing  it  out  by  the  side  of  the  gall-bladder 
drain  or  through  a  separate  stab  wound.  This  is  usually  removed 
within  twenty-four  hours. 

The  wound  is  closed  by  continuous  catgut  sutures,  first  to 
peritoneum  and  deep  rectus  sheath,  and  next  to  the  anterior 
rectus  sheath.*  Lastly,  the  skin  margins  are  brought  together 
by  means  of  Michel's  clips.  From  one  to  three  interrupted 
silkworm  gut  sutures  are  inserted  quite  1  inch  from  the  line  of 
incision,  and  brought  out  1  inch  beyond  the  incision  on  the 
other  side ;  they  take  up  the  anterior  sheath  of  the  rectus  and 
serve  to  support  the  whole  wound. 

To  those  having  little  experience  in  these  operations  the  modifi- 
cations I  have  employed  may  seem  trivial,  but  to  those  who  have 
experienced  the  difficulties  of  the  ordinary  operation  of  removing 
gall-stones  from  a  contracted  gall-bladder  or  from  the  cystic  or 
common  ducts,  I  feel  sure  the  method  I  have  described,  which 
enables  the  whole  of  the  bile  passages  to  be  dealt  with  as  a 
straight  tube  close  to  the  surface,  will  be  sufficiently  appre- 
ciated. 

In  these  operations  I  employ  forcipressure  for  the  immediate 
arrest  of  haemorrhage,  but  I  find  it  is  more  satisfactory  also  to  ligature 
all  the  bleeding  points,  as  in  jaundiced  cases  the  compressed  and 
unligatured  vessels  are  apt  to  bleed  subsequently  and  to  lead  to 
complications  that  are  avoidable  by  careful  haemostasis.  For  the 
same  reason  I  prefer  to  divide  and  ligature  firm  visceral, 
especially  hepatic,  adhesions,  when  this  is  practicable,  rather  than 
as  formerly  to  separate  them  with  the  finger  or  tear  them 
through. 

If  the  liver  is  slightly  torn  in  separating  adhesions,  the  bleeding 
must  be  carefully  arrested  before  the  abdomen  is  closed.  Sponge 

44—2 


692     The  Surgical  Treatment  of  Cholelithiasis. 

pressure  is  usually  sufficient  if  the  laceration  is  small  ;  but  if  the 
laceration  is  extensive,  deep  catgut  sutures  applied  by  means  of  a 
round  intestinal  needle,  will  usually  accomplish  the  desired  effect ; 
or  this  failing,  gauze  pressure,  the  plug  being  left  in  until  it 
becomes  loose,  will  be  certain  to  answer. 

Nothing  can  be  simpler  than  an  ordinary  cholecystotomy  with  a 
distended  gall-bladder  or  even  with  a  gall-bladder  of  ordinary  size, 
where  a  small  incision  suffices  to  expose  the  sac,  which  is  emptied 
by  the  aspirator.  The  collapsed  viscus  is  then  brought  through 
the  wound  and  surrounded  by  sterilised  gauze  ;  it  is  then  incised 
through  the  point  where  the  needle  was  inserted,  and  through  the 
wound  in  the  fundus  the  gall-stone  scoop  is  inserted  and  all  gall- 
stones are  removed,  a  probe  or  the  finger  being  employed  to  prove 
the  ducts  clear.  A  firm  rubber  tube,  much  firmer  than  the  drainage 
tubes  ordinarily  sold,  is  then  inserted  from  ^  to  1  inch  into 
the  gall-bladder,  the  edges  of  the  incision  being  drawn  firmly 
around  it  by  a  catgut  purse-string  suture,  which  is  tied  and  cut 
short,  the  tube  being  fixed  in  position  by  a  catgut  suture,  which 
transfixes  the  tube  and  the  edges  of  the  incision  in  the  gall-bladder. 
The  edges  of  the  incision  in  the  gall-bladder  are  then  fixed  to  the 
aponeurosis  by  three  or  four  catgut  stitches,  but  never  to  the  skin 
unless  a  permanent  biliary  fistula  is  intended.  This  tube  is 
sufficiently  long  to  pass  into  a  bottle  by  the  side  of  the  patient ;  it 
drains  all  the  bile  away  from  the  wound,  and  by  the  time  the  catgut 
has  dissolved  the  wound  will  have  healed  by  first  intention  except 
where  the  tube  was,  and  that  part  heals  by  granulation  within  the 
next  week  or  two  if  the  ducts  are  clear. 

What  has  been  called  the  "  ideal  "  operation,  in  which  the 
opening  in  the  gall-bladder  is  immediately  closed  and  returned  into 
the  abdomen,  was  suggested  by  Langenbach ;  but  as  it  does  away 
with  the  beneficial  effects  of  drainage,  and  is,  moreover,  attended 
with  more  risk  than  the  ordinary  operation,  it  is  not  satisfactory. 

A  simple  operation  is  quite  the  exception,  the  gall-bladder  being 
usually  contracted  and  surrounded  by  adhesions ;  moreover,  in 
these  cases  the  obstruction  will  usually  be  found  in  the  cystic  or 
common  ducts.  The  advantage  of  the  complete  operation  that  I 
have  described,  in  which  the  edge  of  the  liver  is  lifted  up  and  the 
bile  passages  brought  well  under  view,  will  be  experienced  in  this 
class  of  cases. 

The  next  question  will  be  :  How  is  the  contracted  gall-bladder 
to  be  dealt  with  ?  If  it  is  too  small  to  be  brought  to  the  parietes 
and  otherwise  healthy  and  sufficiently  large  to  admit  a  drainage  tube, 
the  method  of  fixing  the  tube  by  purse-string  suture  just  described 


The  Surgical  Treatment  of  Cholelithiasis.     693 

will  be  quite  safe,  even  if  the  opening  in  the  gall-bladder  has  to  be 
left  2  inches  or  3  inches  from  the  surface,  for  the  onientura  can  be 
made  to  lie  against  the  tube,  and  by  the  time  that  the  catgut  is 
dissolved  a  track  of  adhesions  will  have  formed  that  will  quite 
effectually  prevent  extravasation ;  but  in  order  to  make  assurance 
doubly  sure,  especially  if  there  has  been  any  unavoidable  soiling,  I 
frequently  insert  a  small  split  drainage  tube  with  a  little  gauze  in 
it  quite  down  to  the  gall-bladder  and  bring  it  out  by  the  side  of  the 
first  tube. 

If  the  gall  bladder  is  so  contracted  as  to  be  incapable  of  admit- 
ting a  tube,  it  may  either  be  closed  by  suture,  the  line  of  union 
being  protected  from  hurtful  leakage  by  a  strip  of  gauze  laid  over 
it  and  brought  to  the  surface  through  a  rubber  tube,  or  the  con- 
tracted and  useless  remains  of  the  gall-bladder  may  be  removed  by 
cholecystectomy. 

When  the  gall-bladder  is  very  much  contracted,  cholecystectomy  is 
both  easy  and  effectual,  as  the  attachments  to  the  liver  are  readily 
dissected  off  without  tearing  the  liver  substance.  The  duct  is 
seized  with  strong  pressure  forceps  and  crushed,  thus  making  a 
groove  in  which  the  ligature,  preferably  of  catgut,  lies  quite  snugly. 
Any  vessels  that  bleed  are  ligatured,  and,  as  a  matter  of  precaution 
(for  the  parts  being  dealt  with  are  necessarily  infected),  a  strip  of 
gauze  is  left  in  contact  with  the  end  of  the  ligatured  duct  and 
brought  to  the  surface  through  a  split  drainage  tube. 

If,  as  frequently  happens,  gall-stones  are  so  firmly  fixed  in  the 
cystic  duct  that  they  cannot  be  pressed  backward  into  the  gall- 
bladder, it  is  better  not  to  use  force  but  to  incise  the  duct  over  the 
stone  and,  after  clearing  the  duct,  to  close  it  by  a  double  row  of 
sutures  to  mucous  membrane  and  serous  coat  respectively. 

If  the  concretions  are  in  the  common  duct,  either  fixed  or 
floating,  it  is  just  as  easy,  with  the  duct  well  under  the  eye  and 
near  the  surface,  to  incise  it  and  remove  the  stones  as  it  is  to  open 
the  gall-bladder.  All  such  instruments  as  handled  needles  and 
Halsted's  hammer  are  quite  unnecessary,  for  the  incision  in  the 
duct  can  as  readily  be  closed  by  means  of  a  curved  round  needle 
(sewing-needle  pattern)  in  the  fingers  as  by  any  more  complicated 
apparatus.  But  before  closing  the  duct  it  is  of  the  utmost 
importance  to  ascertain  that  there  are  no  stones  left  either  in  the 
ampulla  of  Yater  or  in  the  hepatic  duct ;  and  although  the  fingers 
manipulating  the  outside  of  the  ducts  can  give  information  as  to 
any  large  stones,  it  would  be  easy  to  overlook  small  ones  unless  the 
scoop  is  passed  freely  upwards  into  the  hepatic  ducts  and  down- 
^yards  behind  the  duodenum,  or  if  necessary  the  opening  in  the 


694     The  Surgical  Treatment  of  Cholelithiasis. 

duct  can  be  made  sufficiently  large  to  admit  the  finger  for  explora- 
tion. 

I  usually  pass  a  large  probe  down  into  the  duodenum  through 
the  papilla  to  be  sure  that  the  passage  is  quite  free.  In  one  case, 
not  being  able  to  pass  the  probe  beyond  the  papilla,  I  opened  the 
duodenum  and  found  a  stricture  of  the  common  duct  close  to  its 
termination,  which  I  divided  by  freely  laying  the  papilla  open  over 
a  director. 

In  quite  a  number  of  cases,  after  the  common  duct  has  been 
cleared,  I  have  found  stones  in  the  hepatic  ducts  which  I  have 
removed  by  the  scoop. 

In  some  cases  the  common  bile  duct  is  found  dilated  to  the  size 
of  the  small  intestine,  and  if  the  gall-bladder  and  cystic  duct  are 
small  and  so  contracted  as  to  be  useless  for  drainage,  a  firm  rubber 
tube  is  inserted  into  the  incision  in  the  duct  and  pushed  a  little 
way  up  into  the  hepatic  duct,  the  tube  being  surrounded  by  a  purse- 
string  suture  and  fixed  in  position  by  one  or  two  catgut  stitches. 

If  a  stone  is  impacted  in  the  duodenal  end  of  the  common  duct, 
it  may  sometimes  be  more  easily  reached  through  a  vertical 
incision  in  the  second  part  of  the  duodenum  (duodeno- 
choledochotomy),  when  the  concretions  can  be  directly  cut  down 
on  through  the  posterior  wall  of  the  duodenum,  or  the  papilla  can 
be  laid  open  over  a  director ;  it  is  then  easy  to  pass  the  gall-stone 
scoop  up  the  common  duct  in  order  to  be  certain  that  it  is  free 
from  concretions.  All  that  is  now  necessary  is  to  close  the  anterior 
duodenal  wound  by  a  continuous  catgut  suture  for  the  mucous 
membrane,  and  a  continuous  silk  or  celluloid  thread  for  the  serous 
margins. 

With  the  better  exposure  of  the  common  duct  secured  by  the 
operation  just  described,  duodeno-choledochotomy  will  be  seldom 
called  for,  as  the  gall-stone  scoop  can  so  freely  be  used  through 
the  incised  duct. 

Cholecystenterostomy  has  been  advocated  by  some  surgeons 
for  obstruction  in  the  common  duct  by  gall-stones,  the  gall-bladder 
being  connected  to  the  duodenum.  In  my  earlier  practice  I 
performed  a  number  of  these  operations,  but  since  adopting  the 
easy  and  effectual  method  of  exposing  the  whole  length  of  the  bile 
ducts  I  have  practically  discarded  this  operation  for  gall-stones, 
for  it  leaves  the  cause  untouched,  and  should  the  artificial  opening 
close,  the  symptoms  inevitably  return. 

Cholelithiasis  and  Enlargement  of  Pancreas. — In  common 
duct  cholelithiasis,  especially  when  there  is  a  small  floating  gall- 
stone, it  is  common  to  find  the  head  of  the  pancreas  enlarged  and 


The  Surgical  Treatment  of  Cholelithiasis.     695 

hard,  the  result  of  chronic  pancreatitis ;  this  may  give  rise  to  the 
suspicion  of  cancer  of  the  head  of  the  pancreas,  and  may  lead  to 
an  unfavourable  prognosis  being  given,  but  it  is  well  to  reserve 
our  opinion  in  such  cases  and  to  give  the  patient  the  benefit  of  the 
hope  of  cure  through  long-continued  drainage  by  the  operation  of 
cholecystenterostomy. 

Malignant  Disease. — When  gall-stones  are  associated  with 
cancer  of  the  gall-bladder,  liver,  or  pylorus,  a  much  more  extensive 
operation  may  have  to  be  done,  as  in  the  following  cases : 

Excision  of  cancer  from  liver,  gall-bladder  and  pylorus  ;  recovery. 
A  woman,  aged  63.  History  of  pain  and  jaundice.  Great  loss 
of  flesh  and  strength.  Tumour  in  gall-bladder  region.  Operation, 
August  10th,  1900.  Mass  of  growth  discovered  in  liver,  gall- 
bladder and  pylorus.  Cholecystectomy,  pylorectomy  and  partial 
hepatectomy  performed.  Good  recovery.  Patient  well,  and  in 
good  health  some  years  later.  Microscopic  examination  showed 
the  disease  to  be  cancer. 

Excision  of  cancer  of  liver  and  gall-bladder ;  recovery.  A  man, 
aged  46.  Seven  years'  gall-stone  attacks.  Infective  cholangitis. 
Loss  of  4  stone  in  weight.  Jaundice.  Operation,  June  26th, 
1899.  Tumour  of  liver  adjoining  gall-bladder  excised  by  wedge- 
shaped  incision ;  gall-bladder  also  excised.  Large  number  of  gall- 
stones removed  and  choledochenterostomy  performed.  Complete 
and  perfect  recovery.  Patient  in  excellent  health  at  present  time, 
eleven  years  after  operation.  Microscope  showed  disease  removed 
to  be  cancer. 

But  these  are  exceptional  cases,  as  there  were  no  secondary 
manifestations  of  disease  in  the  liver  or  elsewhere.  Had  there 
been  such,  I  should  have  simply  concluded  the  operation  as  an 
exploratory  one. 

Intervisceral  Fistula. — In  detaching  adhesions  it  may  be  found 
that  there  is  a  fistula  between  the  gall-bladder  and  stomach,  pylorus 
or  bowel,  and  a  careful  search  must  always  be  made  for  this,  lest 
an  opening  into  one  of  the  hollow  viscera  be  left,  which  would 
probably  mean  extravasation  and  death. 

Cholelithotrity. — I  have  now  entirely  given  up  cholelithotrity 
as  a  set  operation,  as  although  in  some  of  my  earlier  cases  it 
answered  well,  in  several  the  fragments  did  not  pass  and  gave 
further  trouble.  Moreover,  the  very  complete  exposure  which  the 
complete  operation  gives  renders  all  uncertain  methods,  such  as 
crushing,  quite  unnecessary. 

After-Treatment. — Expedition  in  operating  is  an  important 
factor  in  lessening  shock,  especially  in  abdominal  surgery,  for  it 


696     The  Surgical  Treatment  of  Cholelithiasis. 

stands  to  reason  that  prolonged  manipulation  and  exposure  of 
the  viscera  in  patients  so  ill  as  the  class  of  cases  we  are  now 
considering  must  generally  be  will  be  badly  borne,  for  it  is  not 
only  the  work  of  the  surgeon  but  the  deep  anaesthesia  that  adds 
to  the  shock,  since  for  these  operations  to  be  expeditiously 
performed  the  muscles  must  be  well  relaxed.  Choledochotoniy 
should  occupy  from  half  an  hour  to  an  hour,  and  only  in  case  of 
unusual  complications  a  little  longer. 

After  operation  1  pint  of  saline  fluid,  with  1  oz.  of  brandy, 
is  given  by  enema,  and  5  niin.  of  liq.  strychnine  [U.S.P. 
strychnin,  hydrochlor.  gr.  -£%~\  are  given  subcutaneously,  this  being 
repeated  if  called  for.  Subcutaneous  injections  of  saline  fluid  or 
intravenous  infusion  are  only  rarely  required. 

Beyond  sips  of  hot  water  or  hot  tea  from  time  to  time,  all 
feeding  is  by  the  rectum  for  the  first  twenty-four  hours.  After  forty- 
eight  hours,  if  there  is  no  vomiting,  milk  and  soda  and  barley-water 
can  be  freely  given.  A  little  plasrnon  dissolved  in  the  tea  or  beef- 
tea  or  barley-water  considerably  adds  to  the  nutritive  value  of 
the  fluid.  Light  custard  pudding  is  usually  given  on  the  fourth 
day,  fish  on  the  fifth,  and  chicken  on  the  sixth,  after  which  the 
diet  becomes  almost  normal. 

The  bowels  are  not  disturbed  before  the  fifth  or  sixth  day, 
and  then  only  by  enema,  unless  there  is  vomiting  or  distension, 
and  in  case  of  either  of  these  complications  1  gr.  of  calomel  is 
administered,  and  followed  by  2  oz.  of  apenta  water  every  two 
hours  until  it  acts  or  until  flatus  passes  freely,  this  being  at  times 
helped  by  the  rectal  tube  or  by  a  turpentine  enema. 

Morphine  is  avoided,  if  possible,  after  all  my  abdominal 
operations,  as  it  tends  to  paralyse  the  intestines  and  leads  to  an 
accumulation  of  flatus.  I  believe  that  abstention  from  the  use  of 
morphine  as  a  routine  measure  is  a  great  feature  in  the  success  of 
abdominal  surgery,  just  as  I  feel  sure  that  in  the  past  it  has  killed 
may  patients  who  would  otherwise  have  done  well. 

If  a  sedative  is  needed,  10  gr.  of  aspirin  will  be  found  useful,  and 
this  can  be  repeated  in  two  hours  if  required.  In  case  of  vomiting 
being  troublesome  or  epigastric  distension  persisting,  gastric  lavage 
will  be  found  useful,  and  when  the  stomach  is  emptied  a  dose  of 
apenta  water  may  be  left  in  it  to  incite  peristalsis.  Under  these 
circumstances  no  food  or  fluid  is  allowed  by  the  mouth,  but  plenty 
of  fluid  in  the  shape  of  normal  saline  is  given  by  rectum. 

As  a  rule  recovery  is  uneventful,  and  for  the  most  part  after- 
treatment  is  negative.  The  stitches  are  removed  on  the  eighth  day, 
and  the  tube  usually  comes  away  about  the  same  time ;  the  wound 


The  Surgical  Treatment  of  Cholelithiasis.     697 

will  generally  have  healed  by  first  intention,  and  the  spot  where  the 
tube  was  heals  by  granulation.  The  dressings  are  of  the  simplest: 
sterilised  gauze  and  sterilised  wool. 

The  chief  points  to  bear  in  mind  are  that  we  should  operate  earlier, 
before  serious  complications  have  ensued,  and  that  when  operating 
we  should  be  thorough  and  expeditious. 

A.  W.  MAYO-ROBSON. 


698 


FISTULA    OF    THE    GALL-BLADDER    AND    BILE 

DUCTS. 

FISTULA  in  connection  with  the  bile  passages  are  by  no  means 
uncommon,  and  their  variety  is  considerable.  They  result  from 
operation  or  from  disease,  and  in  the  latter  case  they  are  due  to 
ulceration  resulting  from  gall-stones  or  cancer. 

The  fistulous  channel  may  either  be  direct  or  indirect,  in  the 
former  being  caused  by  an  advancing  ulcer  setting  up  local  peri- 
tonitis and  causing  adhesion  of  the  gall-bladder  or  bile  ducts  to  one 
of  the  neighbouring  hollow  viscera,  or  to  the  parietal  peritoneum. 
The  extension  of  the  ulcer  continuing,  a  communication  is 
established  with  the  contiguous  channel  or  with  the  surface.  In 
the  indirect  variety  the  perforation  occurs  first  into  an  adjoining 
parenchymatous  organ  or  into  a  localised  abscess,  and  then  into  an 
adjacent  hollow  viscus  or  on  to  the  surface  of  the  body  at  some 
part. 

A  fistula  may  also  arise  from  a  local  abscess  forming  outside  the 
biliary  passages  around  the  primary  focus  of  inflammation  and  then 
bursting  into  the  adjoining  cavities,  which  are  thus  made  to 
communicate. 

Although  the  establishment  of  a  fistula  is  at  times  dangerous, 
and  at  others  excessively  annoying  or  uncomfortable,  in  many  cases 
it  forms  one  of  nature's  methods  of  relief,  and  the  surgeon  in 
forming  a  permanent  biliary  fistula  in  otherwise  incurable  jaundice, 
or  in  making  an  anastomosis  between  the  bile  passages  and  the 
intestine  for  the  like  purpose,  is  taking  a  leaf  from  nature's 
book. 

Many  of  the  fistulse  are  mere  pathological  curiosities,  quite  undiag- 
nosable,  and  only  capable  of  being  discovered  post-mortem.  Many 
must  form  and  heal,  leaving  the  patient  cured,  and  thus  not  only 
are  they  not  discovered,  but  they  are  probably  not  even  suspected  ; 
for,  contrary  to  what  one  might  suppose,  fistulse  betwen  the  bile 
passages  and  other  hollow  viscera  in  the  majority  of  cases  heal 
spontaneously,  leaving  only  visceral  adhesions,  so  that  the  fistulse 
are  comparatively  rarely  found  post-mortem. 

Post-operative  Fistulae  may  be  mucous  or  biliary. 

Mucous  Fistulce  are  occasionally  seen  after  the  operation  of 
cholecystotorny,  when  the  obstruction  in  the  cystic  duct  has  not 
been  overcome,  or  when  that  duct  is  the  seat  of  stricture. 


Fistulae  of  the  Gall-Bladder  and  Bile  Ducts.    699 

The  treatment  consists  in  removing  the  obstruction  or,  where  that 
is  impracticable,  in  performing  cholecystectomy. 

Biliary  Fistula  following  on  operation  is  quite  a  different  matter 
from  mucous  fistula,  as  although  in  some  cases  it  is  compatible 
with  good  health,  the  inconvenience  caused  by  30  oz.  of  bile  flow- 
ing from  the  fistula  daily  produces  so  much  discomfort  that  in 
all  the  cases  which  have  conie  under  my  notice  the  patients  have 
preferred  to  accept  the  risks  of  operation  rather  than  to  retain  their 
disability. 

The  treatment  of  biliary  fistula  should,  where  possible,  be  effected 
by  removing  the  cause ;  but  as  in  certain  cases  this  is  impracti- 
cable or  impossible,  other  means  have  to  be  considered. 

If  the  ducts  are  clear  and  the  fistula  is  small,  the  application  of 
the  actual  cautery  to  the  margin  of  the  fistula  will  frequently  result 
in  its  closure. 

Or  the  fistula  may  be  dissected  from  the  skin  margin  without 
opening  the  peritoneum,  afterwards  doubling  in  the  mucous  edges, 
suturing  them  accurately,  and  over  this  applying  one  or  two  layers 
of  buried  sutures  before  bringing  together  the  skin. 

When,  however,  the  ducts  cannot  be  cleared,  and  the  gall-bladder 
is  large  enough  to  permit  of  it,  the  operation  of  cholecystenteros- 
tomy  may  be  performed. 

Pathological  Surface  Fistulae  usually  open  at  the  umbilicus, 
the  abscess  following  the  course  of  the  remains  of  the  umbilical 
vein ;  but  they  may  form  at  any  part  of  the  abdominal  wall,  even 
near  the  pubes,  or  on  the  left  side  of  the  abdomen. 

In  operating  on  these  cases  it  is  advisable  to  purify  the  fistula  as 
far  as  possible,  and  to  scrape  away  all  granulations  before  opening 
the  peritoneal  cavity  to  get  at  and  clear  the  bile  ducts.  By  adopting 
these  precautions  no  untoward  results  are  likely  to  occur. 

Biliary  Gastric  Fistula  is  less  common  than  might  be  thought, 
for  the  pylorus  is  not  infrequently  adherent  to  the  gall-bladder. 

Operation  may  be  necessary  on  account  of  the  irritation  caused 
by  gall-stones  and  infected  bile  in  the  stomach. 

A.    W.    MAYO-ROBSON. 


700 


INFLAMMATORY   AFFECTIONS  OF  THE  GALL- 
BLADDER AND  BILE  DUCTS. 

ACUTE  and  chronic  catarrhal  jaundice  are  subjects  of  medical 
rather  than  surgical  interest ;  but  it  must  not  be  forgotten  that 
chronic  catarrhal  cholangitis,  by  simulating  jaundice  due  to  organic 
mischief,  such  as  cholelithiasis,  pancreatitis,  cancer,  or  hyatids,  has 
some  important  surgical  bearings,  and  that  when  medical  means 
have  failed,  surgical  treatment  must  be  considered. 

It  should  also  be  borne  in  mind  that  the  jaundice  accompanying 
cancer  of  the  liver  is  frequently  catarrhal,  and  therefore  capable  of 
being  relieved  by  treatment,  although  the  original  disease  persists. 
Also  that  the  evanescent  jaundice  following  on  cholelithic  attacks 
is  often  catarrhal,  and  not  due  to  the  mechanical  obstruction  of  a 
gall-stone. 

The  treatment  of  chronic  catarrhal  jaundice  is  at  first  medical. 
If  the  disease  proves  obstinate,  a  course  of  treatment  at  Leamington, 
Bath,  Harrogate,  or  Carlsbad  will  be  likety  to  do  good  if  the  ailment 
is  functional ;  but  that  failing,  the  question  of  some  organic  cause, 
such  as  gall-stones  that  may  be  removable  by  surgical  treatment, 
should  be  considered.  Even  when  the  obstruction  is  not  removable, 
as  in  disease  of  the  head  of  the  pancreas  compressing  the  common 
bile  duct,  great  relief  may  be  given  by  drainage  of  the  bile  duct 
either  by  means  of  cholecystotomy  or  by  cholecyst-enterostomy. 
If  the  disease  of  the  pancreas  is  malignant,  relief  only  will  be 
effected,  but  if  the  pancreatic  swelling  is  dependent  on  interstitial 
pancreatitis  the  operation  may  prove  completely  curative. 

Catarrhal  Cholecystitis  or,  "  chronic  catarrh  of  the  gall-bladder 
without  jaundice,"  forms  a  distinct  and  definite  disease,  and  I  have 
seen  several  cases  in  which  cholelithiasis  had  been  diagnosed  and 
operation  advised,  but  where  neither  the  gall-bladder  nor  ducts 
contained  anything  firmer  than  thick  ropy  mucus,  which  was 
apparently  the  cause  of  painful  contractions  of  the  gall-bladder 
simulating  gall-stone  seizures. 

Should  medical  treatment  fail  to  relieve,  it  may  be  difficult  to 
distinguish  chronic  catarrh  of  the  gall-bladder  from  cholelithiasis ; 
but  if,  under  the  belief  that  the  case  is  one  of  gall-stones,  the  gall- 
bladder is  exposed  and  no  concretions  found,  cholecystotomy, 
followed  by  drainage,  will  be  likely  to  effect  a  cure. 

In  chronic  catarrh  of  the  gall-bladder,  regular  exercise,  massage 


Inflammatory  Affections   of  the  Gall-Bladder.  701 

over  the  hepatic  region,  the  avoidance  of  anything  tight  around 
the  waist,  which  will  increase  the  dependence  of  the  fundus  of  the 
gall-bladder,  careful  regulation  of  the  diet,  and  the  judicious 
employment  of  saline  aperients,  should  be  adopted  in  all  cases. 

The  spasmodic  attacks  may  require  the  administration  of  a 
sedative,  and  I  have  found  10  grains  of  aspirin  of  great  service. 
The  dose  may  be  safely  repeated  in  an  hour  or  two  if  required ; 
but  in  some  cases  nothing  short  of  the  subcutaneous  injection  of 
morphia  will  do  any  good. 

If  after  a  few  weeks  of  general  treatment  the  symptoms  are  not 
relieved,  the  case  will  probably  be  thought  to  be  one  of  gall-stones, 
and  operative  treatment  may  be  considered  advisable. 

Even  if  the  gall-bladder  and  ducts  are  found  free  from  gall-stones, 
cholecystotomy  and  drainage  should  nevertheless  be  performed, 
and  it  will  be  found  useful  after  the  third  day  to  gently  syringe  a 
little  sterilised  warm  water  through  the  drainage  tube  daily  so  as 
to  wash  out  the  ducts.  After  a  fortnight  or  more  the  tube  may  be 
left  out  and  the  wound  allowed  to  close. 

General  treatment  directed  to  the  cause  should  be  continued  for 
some  time  afterwards.  In  fact,  obstinate  catarrh  of  the  gall- 
bladder should  be  treated  like  catarrh  of  the  urinary  bladder,  first 
by  medical  and  general  remedies,  and  these  failing,  physiological 
rest  should  be  secured  by  means  of  drainage. 

Obliterative  Cholecystitis  and  Cholangitis. — It  is  now  well 
recognised  that  repeated  attacks  of  appendicitis  may  ultimately 
lead  to  obliteration  of  the  veriform  appendix,  which  may  be  dis- 
covered as  a  simple  cord  without  any  lumen,  in  the  centre  of  firm 
adhesions. 

The  same  state  may  be  brought  about  in  the  gall-bladder  and 
bile  ducts  by  repeated  attacks  of  inflammation,  so  that  it  is  not 
very  uncommon  to  find  the  gall-bladder  and  cystic  duct  represented 
by  a  mere  fibrous  cord  surrounded  by  adherent  viscera,  and  unless 
carefully  sought  for  it  may  be  thought  that  they  have  been  con- 
genitally  absent. 

Between  this  form,  which  may  be  conveniently  termed  oblitera- 
tive  cholecystitis,  and  the  ordinary  contracted  gall-bladder  so 
frequently  seen  in  operating  for  gall-stones,  every  degree  of 
deformity  may  exist. 

The  gall-bladder  may  be  only  partly  obliterated,  and  the  small 
amount  of  mucous  membrane  left  may  continue  to  secrete  a  little 
mucus,  and  keep  up  a  constant  state  of  irritation  resembling  true 
gall-stone  seizures,  or  the  cystic  duct  may  be  obliterated,  and  the 
gall-bladder  may  form  a  cyst  containing  mucus,  quite  separated 


702  Inflammatory  Affections  of   the  Gail-Bladder. 

from  the  bile  channels  proper.  In  nearly  all  these  cases  the 
recurring  pains  call  for  operation,  and  unless  the  apparently 
insignificant  and  almost  obliterated  remains  are  taken  away,  the 
attacks  of  pain  often  associated  with  fever  will  continue  and  lead  to 
serious  deterioration  of  health. 

Croupous  Inflammation  of  the  Gail-Bladder  and  Bile  Ducts. 
— It  had  been  noticed  as  far  back  as  1820  by  Dr.  Richard  Powell 
that  membranous  or  croupous  enteritis  was  frequently  associated 
with  attacks  resembling  gall-stone  seizures. 

From  a  number  of  cases  that  I  have  seen  and  observed,  some  of 
them  having  been  submitted  to  operation  without  finding  gall- 
stones, but  where  there  was  abundant  evidence  of  inflammation  of 
the  gall-bladder  and  bile  ducts,  I  formed  the  opinion  that  the  cause 
of  the  painful  attacks  followed  by  slight  jaundice,  in  cases  of 
membranous  enteritis,  is  the  formation  of  membrane  in  the  bile 
passages,  which,  partly  obstructing  the  bile  flow,  sets  up  spasm  of 
the  gall-bladder,  just  as  a  gall-stone  or  even  a  lump  of  tenacious 
mucus  will  do. 

Owing  to  the  disintegrating  effect  of  the  bile  and  of  the  intestinal 
secretion  it  seldom  happens  that  a  true  cast  of  the  gall-bladder  or 
bile  ducts  is  discovered,  as  occurred  in  a  case  related  by  Dr. 
Clennell  Fenwick. 

If  under  treatment  by  saline  aperients,  such  as  Carlsbad  salts 
given  the  first  thing  in  the  morning  and  careful  dieting,  the 
symptoms  do  not  abate,  the  question  of  drainage  of  the  gall-bladder 
by  cholecystotomy  will  be  well  worth  considering,  and  at  the  time 
of  operation  adhesions  of  the  gall-bladder  to  the  neighbouring 
viscera  should  be  broken  down. 

Simple  Empyema  of  the  Gall- Bladder. — Suppurative  catarrh 
or  simple  empyema  of  the  gall-bladder,  or  suppurative  cholecystitis, 
is  as  a  rule  associated  with  gall-stones  ;  but  tumours  of  the  bile 
ducts,  typhoid  and  other  fevers,  and  unexplained  conditions  may 
also  be  the  predisposing  factors,  though  infection  by  pyogenic 
organisms  is  probably  in  every  case  the  true  exciting  cause. 

Empyema  of  the  gall-bladder  must  always  be  looked  on  as  a 
serious  affection,  both  on  account  of  its  causes  and  its  sequelae,  but 
from  a  clinical  standpoint  there  is  one  form  which  is  decidedly  less 
serious  than  the  other.  The  treatment  of  the  less  serious  will  be 
considered  first  under  the  term  "  simple  empyema  of  the  gall- 
bladder "  ;  the  more  serious  form  will  be  considered  later  as  a  distinct 
and  special  disease  under  the  name  of  "  phlegm onous  cholecystitis." 

The  pus  may  form  an  abscess,  which  may  even  burst  at  a 
distance  from  its  origin — for  instance,  over  the  pubes  or  over  the 


Inflammatory  Affections  of  the  Gall-Bladder.   703 

caecum — or  it  may,  after  setting  up  adhesions  to  adjoining  viscera, 
be  discharged  into  the  duodenum,  colon,  stomach  or  pelvis  of  the 
kidney ;  or  passing  into  the  liver  it  may  lead  to  abscess  of  that 
organ ;  or  perforating  the  diaphragm,  it  may  discharge  into  the 
pleura  and  set  up  empyema,  or  into  the  pericardium  and  incite 
pericarditis,  or  into  the  peritoneal  cavity  and  produce  acute  general 
peritonitis. 

There  are  generally  peritoneal  adhesions  which  prevent 
extravasation  into  the  general  peritoneal  cavity,  but  the  pus  may 
make  its  way  into  neighbouring  organs.  On  several  occasions 
I  have  found  a  cavity  in  the  liver  containing  pus  and  gall-stones 
communicating  with  the  diseased  gall-bladder. 

In  several  cases  I  have  evacuated  and  drained  successfully  a 
large  subphrenic  abscess  between  the  liver  and  diaphragm,  due  to 
a  ruptured  empyema  of  the  gall-bladder. 

If  we  bear  in  mind  the  pouch  of  peritoneum  in  front  of  the  right 
kidney,  it  is  not  to  be  wondered  at  that  a  collection  of  pus  should 
at  times  form  in  that  region  resembling  a  peri-renal  abscess,  though 
inside  the  peritoneum  and  limited  by  adhesions. 

An  abscess  of  the  gall-bladder  requires  treating  on  general 
surgical  principles  by  opening  and  draining  ;  but  the  cause  must 
not  be  overlooked,  as  it  may  often  be  removed  at  the  same  time 
that  the  abscess  is  evacuated. 

The  walls  of  the  gall-bladder  may  be  found  so  friable  as  to  be 
incapable  of  holding  sutures,  or  there  may  be  small  abscesses  in 
the  inflamed  wall  of  the  gall-bladder  itself;  in  such  cases 
cholecystectomy  may  be  required,  as,  indeed,  it  is  whenever  the 
walls  of  the  gall-bladder  are  seriously  damaged  or  the  cystic  duct 
is  ulcerated  or  strictured. 

In  abscess  due  to  empyema  of  the  gall-bladder  reaching  the 
surface  at  some  distance  from  the  seat  of  the  origin,  it  may  be 
wise  at  first  simply  to  open  and  drain  the  abscess,  and  on  some 
future  occasion  to  perform  cholecystotomy  or  cholecystectomy. 

But  it  may  be  feasible  after  opening  the  superficial  abscess  to 
dilate  the  fistula  leading  to  the  gall-bladder  and  remove  the  stones, 
afterwards  leaving  a  tube  in  the  gall-bladder.  This  may  possibly 
be  effected  without  detaching  the  adherent  gall-bladder  from  the 
surface. 

In  some  cases  of  empyema  the  patient  may  not  be  in  a  fit 
condition  to  bear  a  prolonged  operation,  and  it  may,  therefore,  be 
wiser  to  perform  a  simple  cholecystotomy,  and  to  defer  the  removal 
of  the  cause  until  an  examination  of  the  discharge  shows  it  to  be 
sterile  or  nearly  so. 


704      Inflammatory  Affections   of  the  Bile  Ducts. 

Acute  Phlegmonous  Cholecystitis  and  Gangrene  of  the  Gail- 
Bladder. — Acute  or  phlegmonous  inflammation  of  the  gall-bladder 
was  described  by  Courvoisier  in  1890  under  the  name  of  acute 
progressive  empyema  of  the  gall-bladder,  and  he  states  that  it 
usually  terminates  fatally  in  a  few  days  from  diffuse  peritonitis. 
Only  seven  cases  are  regarded  in  Courvoisier's  statistics. 

Potain  also  mentions  that,  in  addition  to  the  ordinary  variety 
of  empyema  of  the  gall-bladder,  there  is  a  very  grave  condition  of 
acute  empyema  which  is  followed  by  rapid  peritonitis  and  death. 
In  one  case  which  he  describes  death  occurred  on  the  second  day 
after  the  onset  of  the  attack,  and  although  there  was  no  perforation 
of  the  walls  of  the  viscus,  infection  had  spread  through  the  coats 
to  the  general  peritoneal  cavity. 

Although  the  condition  is  usually  associated  with  gall-stones, 
acute  cholecystitis  may  arise  quite  independently,  in  this  way 
resembling  appendicitis,  which  may  occur  without  the  presence  of 
concretions  or  foreign  bodies. 

Typhoid  and  typhus  fevers,  cholera,  malaria,  sepsis  after 
operation,  puerperal  fever,  and  other  conditions  may  give  rise 
to  it. 

Eelief  of  pain  by  subcutaneous  injections  of  morphia  will 
probably  always  be  demanded  as  a  primary  measure,  and  as  it  is 
often  impossible  to  make  a  diagnosis  of  the  serious  condition  within 
the  first  few  hours,  warm  applications  should  be  used  and  absolute 
rest  enjoined,  all  feeding  by  the  mouth  being  stopped  and  the  relief 
of  symptoms  as  they  arise  being  attended  to  ;  but  as  soon  as  the 
diagnosis  of  acute  cholecystitis  is  suspected  and  it  is  found  that  the 
patient  is  getting  worse,  an  exploratory  incision  should  be  made, 
and  if  phlegmonous  cholecystitis  is  found,  the  gall-bladder  should 
be  removed  and  the  right  hypochondrium  drained. 

If  in  the  subacute  cases  the  inflammation  becomes  localised, 
and  a  swelling  with  tenderness  be  found  beneath  the  right  costal 
margin,  incision  and  drainage  is  called  for,  when1  at  the  same 
time  cholecystotomy  may  be  performed,  and  if  gall-stones  be  present 
in  the  gall  bladder  or  ducts  they  may  be  removed.  If  the  patient 
is  too  ill  to  bear  a  prolonged  operation,  the  latter  procedure  may  be 
left  to  a  subsequent  occasion. 

Gangrene  of  the  gall-bladder  is  an  advanced  stage  of  phlegmonous 
cholecystitis  and  requires  the  same  treatment,  cholecystectomy. 

Infective  Cholangitis. — Infective  cholangitis  or  infective  catarrh 
of  the  bile  ducts  was  first  described  by  Charcot  under  the  name  of 
intermittent  hepatic  fever.  It  is  usually  due  to  gall-stones  in  the 
common  duct,  which  favour  the  entrance  of  organisms  from  the 


Inflammatory  Affections  of  the  Bile  Ducts.   705 

intestine  through  the  duodenal  orifice ;  but  anything  causing 
obstruction  of  the  common  or  hepatic  ducts  may  lead  to  infection 
of  the  retained  bile.  Thus  I  have  known  infective  cholangitis  to 
follow  on  chronic  pancreatitis,  cancer  of  the  pancreas,  cancer  of  the 
common  bile  duct,  hydatid  disease,  ascarides  in  the  bile  duct, 
pancreatic  calculus,  and  stricture  of  the  common  duct,  besides 
general  ailments  such  as  typhoid  fever  and  influenza. 

Drainage  of  the  bile  ducts  either  by  cholecystotomy  or  chole- 
dochotomy  is  the  first  essential,  but  if  possible  the  cause  should  at 
the  same  time  be  removed. 

There  can  be  no  doubt  in  the  minds  of  those  who  have  observed 
many  of  these  cases  that  it  is  better  to  anticipate  the  complication, 
and  as  soon  as  medical  treatment  has  been  fairly  tried  and  failed, 
the  removal  of  gall-stones  by  surgical  means  should  be  resorted  to 
before  infection  of  the  bile  passages  has  occurred. 

Suppurative  Cholangitis. — Suppurative  cholangitis  or  suppu- 
rative  catarrh  of  the  bile  passages  is  a  subject  of  deep  interest,  and 
a  disease  of  serious  import,  not  only  on  account  of  its  causes  but 
from  the  combined  effects  of  biliary  obstruction  and  stagnation  with 
septic  infection,  and  their  local  and  constitutional  effects. 

Besides  gall-stones,  hydatid  disease,  ascarides,  cancer  of  the  bile 
ducts,  typhoid  fever,  and  influenza  may  cause  Suppurative  cholan- 
gitis, and  it  is  probable  that  the  disease  not  infrequently  complicates 
other  acute  infectious  ailments. 

Unless  free  evacuation  and  drainage  of  the  infected  contents  of 
the  bile  passages  can  be  accomplished,  either  naturally  or  arti- 
ficially, treatment  is  practically  useless.  Therefore,  if  practicable, 
cholecystotomy  should  be  performed,  and  free  drainage  established 
and  continued  until  the  bile  is  sterile  or  nearly  so. 

Although  good  results  cannot  be  expected  in  all  cases,  an 
amelioration  of  the  symptoms  may  be  looked  for  in  a  fair  proportion, 
and  complete  relief  in  others. 

If  a  localised  abscess  is  discovered  in  the  liver,  it  should  be  opened 
and  drained,  and  though  it  is  scarcely  to  be  expected  that  operation 
can  be  always  successful  in  these  more  serious  cases,  the  chance  of 
permanent  benefit  is  worth  snatching  at,  even  in  the  most  desperate 
conditions. 

Of  general  means,  warm  applications  to  the  hepatic  regions,  an 
initial  mercury  purge  followed  by  milder  laxatives,  the  employment 
of  intestinal  antiseptics,  such  as  bismuth  and  salol,  the  relief  of 
pain  by  sedatives,  and  the  treatment  of  symptoms  as  they  arise 
will  afford  some  amelioration,  though  they  will  probably  only  give 
temporary  relief. 

S.T. — VOL.  11.  45 


706   Inflammatory  Affections  of  the  Bile  Ducts. 

Drainage  of  the  bile  ducts  by  cholecystotomy  or  choledochotomy  is 
the  operation  called  for,  and  at  the  same  time  the  obstruction, 
if  one  is  present,  should  if  possible  be  removed,  though  in  some 
cases,  where  the  patient  is  extremely  ill,  the  latter  part  of  the 
operation  may  be  deferred  until  the  drainage  has  cleared  away 
all  the  infective  material. 

Thanks  to  the  opening  in  the  gall-bladder,  a  certain  number  of 
important  therapeutic  results  follow  : 

First. — The  septic  contents  of  the  gall-bladder  are  evacuated. 

Second. — Calculi,  which  are  most  frequently  present  there,  are 
removed. 

Third. — The  other  biliary  passages,  more  or  less  obstructed 
either  by  calculi  or  by  swelling  of  their  walls,  are  rendered  as  free 
as  possible. 

Fourth. — The  septic  bile  is  allowed  to  escape  and  mechanically 
washes  out  the  lower  passages,  carrying  away  through  the  drainage 
tube  many  of  the  infective  elements. 

Fifth. — The  relief  of  pressure  prevents  absorption  of  the  septic 
matter. 

Sixth. — The  relief  to  the  kidneys,  by  allowing  the  bile  to  escape 
freely,  is  also  of  importance,  as  they  are  thus  enabled  to  perform 
their  function  more  freely  in  relieving  the  system  of  septic  and 
other  materials. 

Seventh. — The  swelling  of  the  head  of  the  pancreas,  "  chronic 
pancreatitis,"  so  often  present  when  the  common  bile  duct  is 
obstructed,  subsides  owing  to  the  indirect  drainage  of  the  pancreatic 
ducts. 

Stricture  of  the  Gall-bladder  and  Bile  Ducts.  —  Stricture 
of  the  bile  ducts  is,  I  should  judge  by  my  experience  on  the 
operating  table,  very  common,  especially  stricture  of  the  cystic 
duct,  yet,  if  we  might  judge  by  museum  specimens  alone,  it  would 
seem  to  be  one  of  the  rarer  sequelae  of  ulceration. 

If  the  stricture  is  in  the  hepatic  duct  it  will  lead  to  jaundice 
without  distension  of  the  gall-bladder;  if  in  the  cystic  duct, 
to  distension  of  the  gall-bladder  without  jaundice ;  but  if  in 
the  common  duct,  both  to  jaundice  and  distended  gall-bladder, 
unless  the  latter  is  contracted  as  the  result  of  previous  gall-stone 
trouble. 

Where  extensive  changes  have  not  already  taken  place  in  the  wall 
of  the  gall-bladder,  distension  of  the  organ  with  mucus  or  muco-pus 
will  occur.  If  relief  is  not  afforded  by  operative  measures,  suppu- 
rative  or  phlegmonous  cholecystitis  may  occur,  or  the  distended 
organ  may  rupture  into  the  peritoneum  or  discharge  its  contents  by 


Inflammatory  Affections  of  the  Bile  Ducts.   707 

the  formation  of  a  fistula  between  the  gall-bladder  and  duodenum, 
stomach  or  colon ;  or  the  gall-bladder  may  gradually  dilate  so  as  to 
form  a  tumour  resembling  an  ovarian  cyst. 

Needless  to  say,  stricture  of  the  bile  passages  will  scarcely  call 
for  diagnosis  apart  from  its  cause,  though  different  treatment  will 
be  demanded  when  the  disease  is  recognised  at  the  time  of  opera- 
tion. In  stricture  of  the  cystic  duct  the  gall-bladder  should  be 
removed,  otherwise  a  recurrence  of  the  symptoms  will  occur  when 
the  wound  closes,  or  there  will  be  a  permanent  mucous  fistula. 

As  an  alternative  the  gall-bladder  may  be  short-circuited  into  the 
intestine. 

In  stricture  of  the  common  duct  cholecystenterostomy  must  be 
performed,  otherwise  a  permanent  biliary  fistula  will  certainly 
follow.  At  times,  however,  this  may  be  impracticable,  and  in  such 
cases  drainage  alone  may  be  feasible. 

Perforation  of  the  Gall-bladder  and  Bile  Ducts. — Perforation 
of  the  gall-bladder  or  bile  ducts  must  always  be  serious  on  account  of 
an  escape  of  the  visceral  contents  into  the  peritoneal  cavity,  the 
imminence  of  the  danger,  however,  depending  on  two  factors,  first, 
the  nature  of  the  extra vasated  fluid ;  and  secondly,  the  time  allowed 
to  elapse  before  surgical  relief  is  afforded. 

The  presence  of  healthy  bile  in  the  peritoneum,  due  to  an  injury, 
such  as  a  stab,  a  bullet  wound,  or  a  blow,  in  a  healthy  individual 
may  be  tolerated  for  some  time  without  serious  damage,  as  in  a 
case  recorded  by  Thiersch,  who  successfully  removed  over  40 
pints  of  bile-stained  fluid  from  the  abdominal  cavity  after  the  gall- 
bladder had  been  ruptured  by  a  blow. 

It  is  of  far  more  serious  moment  when  the  extravasated  bile  is 
pathological  as  it  is  for  the  most  part  where  there  is  distension  of 
the  gall-bladder  or  any  disease  of  the  bile  ducts,  for  in  such  cases 
the  bile  is  infective,  and  rapidly  sets  up  a  diffuse  peritonitis,  which, 
unless  speedily  operated  on,  ends  fatally. 

Even  in  such  cases,  if  the  diagnosis  is  made  at  once  and  early 
operation  done,  the  prognosis  is  hopeful. 

In  rupture  of  the  gall-bladder  from  sudden  pressure  induced  by 
straining  at  stool,  vomiting,  sneezing,  efforts  in  parturition,  or  even 
by  blows  over  the  hepatic  region,  there  is  in  all  probability  in  the 
greater  number  of  such  cases  a  predisposition  to  rupture  in  the  shape 
of  thinning  by  ulceration  or  by  long-continued  distension,  otherwise 
the  accident  would  be  much  more  common. 

Such  cases  show  conclusively  that  it  is  folly  to  permit  patients 
with  distended  gall-bladders,  even  though  symptoms  be  only  occa- 
sionally present,  to  go  unoperated  on. 

45—2 


708    Inflammatory  Affections  of  the  Bile  Ducts. 

A  careful  operation  in  these  cases  is  almost  devoid  of  risk,  but 
rupture  is  hazardous  in  the  extreme. 

Massage  in  cases  of  distended  gall-bladder  is  dangerous,  as 
attempts  to  force  impacted  calculi  onward  by  pressure  are  well 
calculated  to  rupture  the  thin  wall  of  the  gall-bladder  or  bile  ducts, 
or  to  cause  perforation  through  the  base  of  an  ulcer,  leading  to 
extravasation  of  infective  matter  into  the  general  peritoneal  cavity, 
and  probably  to  fatal  peritonitis. 

In  the  greater  number  of  cases  perforation  occurs  slowly,  an 
adventitious  cavity  being  formed,  shut  off  from  the  general  cavity 
of  the  peritoneum  by  adhesions  of  the  neighbouring  viscera. 

In  some  cases  the  primary  perforation  may  lead  to  the  forma- 
tion of  a  second  cavity  bounded  by  plastic  lymph,  which  may  again 
rupture  and  lead  to  a  fatal  peritonitis. 

Erdman  gives  a  record  of  thirty-four  cases  of  perforation  with 
four  recoveries.  Of  these  thirty-four  cases  twenty-seven  were  not 
operated  on,  and  all  died.  Of  the  seven  cases  in  which  an  operation 
was  performed  four  recovered  and  three  died.  He  strongly  advo- 
cates cholecystectomy,  and  does  not  approve  of  cholecystotomy  or 
of  repair  of  the  perforation  by  suture. 

The  perforation  may  occur  into  adjoining  parenchymatous  organs. 
On  several  occasions  I  have  removed  gall-stones  from  cavities  in  the 
liver  produced  by  ulceration  and  perforation  of  the  gall-bladder 
or  bile  ducts,  and  direct  passage  of  the  contents  into  the  liver 
tissue. 

If  the  ulceration  and  perforation  occur  from  the  common  duct 
into  the  substance  of  the  pancreas,  acute  pancreatitis  may  follow, 
or  if  less  acute,  an  abscess  of  the  pancreas  may  result  and  require 
evacuation. 

If  the  ulceration  advances  towards  the  adjoining  hollow  viscera, 
stomach,  duodenum  or  colon,  adhesions  as  a  rule  form,  and  the 
perforation  is  effected  quietly. 

In  several  cases  I  have  known  large  gall-stones  to  ulcerate  their 
way  quietly,  and  to  perforate  the  stomach  or  intestine,  only  pro- 
ducing serious  symptoms  from  mechanical  irritation  or  obstruc- 
tion. 

Barely  gall-stones  have  perforated  into  the  pelvis  of  the  right 
kidney,  producing  symptoms  of  renal  calculus. 

Not  infrequently  the  perforation  may  occur  after  adhesion  to  the 
parietal  peritoneum,  when  a  superficial  abscess  may  follow,  discharg- 
ing gall-stones. 

In  perforation  of  the  bile  passages  medical  treatment  is  useless, 
and  to  give  opium  for  the  relief  of  pain  so  disguises  the  symptoms 


Inflammatory  Affections  of  the  Bile  Ducts.  709 

that  a  fatal  sense  of  security  is  given  for  a  time,  and  when  the 
mistake  is  discovered  it  may  be  to.o  late  to  operate. 

As  soon  as  it  is  clearly  made  out  that  perforation  has  occurred, 
or  even  if  it  is  suspected  that  such  is  the  case,  the  abdomen  should 
be  opened  in  the  right  semilunar  line. 

If  pus  and  bile  are  found,  they  should  be  rapidly  wiped  away  with 
gauze  or  wool  sponges,  and  if  the  extravasation  has  gone  beyond 
the  local  area  of  disease,  the  abdomen  should  be  flushed  with  hot 
sterilised  saline  solution. 

The  patient  may  be  too  ill  to  bear  a  prolonged  operation,  and 
if  so,  free  drainage  will  probably  do  all  that  is  necessary. 

In  drainage  it  should  be  borne  in  mind  that  the  right  kidney 
pouch  forms  a  distinct  peritoneal  pocket,  and  that  a  drainage  tube 
applied  through  a  stab  opening  in  the  right  loin  affords  a  free 
exit  for  extravasated  fluids  coming  from  the  neighbourhood  of  the 
gall-bladder.  If  the  whole  peritoneal  cavity  has  been  soiled,  a 
puncture  above  the  pubes  large  enough  for  a  tube  to  be  passed  into 
the  pouch  of  Douglas  may  be  an  advantage. 

If  the  patient  is  in  sufficiently  good  condition  to  permit  a  search 
for  the  rupture,  and  it  can  be  found,  it  may  be  closed  by  fine  silk 
or  catgut  sutures,  but  it  will  be  wise  to  open  and  drain  the  gall- 
bladder at  the  same  time. 

Should  marked  cholecystitis  be  found,  the  question  of  cholecys- 
tectomy  arises  ;  but  when  the  patient  is  in  a  critical  condition  it  is 
a  mistake  to  attempt  too  much,  and,  as  a  rule,  cleansing  and  free 
drainage  will  be  all  that  are  necessary  or  advisable  at  the  time,  the 
removal  of  the  cause  being  left  until  the  patient  is  better  able  to 
bear  a  more  prolonged  operation. 


A.  W.   MAYO  ROBSON. 


REFERENCES. 


Brit.  Med.  Journ.,  1898,  L,  p.  1072,    Journ.  de  Med.  et  Chir.,  November, 
1882  ;  Annals  of  Surgery,  Phila.,  1903,  XXXVII.,  p.  878. 


710 


TUMOURS  OF  THE   GALL-BLADDER. 

Distension  of  the  Gall-bladder. — A  tumour  is  felt  as  soon  as 
retention  occurs  under  tension,  when  the  cyst  full  of  fluid  often 
gives  the  sensation  on  palpation  of  a  pyriform  solid,  it  being  so 
hard. 

A  perceptible  tumour  formed  by  distension  with  gall-stones  is 
rare,  unless  it  happens  that  some  have  become  impacted  in  the 
cystid  duct,  when  a  gradual  enlargement  from  the  retained  mucus 
will  follow.  Occasionally  a  large  single  stone  may  form  a  hard 
perceptible  swelling  below  the  liver. 

The  treatment  is  by  cholecystotomy  if  the  obstruction  can  be 
removed  and  the  gall-bladder  and  cystic  duct  are  not  seriously 
affected,  or  cholecystectomy  if  the  gall-bladder  is  diseased  or  the 
cystic  duct  ulcerated  or  strictured. 

Calcified  gall-bladder,  which  is  due  to  cholelithic  catarrh,  may 
lead  to  the  formation  of  a  hard,  rounded,  painless  tumour,  which  can 
be  readily  excised  if  causing  trouble. 

Hydrops  and  Dropsy  of  the  Gall-bladder  are  terms  used  to 
denote  distension  of  the  gall-bladder  by  mucus.  It  may  result  from 
any  obstruction  in  the  cystic  or  common  ducts,  whether  due  to  gall- 
stones, stricture  or  growth  in  the  ducts,  or  to  cancer  of  the  head  of 
the  pancreas,  provided  that  the  gall-bladder  has  not  atrophied  as 
the  result  of  previous  gall-stone  irritation.  It  is  due  to  the  gradual 
accumulation  of  the  natural  secretion  of  the  mucous  lining,  and  may 
attain  such  a  size  as  to  be  mistaken  for  an  ovarian  cyst,  as  in  cases 
reported  by  Lawson  Tait,  Mayo  and  Kocher,  though  it  is  uncommon 
to  find  the  tumour  of  greater  size  than  15  to  20-.oz.  capacity. 

Where  the  tumour  is  small  and  the  cause  is  removable  the  gall- 
bladder may  be  drained  after  the  obstruction  has  been  removed, 
but  when  the  tumour  is  of  considerable  size  cholecystectomy  should 
be  performed. 

Empyema  of  the  Gall-bladder. — If  the  obstruction  is  asso- 
ciated with  inflammation  the  contents  of  the  gall-bladder  may 
become  purulent  and  an  empyema  of  the  gall-bladder  may  result, 
necessitating  cholecystotomy  or  cholecystectomy. 

Hypertrophy  of  the  Gall-bladder,  forming  a  large  tumour, 
is  not  infrequently  seen  as  a  result  of  cholelithiasis.  The  contents 
may  be  mucus  or  muco-pus,  and  gall-stones  may  or  may  not  be 


Tumours  of  the  Gall-Bladder. 


711 


present  when  the  tumour  is  removed,  though  probably  in  every 
case  biliary  concretions  have  ac.tually  initiated  the  trouble  by 
obstructing  the  outlet  and  producing  cholecystitis. 

Firm  adhesions  to  the  neighbouring  organs,  the  result  of  local 
peritonitis,  form  a  distinct  feature  of  these  tumours,  and  though 
their  separation  may  be  tedious,  this  should  be  done,  and  should  be 
followed  by  cholecystectomy. 

Hydatids   of  the   Gall-bladder. — Hydatid  disease  of  the  gall- 
bladder may  occur  primarily,  but  it  is  more  common  for  the  disease 
to  originate  in  the  liver  and  then  to  burst 
into  the  gall-bladder,  producing  symptoms 
resembling  gall-stone  seizures. 

Complete  removal  of  the  hydatids  and 
drainage  of  the  gall-bladder  i"s  advisable. 

Actinomycosis  of  the  Gall-bladder 
is  extremely  rare,  a  case  which  came 
under  my  care  being  the  only  one  with 
which  I  am  acquainted. 

Evacuation  of  the  soft,  putty-like  con- 
tents of  the  gall-bladder,  followed  by 
drainage  and  the  administration  of  large 
doses  of  iodide  of  potassium,  proved 
completely  curative. 

New  Growths.  —  Of  the  tumours 
dependent  on  new  growth,  cancer  of 
the  gall-bladder  is  the  most  important, 
innocent  growth,  except  of  inflammatory 
origin,  being  extremely  rare. 

The  alleviation  of  symptoms,  especially  FIG.  i.— Adenoma  of  gall-bladder 
of  pain  by  sedatives,  is  usually  all  that  removed  by  author, 

can  be  done,  except  in  those  rare  cases  where  the  disease  is 
limited  to  the  gall-bladder,  when  cholecystectomy  may  be  per- 
formed. 

In  a  limited  number  of  cases  in  which  the  liver  is  affected  by 
direct  extension  from  the  gall-bladder  it  may  appear  feasible  to 
remove  the  whole  disease.  In  such  it  is  probably  right  that  the 
patient  should  get  what  chance  there  is  of  complete  cure. 

The  question  of  operation  is  always  worth  considering  seriously, 
since  the  possibility  of  the  trouble  being  dependent  entirely  on 
inflammation,  the  result  of  gall-stone  irritation,  and  not  on  new 
growth,  cannot  always  be  pre-determined.  Indeed,  even  after  the 
abdomen  has  been  opened  it  is  not  always  easy  to  be  sure  of  the 
exact  condition  of  affairs  until  adhesions  have  been  broken  down. 


yi2  Tumours  of  the  Gall-Bladder. 

It  is  not  very  uncommon  to  find  a  gall-bladder  containing  pus  and 
gall-stones  in  the  centre  of  a  mass  of  omentum  and  adherent  viscera 
so  hard  as  very  closely  to  simulate  new  growth.  In  such  cases,  of 
course,  all  that  is  necessary  in  order  to  effect  a  cure  is  to  remove 
the  gall-stones  and  drain  or  remove  the  gall-bladder. 

"Whether  it  is  worth  trying  thus  to  remove  a  localised  cancer  of 
the  liver  and  gall-bladder  is  a  question  which  can  only  be  solved  by 
more  extended  experience,  but  I  am  inclined  to  think  from  the  after- 
history  of  several  cases  on  which  I  have  operated  that,  even  when 
recurrence  took  place,  the  respite  gained  to  the  patient  more  than 
counterbalanced  the  danger  of  the  operation.  In  similar  cases, 
where  no  attempt  at  radical  treatment  was  made,  the  course  .of 
events  does  not  seem  to  have  been  nearly  so  satisfactory,  for  the 
disease  steadily  progressed  to  a  fatal  termination,  and  the  patients 
had  not  even  the  satisfaction  of  a  respite,  or  the  hope  of  recovery 
engendered  by  the  knowledge  that  the  malignant  disease  had  been 
removed  ;  moreover,  in  two  cases  the  patients  were  well  after  some 
years. 

Sarcoma  of  the  gall-bladder  is  much  less  common  than  carcinoma, 
but  it  is  occasionally  found.  Musser  collected  three  cases  of 
sarcoma,  and  Rolleston  (Clinical  Journal,  April  7th,  1897)  has 
reported  another,  which  on  examination  was  found  to  be  a  case  of 
spindle-celled  sarcoma.  If  recognised  in  time,  removal  might  be 
possible. 

Simple  groicths  in  the  gall-bladder  are  as  a  rule  not  of  great 
clinical  importance,  except  as  precursors  of  malignant  disease, 
though  I  have  removed  the  gall-bladder  successfully  on  two  occa- 
sions for  simple  adenoma. 

A.    W.    MAYO-ROBSON. 

EEFEKENCE. 
Boston  Med.  and  Surg.  Journ.,  1889,  CXXL,  p.  581. 


7*3 


TUMOURS   OF   THE    BILE    DUCTS. 

Cystic  Tumours. — Tumours  of  the  bile  ducts,  per  se,  only  occa- 
sionally form  a  projection  so  large  as  to  be  distinguished  through  the 
abdominal  walls.  A  tumour  is,  however,  in  some  cases  present 
sooner  or  later  on  account  of  the  obstruction  in  the  ducts  and 
secondary  distension  of  the  gall-bladder.  The  common  duct  has 
been  found  dilated  to  such  a  size  as  to  form  a  cystic  tumour,  pre- 
senting all  the  characteristics  of  a  distended  gall-bladder,  the  gall- 
bladder itself  being  atrophied. 

I  have  had  a  personal  operative  experience  of  three  cases.  Tn 
one  the  operation  of  choledochostomy  was  performed  after  chole- 
lithotrity  had  been  done,  the  patient  making  an  excellent  recovery ; 
in  the  other  choledochenterostomy  after  cholecystectomy,  the 
patient  also  doing  well.  In  the  third  case,  after  removing  the  gall 
bladder,  I  short-circuited  the  tumour  formed  by  the  distended 
common  bile  duct  into  the  duodenum.  The  patient,  a  lady  of 
twenty-eight,  made  a  good  recovery  and  has  remained  well  for  seven 
years. 

Simple  drainage  and  the  establishment  of  a  biliary  fistula  has 
been  almost  always  fatal  in  similar  cases  reported  by  Terrier  and 
others. 

Solid  Tumours  of  the  bile  ducts  may  be  simple  or  malignant. 

Simple  tumour  is  rare,  though  several  have  been  reported, 
and  in  one  case  I  was  able  to  remove  an  adenoma  of  the  cystic 
duct. 

Primary  malignant  disease  of  the  bile  ducts  is  almost  invariably 
fatal,  as  might  be  expected  from  their  histological  structure, 
columnar-celled  carcinoma.  Musser  collected  eighteen  cases,  and 
found  all  of  them  to  be  formed  by  cylindrical-celled  carcinoma ; 
while  out  of  other  sixteen  collected  by  Rolleston,  fourteen  showed 
similar  histological  characters,  and  two  were  cases  of  encephaloid 
cancer.  That  the  growth  may  in  the  first  instance  be  a  papilloma, 
subsequently  assuming  malignancy,  is  suggested  by  the  fact  that 
the  tumour  usually  projects  into  the  lumen  of  the  canal  as  a 
villous-like  mass,  while  at  the  same  time  the  submucous  tissue  is 
infiltrated  to  a  greater  or  less  extent. 

The  tumour  is  most  frequently  situated  in  the  common  duct 


Tumours  of  the  Bile  Ducts. 


towards  its  lower  end  ;  but  the  cystic  or  hepatic  ducts  may  be  first 
affected.  In  Musser's  eighteen  cases  the  hepatic  ducts  were  alone 
involved  three  times,  the  cystic  and  hepatic  ducts  once,  and  the 
common  duct  fourteen  times.  Rolleston  reported  seventeen  cases, 
and  in  these  the  common  duct  alone  was  the  seat  of  the  tumour  on 
fifteen  occasions  (the  lower  end  of  the  duct  being  involved  ten 
times)  and  the  cystic  duct  twice ;  but  in  one  of  the  latter  cases 
there  was  also  an  apparently  distinct  growth  at  the  lower  end  of  the 
common  duct. 

If  discovered  sufficiently  early,  removal  of  the  tumour  may  be 
attempted,  and  has  in  fact  been  carried  out  by  Halstead,  Mayo  and 
Moynihan,  though  the  relief  was  only  for  a  short  time. 

In  the  cases  I  have  seen  the  disease  had  advanced  too  far  for 
radical  treatment,  though  relief  to  the  jaundice  was  given  by  the 
performance  of  cholecyst-enterostomy  when  the  growth  involved  the 
common  duct. 

Cancer  of  the  Ampulla  of  Vater. — This  condition  was  probably  first 
described  by  McNeal  in  1835.1 

BILE  Ducr 

OF  S/tHWX/Nt 


FIG.  1. 

The  growth  may  arise  in  the  mucous  membrane  covering  the 
duodenal  surface  of  the  biliary  papilla,  in  the  mucous  membrane  of 
the  ampulla  of  Vater,  at  the  termination  of  the  common  bile  duct  and 
at  the  termination  of  Wirsung's  duct.  The  accompanying  diagram 
illustrates  these  distinctions. 

Confusion  may  also  arise  between  carcinoma  of  the  head  of  the 
pancreas  and  primary  carcinoma  of  the  ampulla  Vateri.  Carcinoma 
of  the  pancreas,  however,  is  spheroidal-celled,  while  carcinoma  of 
the  ampulla  of  Vater  is  columnar-celled.  Growth  may  also  extend 
to  the  ampulla  of  Vater  from  the  termination  of  the  common  bile 
duct  or  from  Wirsung's  duct.  The  treatment  of  this  condition  is 
merely  palliative  by  the  performance  of  cholecyst-enterostomy,  which 


Tumours  of  the  Bile  Ducts.  715 

by  establishing  another  route  for  the  bile  entering  the  intestine 
relieves  the  most  distressing  symptoms  due  to  jaundice. 

A.  W.  MAYO  ROBSON. 

EEFEKENCE. 

1  In  the  North  American  Archiv.,  Baltimore,  and  was  later  drawn  attention 
to  by  Stokes  in  1846  (Dublin  Quart.  Journ.  of  Med.  Sci.,  1846,  N.  S.,  II., 
p.  505).  More  recently  the  subject  has  been  fully  dealt  with  by  M.  Hanot 
(Archiv.  Gen.  de  Mcd.,  Paris,  1896),  M.  Durand-Fardel  (La  Presse  Medicale, 
1896,  VIII6,  Ser.  VI.,  p.  547),  M.  Kenduand  H.  D.  Eolleston  (Medical  Chronicle, 
1896,  N.  S.,  IV.,  p.  241,  and  Lancet,  1901,  I.,  p.  467),  who  in  a  most  instructive 
paper  on  the  subject  of  carcinoma  of  the  ampulla  of  Vater,  draw  attention 
to  the  varieties  of  malignant,  growth  which  may  be  met  with  in  this  region. 


yi6 


INJURIES  AND  DISEASES  OF  THE  PANCREAS. 
INJURIES    OF   THE   PANCREAS. 

INJURIES  of  the  pancreas  for  operative  treatment  may  be  divided 
into  (1)  lacerations  due  to  direct  violence,  (2)  bullet  wounds, 
(3)  penetrating  wounds  and  stabs. 

The  treatment  at  first  will  be  directed  to  the  shock  and  collapse 
which  usually  accompany  the  accident,  but  as  soon  as  reaction  has 
been  established  the  question  of  operative  interference  will  arise.  If 
there  are  signs  of  haemorrhage,  the  abdomen  must  be  opened  and 
an  attempt  made  to  secure  the  bleeding  points.  If  a  laceration  of 
the  gland  is  found,  deep  and  superficial  sutures  must  be  applied, 
but  care  should  be  taken  to  avoid  including  Wirsung's  duct. 

In  the  treatment  of  gunshot  injuries  and  stab  wounds,  if  the 
patient  is  in  a  position  where  operation  can  be  efficiently  under- 
taken, the  earlier  it  is  carried  out  the  better. 

Any  bleeding  points  should  be  secured,  and  a  careful  but  rapid 
search  made  for  injury  to  the  stomach,  intestine,  liver,  etc.  The 
wound  of  the  pancreas  may  be  sutured,  but  if  there  is  much 
laceration  it  may  be  necessary  to  re-sect  a  portion  of  the  gland  and 
unite  the  clean-cut  edges  by  sutures.  Care  must  be  taken  to  avoid 
the  main  duct,  the  superior  mesenteric  artery  and  the  portal  vein. 
Complete  disorganisation  of  the  gland  can  only  be  treated  by  plug- 
ging and  drainage,  for  it  is  practically  impossible  to  remove  it,  and 
the  attempt  is  not  justifiable  on  physiological  grounds.  When 
suture  is  possible  drainage  should  always  be  adopted,  for  there  is 
invariably  a  certain  amount  of  leakage,  and  if  an  exit  is  not  pro- 
vided for  the  exuding  secretion  local  disturbances  and  peritonitis 
may  result.  It  is  noteworthy  that  in  two  cases  where  an  injury  of 
the  pancreas  was  sutured,  but  no  drainage  was  provided,  a  localised 
destruction  of  tissue  was  found  post-mortem.  Drainage  has  usually 
been  provided  through  the  abdominal  wound,  but  a  posterior  open- 
ing, such  as  Jephson  adopted  in  his  case,  and  which  was  also  carried 
out  by  me  in  another  instance,  is  probably  more  efficient.  It  is 
frequently  stated  that  wounds  of  the  pancreas  are  almost  always 
fatal,  but  this  is  not  necessarily  the  case  if  suitable  operative 
measures  are  quickly  undertaken.  Of  the  twenty-one  cases  of  injury 
of  the  pancreas  due  to  gunshot  wounds  of  which  I  have  found  records 


Inflammatory  Affections  of  the  Pancreas.     717 

fifteen  were  operated  on,  and  nine  of  these  recovered  (Brarnann 
two,  Hahn,  Nini,  Borchardt,  Slavsky,  Jephson,  Otis  and  Becker). 
Of  the  six  in  which  death  occurred  the  injury  of  the  pancreas  was 
not  discovered  in  three,  so  that  in  nine  out  of  twelve  instances  it 
may  be  considered  that  the  operation  saved  the  patient's  life,  for  all 
but  one  of  the  cases  in  which  operation  was  not  resorted  to  died. 

A.  W.  MAYO-ROBSON. 


7i8 


ACUTE    PANCREATITIS. 

THE  pain  at  the  onset  is  so  acute  as  to  necessitate  the  administra- 
tion of  morphine,  and  the  collapse  will  probably  demand  stimulants, 
which,  on  account  of  the  associated  vomiting,  may  have  to  be  given 
by  enema.  In  the  early  stages  the  symptoms  may  be  so  indefi- 
nite that  the  indications  for  surgical  treatment  are  often  not  clear 
enough  to  demand  immediate  operation ;  but  as  soon  as  acute 
pancreatitis  is  suspected,  the  surgeon  must  not  wait  until  collapse 
has  passed  off,  as  that  may  be  dependent  on  septic  absorption,  which 
can  only  be  relieved  by  operation.  The  simulation  of  intestinal 
obstruction  will  probably  lead  to  efforts  to  secure  an  evacuation  of 
the  bowels  and  relief  to  the  distension.  Just  as  in  perforative  or 
gangrenous  appendicitis  an  early  evacuation  of  the  septic  matter 
is  necessary  to  recovery,  so  in  this  equally  lethal  affection  an  early 
exploration  through  the  middle  line  above  the  umbilicus  is  indicated, 
in  order,  if  possible,  to  relieve  tension,  to  evacuate  septic  material, 
to  secure  free  drainage,  and  to  arrest  the  haemorrhage  which  leads 
to  disintegration  and  necrosis  of  the  pancreas.  The  after-treat- 
ment will  be  chiefly  diracted  to  combating  shock  and  keeping  up 
the  strength  until  the  materies  morbi,  both  local  and  general,  can 
be  thrown  off.  Even  if  no  pus  is  found,  no  harm  should  accrue 
from  such  an  exploration,  which  can  be  made  in  a  few  minutes 
through  an  incision  in  the  middle  line  above  the  umbilicus. 

After  establishing  the  diagnosis  by  the  discovery  of  a  swelling  in 
the  region  of  the  pancreas,  with  effusion  of  blood  and  associated 
with  fat  necrosis,  a  posterior  incision  in  the  left  costo-vertebral 
angle  will  sometimes  enable  the  diseased  organ  to  be  very  freely 
drained  for  the  evacuation  of  pus  and  gangrenous  material  without 
risk  to  the  general  peritoneal  cavity,  and  with  little  danger  of 
retained  septic  matter,  as  the  drainage  will  be  a  dependent  one. 
If,  however,  the  inflammatory  collection  in  the  tensely  distended 
and  inflamed  gland  is  directly  incised  through  the  anterior 
abdominal  wound,  gauze  packing  and  gauze  drainage  may  usually 
be  relied  on  to  prevent  general  infection  of  the  peritoneum.  If  there 
are  signs  of  an  obstructed  common  bile  duct,  the  gall-bladder  should 
be  drained,  and  if  gall-stones  are  discovered  they  should  be  removed, 
if  this  can  be  done  without  seriously  adding  to  the  length  of  the 
operation  ;  otherwise  they  may  be  left  and  removed  on  a  subsequent 


Acute  Pancreatitis.  719 

occasion  if  free  drainage  of  the  bile  passages  can  be  secured.  I  have 
had  six  cases  of  acute  pancreatitis  under  my  care,  and  have  operated 
on  four,  of  which  two  recovered.  Of  the  two  cases  where  operation 
was  not  consented  to,  and  where  medical  treatment  alone  was 
carried  out,  death  occurred  in  the  first  case  on  the  third  day,  and  in 
the  second  case  after  a  week's  illness,  attended  in  both  with  great 
pain  and  incessant  vomiting. 

A.  W.  MAYO-ROBSON. 


720 


SUBACUTE    PANCREATITIS. 

THE  subacute  form  of  pancreatitis  is  more  amenable  to  treatment 
as  the  indications  are  so  much  more  definite,  and  there  is  more  time 
for  careful  consideration.  Though  it  has  usually  been  attacked 
only  when  an  abscess  has  formed  and  is  manifestly  making  its  way 
to  the  surface,  yet  there  is  no  reason  why  in  some  cases  surgical 
treatment  should  not  be  adopted  at  an  earlier  stage.  As  in  the 
acute  condition,  morphine  may  be  required  to  relieve  the  pain  and 
to  lessen  the  collapse.  Distension,  if  present,  demands  attention, 
and  may  have  to  be  relieved  by  lavage  of  the  stomach  and  turpen- 
tine enemata,  or  by  the  administration  of  calomel  by  the  mouth. 
Calomel  is  also  of  benefit  as  an  intestinal  antiseptic,  for  which 
purpose  it  may  be  given  in  small  repeated  doses  followed  by  a 
saline  aperient.  As  soon  as  the  constipation  is  relieved,  diarrhoea 
is  apt  to  supervene,  when  salol  and  bismuth,  with  small  doses  of 
opium,  may  be  given.  If  surgical  treatment  is  decided  on,  a  median 
incision  above  the  umbilicus  will  enable  the  operator  to  palpate 
the  pancreas  and  to  locate  any  incipient  collection  of  pus,  which,  if 
practicable,  should  then  be  evacuated  by  a  posterior  incision  in 
the  left  or  right  costo-vertebral  angle.  If  the  posterior  incision  is 
thought  impracticable,  the  collection  of  pus  may  be  removed  by 
aspiration  and  the  cavity  opened  and  packed  with  gauze,  which 
may  be  brought  forwards  through  a  large  rubber  tube,  which 
procedure  will,  in  the  course  of  twenty-four  to  forty-eight  hours, 
establish  a  track  isolated  from  the  general  peritoneal  cavity. 

In  abscess  of  the  pancreas,  which  usually  assumes  the  form  of 
subacute  pancreatitis,  and  which  we  must  distinguish  from  the 
acute  suppurative  pancreatitis  where  the  pus  is  diffused  through 
the  gland,  or  where  the  abscesses  are  small  and  multiple,  the 
suppurating  process  is  limited  by  a  pouring  out  of  lymph,  so  that 
should  the  patient  survive  the  initial  more  acute  stage  and  a 
discovery  of  the  pus-containing  cavity  is  made,  the  condition  is  one 
decidedly  amenable  to  treatment  by  drainage.  The  anatomical 
relation  will  readily  explain  the  course  along  which  the  pus  burrows 
should  it  burst  through  its  lymph  barriers ;  for  instance,  in  one 
case  an  abscess  formed  and  was  opened  in  the  right  loin  of  a  young 
man,  aged  twenty-four  years,  that  had  been  mistaken  for  a  perirenal 
abscess,  yet  the  kidney  was  quite  healthy  and  the  grumous  pus  had 


Subacute  Pancreatitis.  721 

come  from  the  pancreas  and  passed  behind  the  peritoneum  covering 
the  second  part  of  the  duodenum  :  the  patient  recovered  completely. 
In  another  case  an  abscess  was  opened  in  the  left  iliac  region  that 
had  apparently  started  from  the  body  of  the  pancreas,  and  which 
had  burrowed  in  the  same  way  behind  the  peritoneum.  The 
patient  recovered  from  the  operation,  but  developed  trouble  in  the 
left  side  of  the  thorax  and  died  suddenly  several  weeks  later.  In 
one  case  the  abscess  was  subphrenic.  In  another,  where  the 
symptoms  were  rather  acute  and  the  patient  was  extremely  ill,  pus 
was  discovered  between  the  liver  and  the  stomach,  and  although 
drainage  was  apparently  complete,  the  patient  succumbed  in  a  few 
days  to  exhaustion  due  to  the  septic  process  that  had  been  initiated 
before  the  abscess  was  opened.  In  two  other  cases  the  sequence  of 
suppurative  catarrh,  abscesses  of  the  pancreas  were  successfully 
drained  through  a  tube  in  the  common  bile  duct  after  removing  the 
gall-stones  which  had  obstructed  Wirsung's  duct.  In  one  of  these 
cases  the  patient,  a  woman,  aged  seventy-two,  recovered  completely. 
The  other,  a  man,  aged  forty,  recovered  from  the  operation,  but 
three  months  afterwards  died  from  exhaustion,  and  at  the  necropsy 
the  empty  abscess  cavity  was  discovered  in  the  head  of  the 
pancreas,  the  rest  of  the  gland  being  affected  with  chronic 
interstitial  inflammation.  In  one  case — in  a  man,  aged  thirty-five 
years — a  pancreatic  abscess  burst  into  the  stomach,  setting  up 
acute  gastritis,  the  condition  having  been  proved  by  an  exploratory 
operation.  It  was  treated  by  gastro-enterostomy  to  drain  away  the 
foul  stomach  contents.  The  patient  is  now  quite  well,  eight  years 
later.  In  another  case,  in  a  married  woman  aged  twenty-six,  the 
abscess  apparently  burst  into  the  bowel,  and  though  recovery  was 
tardy,  she  ultimately  got  well  without  operation.  The  diagnosis 
was  made  from  the  symptoms  and  by  an  examination  of  the 
swollen  pancreas  under  an  anaesthetic  and  subsequently  by  the 
presence  of  a  pancreatic  reaction  in  the  urine.  It  is  important  in 
these  cases  to  see  that  the  cause  is  removed,  if  that  be  possible — for 
instance,  gall-stones  or  pancreatic  calculi — so  that  if  recovery  occurs 
there  may  be  no  fear  of  relapse. 

It  will  thus  be  seen  that  out  of  eight  cases  of  abscess  of  the 
pancreas,  seven  were  operated  on,  with  recovery  from  operation  in 
five,  though  in  one  of  the  cases  the  relief  was  only  for  a  few  weeks 
and  in  another  for  a  few  months. 

When  inflammation  of  the  pancreas  has  ended  in  abscess,  chronic 
interstitial  pancreatitis  will  also  probably  be  present,  as  was  shown 
at  the  necropsy  of  one  case  that  died  some  months  subsequently. 
It  is  possible  that  in  some  cases  the  interstitial  change  may  be 

S.T.— VOL.  n.  46 


722  Subacute  Pancreatitis. 

local,  though  in  others  it  will  be  general,  and  may  then  lead  to 
atrophy  of  the  gland  and  to  glycosuria. 

A  search  through  literature  reveals  a  considerable  number  of 
pyaemic  abscesses  of  the  pancreas,  but  those  resulting  from  subacute 
pancreatitis  have  been  rarely  recorded.  Besides  seven  operations 
for  abscess  of  the  pancreas  with  two  deaths  above  referred  to,  there 
have  been  seven  others  recorded  with  three  deaths.  Thus,  of  fourteen 
cases  five  died,  giving  a  mortality  of  35'6  per  cent. 

A.  W.  MAYO-ROBSON. 


723 

CHRONIC   PANCREATITIS. 

BEFORE  considering  either  the  "medical  or  surgical  treatment  of 
pancreatitis  the  importance  of  preventive  treatment  must  be  insisted 
on  by  attention  to  the  causes,  some  of  which,  such  as  gall-stones,  are 
removable  by  operation  in  the  very  early  stages  with  a  very  small  risk, 
certainly  not  more  than  1  per  cent,  in  skilled  hands.  Duodenal 
catarrh  as  a  cause  of  pancreatic  catarrh  and  of  interstitial  pan- 
creatitis is  remediable  by  medical  treatment ;  and  duodenal  ulcer, 
another  cause,  if  not  remedied  by  careful  and  thorough  general 
treatment,  can  be  cured  by  gastro-enterostomy  with  a  very  small  risk. 
If  after  a  fair  trial  of  general  treatment,  care  in  diet,  wet  packs  to 
the  epigastrium,  rest,  and  mild  mercurial  purges,  not  too  long 
continued,  the  symptoms  persist  and  the  signs  of  failure  in 
pancreatic  digestion  and  metabolism  are  manifesting  themselves, 
the  question  of  surgical  treatment  should  be  seriously  considered, 
especially  when  the  disease  is  associated  with  jaundice,  for  the 
condition  is  one  that,  if  not  relieved  early,  will  certainly  lead  to 
serious  degeneration  of  both  the  liver  and  pancreas,  and  become 
dangerous  to  life  in  several  ways. 

Rational  treatment  should  aim  at  the  cause,  whether  that  be  gall- 
stones, pancreatic  calculi,  duodenal  catarrh,  duodenal  or  gastric  ulcer, 
alcoholism  or  syphilis. 

In  operating  for  chronic  pancreatitis,  when  medical  treatment  has 
failed  to  relieve,  the  surgeon  must  be  prepared  to  do  a  thorough 
operation  so  as  to  expose  the  whole  length  of  the  common  bile  duct 
;is  well  as  the  head  of  the  pancreas.  He  will  then  be  able  to  remove 
the  cause,  should  it  prove  to  be  a  gall-stone,  or  a  pancreatic  calculus, 
or  any  other  removable  condition.  In  the  absence  of  some  obvious 
removable  cause,  it  is  advisable  to  secure  efficient  drainage  of  the 
infected  bile  duct  and  pancreatic  duct,  either  by  cholecystotomy  or 
cholecyst-enterostomy,  preferably  the  latter.  Where  the  pancreatic 
disease  is  dependent  on  duodenal  catarrh  associated  with  ulcer  of 
the  duodenum,  it  may  be  advisable  at  the  same  time  that  the  bile 
passages  are  drained  to  perform  also  a  gastro-enterostomy  in  order 
to  cure  the  original  cause  of  the  disease.  Experience  has  taught 
that  if  the  cause  can  be  removed  at  an  early  stage  an  absolute  cure 
is  possible ;  and  though  restoration  of  the  damaged  gland  in  more 
advanced  cases  cannot  always  be  promised,  yet  the  arrest  of  the 
morbid  process  may  be  looked  for,  and  the  remaining  portion  of  the 
pancreas  will  be  able  to  carry  on  the  metabolic  and  even,  if  in- 
completely, the  digestive  functions  of  the  gland. 

A.  W.  MAYO-ROBSON. 
46-2 


724 


PANCREATIC   CALCULI. 

RELIEF  to  pain  may  be  given  by  sedatives,  and  other  treatment 
must  be  adopted  as  occasion  arises,  but  as  soon  as  pancreatic  stones 
can  be  diagnosed,  they  should  be  removed,  as  destruction  of  the 
pancreas  is  otherwise  certain,  and  it  is  quite  clear  that  medical 
treatment  can  do  no  real  good  in  these  cases. 

Surgical  treatment  has  until  quite  recently  been  merely  palliative, 
but  fortunately  it  now  offers  a  reasonable  hope  of  cure. 

Operation     of     Pancreo-lithotomy.  —  Eor    the    purpose    of 

removing  calculi  from  the  pancreas  an  incision  1  inch  to  the  right 

of   the  middle  line  above  the  umbilicus  will  be  found  the  most 

convenient,  as  the  fibres  of  the  right  rectus  can  be  split,  or  better, 

the  rectus  drawn  outwards,  and  the  incision  lengthened  upwards 

and  downwards  without  necessarily  weakening  the  abdominal  wall. 

A  sand-bag  under  the  lumbar  spine  will  bring  the  gland   several 

inches  nearer  the  surface.     If  the  opening  of  the  duct  of  Wirsung 

has  to  be  explored,  the  second  part  of  the  duodenum  may  be  incised 

and  the  papilla  common  to  the  bile  duct  and  pancreatic  duct  laid 

open,  when  the  edge  of  the  opened  diverticulum  of  Vater  can  be 

seized  with  small  catch  forceps  and  drawn  to  the  surface  ;  a  probe  or 

fine  forceps  can  then  be  readily  passed  into  Wirsung's  duct  and  the 

concretions  removed.      If  the  .calculi  are  more  deeply  placed  in  the 

ducts,   the   pancreas   may   be  exposed  either  through  the  gastro- 

hepatic  omentum  by  drawing  the  stomach  downwards,  or  by  lifting 

the  stomach  it  may  be  reached  through  a  slit  in  the  omentum  or  by 

raising  the  colon,  by  a  slit  in  the  transverse  meso-colon ;  or  by 

freeing  the  duodenum  from  the  parietes  the  back  of  the  pancreas  may 

be  readily  reached.     The  calculi  may  be  then  cut  down  on  and 

extracted  by  scoop  or  forceps.     Any  bleeding  must  be  arrested  by 

ligatures.     The  duct  can  be  sutured  and  the  incision  in  the  gland 

must  be  brought  together  by  buried  sutures,  the  peritoneal  covering 

being  coapted  by  a  continuous  suture.     If  leakage  is  feared,  a  gauze 

drain  may  be  applied ;  but  the  position  may  be  difficult  for  this, 

and  if  it  has  to  be  done,  the  gauze  must  be  surrounded  by  a  rubber 

drainage  tube  and  brought  through  it  to  the  surface.     In  a  case  of 

pancreo-lithotomy  in  which  I  removed  a  calculus  from  the  centre 

of  the  pancreas,  the  closure  of  the  gland  was  so  secure  as  not  to 

require  gauze  packing,  and  the  result  justified  its  not  being  used. 


Pancreatic  Calculi.  725 

When  the  duodenum  is  opened  it  must  be  closed  in  the  usual  way 
by  a  muco-muscular  and  serous  suture,  the  latter  being  of  fine 
cellulose  thread.  The  incised  papilla  need  not  be  sutured.  If  a 
calculus  is  felt  in  the  head  of  the  gland  but  not  in  the  duct  of 
Wirsung,  it  may  be  reached  by  incising  the  peritoneum  over  the 
duodenum  and  separating  it  gently  from  the  head  of  the  pancreas, 
or  if  more  deeply  placed  near  the  back  of  the  gland,  the  reflection  of 
peritoneum  from  the  duodenum  to  the  abdominal  wall  may  be 
incised  and  the  duodenum  may  then  be  displaced  inwards,  when 
the  back  of  the  pancreas  will  be  exposed  and  if  thought  advisable  it 
may  be  incised  and  treated  as  in  the  incision  from  the  front. 

A.  W.  MAYO-ROBSON. 


726 


PANCREATIC   CYSTS. 

IT  is  quite  clear  that  medical  treatment  can  be  of  no  avail  in  the 
case  of  pancreatic  cysts,  and  that  surgical  treatment  alone  is 
available  for  relief  or  cure. 

Aspiration  and  other  forms  of  tapping  are  inadequate  and 
ineffectual  methods,  which  are  attended  with  more  danger  than  is 
the  operation  of  incision  and  drainage.  They  are  therefore  not  to 
be  recommended  even  for  diagnostic  purposes.  Occasionally  com- 
plete extirpation  of  the  cyst  may  be  performed  as  in  a  case  that 
came  under  my  care  where  the  tumour  returned  a  few  months  after 
it  had  been  apparently  successfully  treated  by  drainage,  and  in 
another  case  recently  operated  on  where  haemorrhage  at  the  time 
of  operation  caused  some  anxiety,  though  the  ultimate  issue  was 
good.  But  the  greater  difficulty  in  performing  excision,  its  imprac- 
ticability in  certain  cases  and  the  greater  mortality  attending  it,  as 
compared  with  the  operation  of  incision  and  drainage,  make  it  quite 
clear  that  drainage  should  always  have  a  fair  trial  unless  the 
circumstances  prove  to  be  very  exceptional,  as,  for  instance,  in  the 
case  of  a  cyst  of  the  tail  of  the  pancreas,  or  in  the  case  of  a 
pedunculated  cyst. 

As  to  the  situation  for  drainage,  that  will  depend  on  circum- 
stances. The  tumour  will  usually  be  attacked  most  readily  from 
the  front,  at  a  point  where  it  very  nearly  reaches  the  surface. 
Occasionally,  however,  it  may  be  drained  from  the  loin. 

Fistula  does  not,  as  a  rule,  follow  the  drainage  of  pancreatic 
cysts,  but  in  some  cases  a  small  fistula  may  persist  and  may  go 
on  for  years  without  hurt  to  the  patient  and  with  very  [little 
discomfort. 

The  following  is  a  description  of  the  operation  usually  per- 
formed :  An  incision  is  made  through  the  parietes  opposite  the  njost 
prominent  part  of  the  cyst.  When  the  peritoneum  is  opened,  the 
finger  can  be  employed  to  ascertain  the  relations  of  the  cyst  and  its 
attachments.  If  the  stomach  is  in  front  of  the  cyst,  it  will  be 
better  to  displace  that  viscus  upwards  and  to  make  a  slit  through 
the  great  omerjtum  in  order  to  expose  the  cyst  wall ;  if  the  colon  is 
in  front,  it  may  be  displaced  downwards.  But  no  rule  can  be 
formulated,  as  the  cyst  must  be  reached  in  the  most  convenient  way, 
and  that  can  be  ascertained  only  when  the  abdomen  is  open.  By 


Pancreatic  Cysts.  727 

means  of  an  aspirator  the  fluid  is  then  drawn  off  and  an  opening 
made  in  the  cyst  sufficiently  large -to  allow  of  a  drainage  tube  being 
inserted.  The  tube  may  then  be  fixed  to  the  margin  of  the  incision 
in  the  cyst  by  a  single  catgut  suture,  and  if  the  opening  into  the 
cyst  is  surrounded  b}-  a  purse-string  suture  which  can  be  tightened 
around  the  tube,  all  fear  of  leakage  from  the  cyst  into  the 
peritoneal  cavity  is  avoided.  Any  vessels  coursing  over  the  cyst 
must  be  avoided,  but  should  an  artery  or  vein  be  pricked  it  must 
be  caught  between  pressure  forceps  and  ligatured. 

The  edge  of  the  cyst  may  then  be  fixed  to  the  aponeurosis  by 
three  or  four  sutures,  but  it  is  better  not  to  attach  it  to  the  skin. 
The  abdomen  is  then  closed,  and  if  the  tube  is  sufficiently  long  it 
will  readily  drain  into  a  bottle  containing  some  antiseptic  fluid.  If, 
on  exploration,  the  cyst  is  found  to  have  a  narrow  attachment  to 
the  pancreas  and  the  adhesions  are  not  too  extensive,  it  may 
possibly  be  shelled  out,  or  the  pedicle  may  be  ligatured,  but  this  is 
rarely  feasible. 

Some  surgeons  have  suggested  the  desirability  of  fixing  the  cyst 
to  the  surface  and  only  opening  it  after  a  few  days,  when  adhesions 
have  formed,  but  the  operation  <i  deux  temps  seems  to  be  quite 
unnecessary. 

Statistics. — In  the  cases  that  I  have  personally  operated  on,  two 
cysts  were  enucleated,  recovery  following ;  drainage  was  carried 
out  in  ten  cases  of  true  cyst,  recovery  following  in  nine,  whereas  of 
two  pseudo-cysts,  one  due  to  traumatic  heemorrhagic  pancreatitis 
and  the  other  to  necrotic  pancreatitis,  one  recovered. 

Out  of  the  160  cases  of  operation  recorded  by  others  there  were  140 
recoveries ;  in  four  cases  the  ultimate  issue  was  doubtful ;  in  eight 
out  of  the  140  reported  recoveries  after  operation  the  patients 
died  subsequently — one  from  diabetes  four  months  later,  one  from 
haemorrhage  one  and  a  half  years  later,  one  from  concomitant 
peritonitis  seven  weeks  later,  one  from  zymotic  fever  a  few  weeks 
later,  and  three,  from  causes  not  stated,  a  few  weeks  later.  Death 
is  recorded  as  the  result  of  operation  in  twenty  cases.  In  five  of 
these  the  cause  of  death  and  the  time  after  operation  are  not  given. 
One  patient  died  in  collapse,  one  died  before  operation  could  be 
completed  (the  next  day),  one  died  from  "  ileus,"  one  died  eighteen 
days  after  operation  (cause  not  stated),  two  died  from  shock,  one 
died  from  gangrene  of  the  pancreas,  and  eight  died  at  an  interval 
not  stated,  one  after  ninety-six  hours,  one  after  six  days,  one  after 
an  exploratory  incision,  two  after  two  days,  one  on  the  eighth  day, 
and  one  on  the  second  day.  In  138  cases  incision  and  drainage 
were  performed,  with  sixteen  deaths,  equal  to  a  mortality  of  11*6  per 


728  Pancreatic  Cysts. 

cent.  In  fifteen  excision  was  performed  with  three  deaths,  equal  to 
a  mortality  of  20  per  cent.  In  seven  partial  excision  was  done,  with 
one  death,  equal  to  a  mortality  of  14'3  per  cent. 

The  evidence  is  clearly  in  favour  of  drainage,  but  the  mortality 
should  be  reduced  by  at  least  one-half. 

A.  W.  MAYO-ROBSON. 


729 


CANCER    OF    THE    PANCREAS. 

MEDICAL  treatment  must  be  purely  symptomatic ;  morphia,  if 
needed,  for  the  relief  of  pain,  calcium  chloride  for  the  prevention 
of  haemorrhage,  pancreatic  extract  to  assist  digestion  and  other 
remedies  for  symptoms  as  they  arise.  Surgical  treatment  is  not 
very  hopeful  and  has  usually  been  undertaken  under  the  idea  that 
the  cause  of  the  jaundice  might  be  a  removable  one,  or  that 
drainage  of  the  bile  ducts  might  afford  relief  to  the  jaundice,  but  if 
the  disease  has  involved  the  head  of  the  pancreas  treatment  can 
only  be  palliative. 

Treatment  may  be  radical  or  palliative.  Ruggi,  of  Bologna, 
removed  through  the  loin  a  cancer  of  the  pancreas  weighing 
23  oz.  It  was  probably  growing  from  the  tail  of  the  gland. 
Complete  recovery  followed,  and  the  patient  was  well  for  three 
months,  after  which  secondary  disease  developed  and  the  patient 
died  at  the  end  of  six  months.  Cades's  was  the  second  successful 
case,  in  1895,  a  tumour  of  the  tail  of  the  pancreas  of  the  size  of  a 
child's  head  being  removed.  Terrier,  in  1892,  removed  a  tumour 
weighing  5  lb.,  but  lost  his  patient.  Of  seventeen,  operations 
for  removal  of  solid  tumours  of  the  pancreas,  nine  recovered 
from  operation,  which,  considering  the  difficulty  of  the  operation 
and  the  depth  of  the  organ  to  be  operated  on,  is  better  than 
one  would  have  expected.  Where  the  after-histories  have  been 
recorded,  the  disease  recurred  within  a  few  months  in  all  the 
malignant  cases.  Successful  pancreatectomies,  it  will  be  seen,  are 
exceptional  and  are  feasible  only  when  the  growth  is  not  involving 
the  head  of  the  gland ;  they,  however,  clearly  demonstrate  that  a 
tumour  of  the  body  or  of  the  tail  of  the  pancreas  may  be  removed 
with  equal  chance  of  recovery,  and  should  the  disease  be  primary 
and  no  secondary  growths  or  glandular  involvement  have  occurred, 
great  prolongation  of  life  is  quite  possible. 

The  palliative  operation  of  cholecyst-enterostomy  for  the  relief  of 
jaundice  in  cancer  of  the  head  of  the  pancreas  is  well  worth  trying, 
if  the  patient  is  seen  at  a  fairly  early  stage  of  the  disease.  I  have 
operated  on  over  thirty  of  these  cases.  Many  of  them  were  too  far 
advanced  to  hope  for  anything  more  than  merely  temporary  relief, 
but  in  some  of  the  less  advanced  cases  life  has  been  prolonged  in 
comfort  for  many  months  or  even  into  the  second  year. 

A.  W.  MAYO-ROBSON. 


730 


AFFECTIONS  AND   DISEASES   OF  THE 
KIDNEY  AND  URETER. 

URINARY  DISORDERS. 

ACETONURIA. 

ACETONURIA  is  a  symptom  of  a  profound  disturbance  of  metabolism 
which  occurs  as  a  complication  of  a  number  of  morbid  states,  and 
which  results  in  the  formation  of  /3-oxybutyric  acid,  often  in  large 
amounts,  by  the  breaking  down  of  fats  and  proteins.  I^rom 
/3-oxybutyric  acid  aceto-acetic  acid  is  readily  formed,  and  from 
aceto-acetic  acid  acetone,  as  the  respective  formulae  show : 

CHS  CH8  CH8 

CHOH  CO  CO 

CH2  CH2  CH8 


'COOH  COOH 

j8-oxybutyric  Aceto-acetic  Acetone, 

acid.  acid. 

No  simple  clinical  test  is  available  for  the  detection  of  /3-oxy- 
butyric acid,  but  aceto-acetic  acid  yields  the  familiar  ferric  chloride 
reaction  of  Gerhardt,  and  acetone  is  readily  detected  by  the  nitro- 
prusside  tests  of  Legal  and  Eothera. 

Mere  withdrawal  of  carbohydrates  from  the  diet  of  a  healthy 
man,  and  d  fortiori  abstinence  from  all  food,  suffices  to  cause 
acetonuria.  Of  morbid  states  diabetes  is  that  in  which  the 
metabolic  disturbances  which  underlie  acetonuria  play  the  most 
conspicuous  part.  As  regards  carbohydrates  the  diabetic  subject 
may  be  said  to  starve  in  the  midst  of  plenty,  for  although  his 
blood  is  rich  in  sugar,  he  has  lost,  to  a  greater  or  less  extent,  his 
power  of  utilising  it.  The  bodies  of  the  acetone  group  are  believed 
to  play  the  leading  role  in  the  causation  of  diabetic  coma. 

Persistent  vomiting,  from  whatever  cause,  also  tends  to  induce 
acetonuria,  to  employ  this  term  in  the  widest  sense  as  including  the 
excretion  of  all  the  members  of  the  acetone  group,  and  the  condition 
is  seen,  in  a  very  pronounced  form,  in  the  rare  affection  of  children 
known  as  cyclic  vomiting.  There  can  be  no  question  that  acetonuria, 


Acetonuria.  731 

and  the  acidosis  of  which  it  is  a  symptom,  are  much  more  readily 
induced  in  children  than  in  adults.  The  aeetonuria  of  delayed 
chloroform  poisoning  may  also  be  due  to  vomiting,  which  is  a  leading 
symptom.  The  fatty  condition  of  the  liver  which  is  met  with  alike  in 
cyclic  vomiting,  in  delayed  chloroform  poisoning  and  in  diabetes,  may 
also  be  ascribed  to  excessive  mobilisation  of  fats.  However,  it  is 
difficult  to  reconcile  clinical  experience  with  the  view  that,  in  the 
conditions  under  consideration,  the  carbohydrate  starvation  which 
results  from  persistent  vomiting  is  the  sole  cause  of  the  acetonsemia, 
for  in  some  cases  there  is  much  acetone  and  aceto-acetic  acid  in  the 
urine  at  an  early  stage  of  the  attack,  whereas  in  some  other  cases 
in  which  there  is  frequent  and  continuous  vomiting  acetonuria 
is  absent.  Nor  is  it  easy  to  explain  on  such  a  theory  the 
frequent  occurrence  of  acetonuria  in  children  suffering  from 
broncho-pneumonia. 

If  the  primary  causal  condition  is  itself  amenable  to  treatment 
the  most  effectual  means  of  coping  with  the  acetoneemia  will  be 
the  removal  of  its  cause,  but  this  is  not  always  possible ;  and 
acidosis,  in  itself,  is  so  serious  a  trouble,  and  in  its  extreme  forms  so 
threatening  to  life,  as  to  call  for  special  therapeutic  measures.  We 
are  compelled  to  treat  the  disease  within  the  disease. 

In  discussing  the  measures  to  be  employed  it  must  be  borne  in 
mind  that  the  bodies  of  the  acetone  group  have  little  specific  toxic 
action,  and  that  the  observed  effects  depend  upon  the  acid  pro- 
perties of  the  more  important  members  of  the  group.  For  their 
neutralisation  the  fixed  alkalies  tend  to  be  withdrawn  from  the 
blood  and  tissues.  Nature  herself  makes  an  attempt  to  combat 
the  mischief,  for  in  carnivorous  animals  and  in  man  a  protective 
mechanism  has  been  evolved,  and  some  of  the  ammonia  which 
normally  goes  to  the  formation  of  urea  is  intercepted  and  employed 
to  neutralise  the  abnormal  acids,  and  thus  the  fixed  bases  are  spared 
to  some  extent.  In  vegetivora,  on  the  other  hand,  which,  owing  to 
the  nature  of  their  diet,  are  little  liable  to  acidosis,  this  protective 
mechanism  is  not  developed.  Hence  it  comes  about  that,  in  man, 
when  acetonuria  is  present  the  excretion  of  ammonia  in  the  urine 
is  unusually  large  and  varies  according  to  the  quantities  of  acid  to 
be  neutralised,  whereas  when  fixed  alkalies  are  given  by  the  mouth 
the  output  of  ammonia  is  thereby  diminished,  there  being  less  call 
upon  the  protective  mechanism.  Conversely  in  any  given  case,  a 
decrease  of  the  excreted  ammonia  after  the  administration  of  a 
fixed  alkali  has  been  accepted  as  evidence  that  the  previous  excess 
of  ammonia  in  the  urine  was  due  to  acidosis. 

The  principles  upon  which  the  treatment  of  acetonaemia  is  based 


732  ,          Acetonuria. 

may  be  summed  up  as  follows  :  If  any  drug  is  being  taken  which 
is  capable  of  provoking  the  formation  of  the  acetone  bodies,  such 
as  a  salicylate  in  large  doses,  its  administration  should  at  once  be 
stopped.  If  there  is  persistent  vomiting  our  treatment  should  be 
mainly  directed  to  its  arrest.  If  there  is  reason  to  think  that 
carbohydrate  starvation  is  concerned  in  the  causation  of  the 
condition  we  should  strive  to  supply  the  need  for  this  class  of  food- 
stuffs ;  and  lastly,  fixed  alkalies  should  be  given  with  a  view  to 
controlling  the  drain  upon  the  fixed  alkalies  of  the  blood  and 
tissues. 

In  cases  of  diabetes,  in  some  of  which  such  acidosis  occurs  in  its 
most  pronounced  form,  we  are  in  a  less  favourable  position  for  its 
treatment  than  when  the  underlying  cause  is  a  temporary  one.  In 
such  cases  the  bodies  of  the.  acetone  group  are  being  formed  in  fresh 
quantities  as  fast  as  they  are  neutralised,  whereas  in  some  toxic 
conditions  their  formation  may  be  practically  at  an  end  before  treat- 
ment is  begun,  and  all  that  is  required  is  to  neutralise  the  acids 
already  in  circulation. 

The  treatment  of  diabetes  and  of  its  complications  is  discussed 
elsewhere  in  this  work,  and  it  will  suffice  to  point  out,  in  this  place, 
that  it  is  easier  to  bring  about  acetonaemia  by  a  rapid  reduction  of 
the  carbohydrates  of  the  diet  than  to  control  it  by  relaxation  of 
diet  when  danger  threatens. 

Sodium  bicarbonate  is  the  alkaline  drug  most  often  employed  in 
the  treatment  of  acidosis,  and  it  has  the  advantage  of  containing 
a  base  which  is  comparatively  innocuous,  an  important  consideration 
when  large  doses  are  required.  The  bicarbonate  may  be  adminis- 
tered in  large  and  frequently  repeated  doses,  according  to  the 
severity  of  the  case.  If  taken  for  long  the  necessary  doses  may 
upset  the  stomach,  but  they  are  usually  well  tolerated,  and  the 
difficulty  encountered  in  rendering  the  urine  alkaline  in  severe 
cases  bears  eloquent  testimony  to  the  quantities  of  acid  which  call 
for  neutralisation. 

In  non-diabetic  cases,  in  which  vomiting  is  a  prominent  symptom, 
it  may  be  necessary  to  give  sodium  bicarbonate  by  the  rectum,  or 
even  to  inject  a  dilute  solution  intravenously.  In  such  cases  sugar 
may  also  be  administered  by  the  mouth  or  by  the  bowel.  It  must 
be  remembered  that  no  inverting  ferment  is  present  in  the  lower 
bowel,  and  it  is  therefore  necessary,  in  rectal  administration,  to 
administer  a  monosaccharid  such  as  glucose,  since  disaccharids 
such  as  cane-sugar  and  lactose  cannot  be  dealt  with. 

In  cases  of  diabetes  the  question  whether  dietary  restrictions 
should  be  relaxed  when  acidosis  threatens,  and  if  so  to  what  extent, 


Albumosuria  and  Peptonuria.  733 

is  one  of  no  small  difficulty,  and  upon  which  opinions  differ.  In 
some  cases  laevulose  is  comparatively  well  dealt  with,  and  may 
prove  a  valuable  aid  in  the  relief  of  carbohydrate  starvation.  In 
spite  of  certain  theoretical  difficulties,  the  fact  remains  that  some, 
but  only  some,  diabetic  patients  from  whose  urine  sugar  has  dis- 
appeared under  a  strict  dietary  regimen,  can  take  considerable  doses 
of  laevulose  without  passing  sugar.  That  the  Isevulose  is  actually 
utilised  in  such  cases  is  shown  by  its  effect  upon  the  respiratory 
quotient. 

Lastly,  as  Otto  Neubauer  has  suggested,  alcohol,  with  its  high 
calorie  value,  may  lend  material  aid  in  restricting  the  breaking 
down  of  the  tissues  from  which  the  acetone  bodies  are  formed,  and 
so  counteract  to  some  extent  the  tendency  to  acidosis. 

ALBUMINURIA. 

The  excretion  of  albumin  in  the  urine,  although  one  of  the  most 
important  of  symptoms,  and  often  a  valuable  guide  to  treatment, 
in  itself  hardly  calls  for  therapeutic  measures.  Even  in  cases  of 
parenchymatous  nephritis,  in  which  the  output  of  albumin  in  the 
urine  is  greatest  and  may  continue  over  long  periods,  the  loss  of 
protein  involved  is  of  quite  subsidiary  importance,  as  compared  with 
the  failure  of  the  excretory  functions  of  the  kidneys  by  which  it  is 
accompanied.  From  time  to  time  drugs,  such  as  rosaniline  and  the 
salts  of  strontium,  have  been  recommended  as  tending  to  diminish 
the  loss  of  albumin,  but  their  use  has  not  been  attended  with  any 
conspicuous  success. 

On  the  other  hand,  Sir  Almroth  Wright  has  shown  that  the 
administration  of  calcium  lactate  is  capable  of  arresting  the 
albuminuria  in  cases  of  the  so-called  functional  kind,  in  which,  as 
he  has  found,  the  coagulability  of  the  blood  is  lowered  and  clotting 
is  delayed.  However,  this  is  important  rather  as  affording  a  test 
for  the  differentiation  of  functional  albuminuria  from  that  due  to 
organic  lesions  of  the  kidneys  than  as  a  method  of  treatment. 

The  calcium  lactate  may  be  administered  in  a  dose  of  60  gr.,  or 
in  a  few  doses  of  20  gr.  each,  and  if  the  case  is  functional,  the 
albumin  should  disappear  from  the  urine  in  a  few  hours  or  a  few 
days.  In  cases  of  nephritis,  on  the  other  hand,  the  albuminuria  is 
not  affected  by  the  taking  of  the  drug. 

ALBUMOSURIA  AND  PEPTONURIA. 

The  excretion  of  proto-  and  deutero-albumoses,  often  spoken  of 
as  peptonuria,  is  often  associated  with  albuminuria,  from  which  it  has 
a  quite  different  significance,  for  it  points  to  morbid  conditions  behind 


734  Cystinuria. 

the  kidneys.  Albumosuria  appears  to  be  an  indication  of  abnormal 
protein  breakdown,  such  as  occurs  during  involution  of  the  uterus 
or  the  resolution  of  a  pneumonic  lung.  It  does  not  in  itself  call  for 
treatment,  nor  does  it  afford  any  clear  indication  for  the  treatment 
of  conditions  to  which  it  is  due. 

ALKAPTONURIA. 

This  very  rare  anomaly  of  protein  metabolism  is  usually  present 
from  birth,  and  persists  through  life.  It  is  little  amenable  to  and 
makes  no  strong  call  for  treatment.  It  is  becoming  evident  that  in 
later  life  alkaptonuric  subjects  are  very  liable  to  develop  the 
peculiar  pigmentation  of  the  cartilages,  and  in  some  cases  of 
surface  structures  also,  to  which  Virchow  gave  the  name  of 
ochronosis,  and  it  is  probable  that  the  chronic  osteo-arthritic 
changes  which  have  repeatedly  been  met  with  in  the  subjects  of 
ochronosis,  are  causally  related  thereto.  These  are  the  only 
pathological  results  which  can  be  assigned  to  alkaptonuria. 

The  output  of  homogentisic  acid,  the  excretion  of  which  is  the 
characteristic  feature  of  the  condition,  can  be  considerably  reduced 
by  restriction  of  the  protein  intake,  but  even  during  fasting  or  on 
a  protein-free  diet  it  only  falls  to  about  half  its  normal  amount. 
The  lifelong  imposition  of  a  diet  very  poor  in  protein  is  certainly 
not  desirable,  merely  in  the  hope  that  by  such  a  diet  the  tendency 
to  develop  ochronosis  or  even  a  chronic  joint  trouble  in  later  life 
may  be  lessened  to  some  extent. 

If,  however,  as  occasionally  happens,  there  is  a  complaint  of 
dysuria,  temporary  restriction  of  protein  foods  may  be  thought 
desirable. 

CHYLURIA  (NON-PARASITIC). 

Of  the  pathology  of  that  variety  of  chyluria  which  is  not  due 
to  the  Filaria  sanguinis  hominis  little  is  known,  but  it  may  be 
presumed  that  in  some  way,  which  need  not  be  the  same  way  in  all 
cases,  a  communication  has  been  established,  as  in  the  parasitic  cases, 
between  the  lymphatic  system  and  the  urinary  tract.  Complete 
rest  will,  in  some  instances,  bring  about  an  arrest  of  the  chyluria, 
and  sometimes  over  so  long  a  period  that  one  is  tempted  to  hope 
that  the  communication  has  closed  and  that  a  permanent  cure  has 
been  brought  about.  However,  resumption  of  an  active  life  is  apt 
to  be  followed  by  a  relapse. 

CYSTINURIA. 

Cystinuria  is  one  of  the  conditions  which  leads  to  calculus  forma- 
tion, and  the  great  liability  of  its  victims  to  this  accident  gives  to 


Haematoporphyrinuria.  735 

this  anomaly  a  very  real  clinical  importance,  in  spite  of  its  extreme 
rarity. 

It  affords  strong  evidence  of '  the  working  of  other  factors 
besides  the  mere  excretion  of  a  sparingly  soluble  compound,  in  the 
causation  of  calculus  formation,  for  whereas  one  cystinuric  patient 
will  produce  a  constant  succession  of  stones,  in  other  cases,  and  even 
in  the  same  case  at  a  different  period,  cystin  may  be  excreted  in 
equal  quantities  for  years  and  yet  no  calculi  be  formed. 

Cystinuria  is  an  error  of  protein  metabolism  which  leads  to  the 
excretion  of  part  of  the  cystin  fraction  of  the  food  and  tissue  proteins 
unchanged.  It  is  probably  congenital  in  most  cases  and  persistent 
throughout  life,  but  in  some  cases  appears  to  be  ternpdrary.  The 
mere  fact  that  crystals  of  cystin  cease  to  be  deposited  from  the  urine 
must  not  be  taken  as  proof  that  the  excretion  of  that  substance  has 
ceased.  As  an  inborn  anomaly  it  is  little  amenable  to  treatment, 
and  its  cessation  in  some  cases  cannot  be  ascribed  to  any  therapeutic 
measures  adopted. 

Some  have  thought  that  the  administration  of  alkalies  has  proved 
beneficial,  by  reducing  the  acidity  of  the  urine,  and  so  the  readiness 
with  which  cystin  is  deposited  from  it. 

One  fact  definitely  established,  by  the  work  of  Alsberg  and  Folin, 
and  of  Wolf  and  Shaffer,  is  that  the  output  of  cystin  is  dependent, 
to  some  extent,  upon  the  intake  of  protein,  and  their  results  point 
to  the  desirability  of  prescribing  a  diet  comparatively  poor  in  protein 
constituents  for  sufferers  from  the  complaint.  However,  to  bring 
about  a  conspicuous  diminution  of  the  cystin  excreted  it  is  necessary 
to  put  the  patient  upon  a  diet  which  is  almost  protein  free,  and  such 
as  could  hardly  be  conformed  to  over  long  periods. 

It  must  be  confessed  that,  up  to  the  present,  we  have  at  our 
disposal  no  efficient  means  of  combating  this  metabolic  error. 

HAEMATOPORPHYRINURIA. 

The  name  "  haematoporphyrinuria  "  is  applied  to  the  excretion  of 
urine  of  various  tints,  from  that  of  tawny  port  wine  to  almost 
complete  blackness,  and  which  is  shown  by  spectroscopic  examina- 
tion to  contain  considerable  amounts  of  haematoporphyrin.  The 
colour  of  such  urines  is  chiefly  due  to  other  less  known  abnormal 
pigments  which  accompany  the  hsematoporphyrin. 

In  the  great  majority  of  cases,  such  haematoporphyrinuria 
results  from  the  administration  of  sulphonal  or  chemically  allied 
drags,  usually  in  medicinal  doses  and  over  considerable  periods. 
Occasionally  it  occurs  as  a  morbid  symptom,  apart  from  the  taking 


736  Haematuria. 

of  any  such  drug,  and  does  not  appear  to  have  any  very  serious 
import  in  such  circumstances. 

In  the  sulphonal  cases,  on  the  other  hand,  it  is  one  of  a  group 
of  toxic  symptoms  of  much  gravity  and  which  often  usher  in  a 
fatal  ending.  Of  these  symptoms  vomiting  and  abdominal  pain 
are  the  most  constant.  Curiously  enough,  this  condition  is  met 
with  almost  exclusively  in  females.  The  development  of  haemato- 
porphyrinuria  is,  in  not  a  few  cases,  the  earliest  toxic  symptom  ;  and 
for  practical  purposes  the  excretion  of  red  urine  by  a  patient  taking 
sulphonal  or  its  allies,  even  though  it  may  not  be  possible  to  carry 
out  the  necessary  examination  for  haematoporphyrin,  should  be 
regarded  as  a  danger  signal.  The  administration  of  the  drug 
should  immediately  be  stopped,  and  sodium  bicarbonate  should  be 
given  in  large  and  frequently  repeated  doses.  This  treatment,  with 
an  alkali,  which  was  originally  recommended  by  Franz  Miiller, 
appears  to  be  of  great  value,  and  the  writer's  experience  leads  him 
to  believe  that  it  not  unfrequently  averts  a  fatal  ending.  This 
suggests  that  the  condition  is  a  form  of  acidosis,  and  the  fact  that 
in  some  records  of  autopsies  the  liver  has  been  found  to  be  fatty, 
as  is  the  case  in  delayed  chloroform  poisoning  with  acetonuria, 
lends  support  to  this  view  of  its  pathology. 

HAEMATURIA. 

FEW  symptoms  of  disease  result  from  a  greater  variety  of  morbid 
conditions  than  does  haematuria.  Among  them  are  haemorrhagic 
fevers  and  other  haemorrhagic  diseases,  such  as  haemophilia  and 
scurvy,  nephritis  and  local  lesions  situated  in  the  kidneys  or  any 
part  of  the  urinary  tract,  including  calculus  formations,  injuries  to 
the  kidneys,  bladder  and  urethra,  and  certain  kinds  of  poisoning. 

In  some  cases  the  loss  of  blood  in  the  urine  is  so  large  that 
treatment  is  imperatively  demanded  for  its  arrest,  and  when 
possible  such  treatment  will  be  directed  to  the  cause  to  which 
haematuria  is  due.  The  first  desideratum  is  to  ascertain  if  possible 
in  what  part  of  the  urinary  tract  the  lesion  is  situated,  for  such 
profuse  haematuria  usually  has  a  local  origin.  For  this  purpose  the 
cystoscope  is  of  very  great  service,  since  by  its  means  it  is  possible 
to  ascertain  whether  the  blood  is  derived  from  the  bladder  or 
prostate,  and  if  it  has  a  higher  source,  whether  it  comes  from  one 
ureter  or  both.  If  the  source  can  be  localised  surgical  measures 
will,  as  a  rule,  be  required.  There  remains  a  class  of  case  in  which 
the  cause  of  profuse  haematuria  remains  obscure,  or  in  which  it  is 
due  to  some  general  disease  little  amenable  to  treatment,  or  again 
in  which  the  general  condition  of  the  patient,  or  doubt  as  to  the 


Lipuria.  737 

integrity  of  the  second  kidney,  is  held  to  contra-indicate  surgical 
treatment. 

In  such  cases  we  must  endeavour  to  control  the  loss  of  blood  by 
the  administration  of  styptic  drugs,  of  which  ergot  is  the  most 
commonly  employed.  In  haemophilia  or  other  conditions  in  which 
coagulation  of  the  blood  is  delayed  the  administration  of  calcium 
lactate  may  be  tried. 

If,  as  is  not  unfrequently  the  case,  the  haematuria  is  brought  on 
by  exertion  or  exercise,  mere  rest  may  prove  a  valuable  therapeutic 
measure. 

INDICANURIA. 

Indicanuria  is  a  symptom  which  affords  a  measure  of  protein 
decomposition  in  the  alimentary  canal  under  the  influence  of  the 
intestinal  bacteria.  The  parent  substance  of  the  indol  absorbed  is 
the  tryptophane  fraction  of  proteins.  After  absorption  the  indol 
is  oxidised  to  indoxyl,  which  is  excreted  in  the  urine,  for  the  most 
part  in  combination  with  sulphuric  acid  as  an  indoxyl  sulphate,  the 
so-called  urinary  indican,  and  in  small  part  as  indoxyl  glycuro- 
nates. 

Even  in  simple  obstinate  constipation  the  excretion  of  indican  is 
apt  to  be  conspicuously  above  the  normal,  as  also  in  any  condi- 
tion in  which  bacterial  decomposition  processes  are  abnormally 
active. 

Urine  rich  in  indican  is  usually  of  normal  tint,  but  in  some 
cases  it  is  rendered  brown  by  higher  oxidation  products  of  indol, 
and,  as  the  colour  becomes  much  darker  on  exposure  to  air,  such 
indicanuria  is  liable  to  be  mistaken  for  melanuria. 

It  is  stated  that  when  there  is  a  collection  of  foatid  pus  in  any 
cavity  of  the  body,  such  as  a  putrid  empyema,  indicanuria  may 
occur  apart  from  intestinal  decomposition.  In  a  case  of  empyema 
which  the  writer  has  observed,  in  which  the  foetid  pus  contained 
bacillus  coli  as  well  as  the  pneumococcus,  the  indicanuria,  which 
was  present,  disappeared  when  the  bowels  were  freely  evacuated  by 
a  dose  of  castor  oil. 

The  treatment  of  indicanuria  consists  in  the  administration  of 
purgatives,  and  preferably  of  such  as  have  an  antiseptic  action, 
such  as  calomel. 

LIPURIA. 

By  this  is  meant  the  excretion  of  fat  in  the  urine  as  an  isolated 
symptom,  and,  apart  from  chyluria.  Lipuria  is  chiefly  seen  after 
fractures  of  bones  and  sometimes  after  the  operation  of  osteotomy, 

S.T.— VOL.  ii.  47 


738  Lithuria. 

the  fat  being  presumably  derived  from  the  exposed  bone  marrow. 
Again,  lipuria  may  result  from  the  administration  of  large 
quantities  of  fat  by  the  mouth,  as  when  olive  oil  is  freely  given 
in  cases  of  cholelithiasis. 


LITHURIA. 

The  term  "lithuria  "  is  a  relic  of  an  age  of  less  exact  knowledge, 
which  owes  its  survival  to  the  difficulty  of  devising  any  euphonious 
name  which  shall  more  correctly  describe  the  phenomenon  to  which 
it  is  applied,  namely,  the  formation  in  the  urine  of  sediments  of . 
amorphous  urates,  or  of  the  familiar  crystals  of  uric  acid  which 
are  modified  in  their  tints  and  forms  by  included  urinary  pig- 
ments. 

Deposits  of  amorphous  urates  are  met  with  in  the  urine  of 
sufferers  from  many  diseases,  and  in  certain  circumstances  in  that 
of  healthy  persons,  especially  in  cold  weather.  As  they  form  only 
after  the  urine  has  been  passed  and  has  cooled  to  the  temperature 
of  the  air,  they  are  only  important  as  indicative  of  the  presence  of 
conditions  which  favour  the  passing  of  the  urates  out  of  solution. 
Such  sediments  must  not  be  regarded  as  affording  evidence  of  an 
excessive  output  of  uric  acid,  although  such  an  excess  in  a  given 
specimen  is  one  of  the  causes  which  favours  their  deposition.  Such 
an  interpretation  is  very  commonly  put  upon  the  uratic  sediments 
which  are  so  commonly  seen  in  the  urine  of  gouty  patients,  but 
elaborate  researches  have  shown  that  the  excretion  of  uric  acid  by 
the  gouty  differs  but  little  from  that  of  healthy  individuals,  and  that 
only  for  brief  periods  immediately  following  acute  attacks  is  there 
any  excessive  output  of  that  substance. 

On  the  other  hand,  deposition  of  crystalline  uric  acid  occurs,  not 
infrequently,  within  the  urinary  passages,  and  seeing  that  this 
substance  is  one  of  the  chief  constituents  of  urinary  calculi,  such 
a  formation  of  crystals  acquires  importance.  Even  the  presence  of 
the  crystals  as  such  may  give  rise  to  symptoms,  and  appears  to  be 
one  of  the  causes  of  hsematuria  in  infants. 

However,  such  crystals  may  be  passed  in  abundance  and  over 
long  periods  by  individuals  who  at  no  time  develop  calculi,  whereas 
the  subjects  of  uric  acid  calculus  formation  may  exhibit  no  special 
liability  to  the  deposition  of  crystals  in  their  urine.  There  can  be 
no  doubt  that  although  the  presence  of  one  of  the  sparingly  soluble 
calculus-forming  substances  is  a  necessary  condition  of  stone  forma- 
tion, and  such  materials  are,  of  course,  invariably  present  in  the 
urine,  something  more  is  required  to  determine  concretion.  This 


Lithuria.  739 

factor  is  almost  certainly  a  catarrhal  condition,  to  the  production 
of  which  the  irritant  action  of  the  crystals  may  contribute.  The 
analogous  formation  of  gallstones  suggests  the  possibility  or  even 
the  probability  of  a  bacterial  origin  of  the  catarrh. 

Excess  of  uric  acid  is  one,  but  only  one,  of  the  conditions  which 
favour  the  separation  of  uric  acid  crystals  in  urine.  In  some  cases 
of  leukaemia  in  which  the  output  of  uric  acid  may  greatly  exceed 
the  normal  limits,  abundant  crystalline  deposits  occur,  but  this 
disease  and  thymus  feeding  are  the  only  causes  of  such  excessive 
excretion,  although  a  like  phenomenon  of  minor  degree  is  observed 
in  pneumonia  and  other  morbid  states.  As  a  rule,  the  daily  output 
of  uric  acid  by  patients  whose  urine  forms  crystalline  sediments  is 
not  above,  and  may  even  be  below,  the  average. 

In  a  mixture  so  complex  as  the  urine  a  variety  of  factors  may 
contribute  to  diminish  the  solubility  of  a  particular  constituent. 
Among  these  the  reaction  holds  an  important  place.  From 
alkaline  or  amphoteric  urines  uric  acid  crystals  are  not  thrown 
down,  .whereas  the  addition  of  an  acid  determines  their  deposition 
from  any  specimen.  Concentration  also  plays  a  part,  a  relative 
excess  of  uric  acid  having  as  potent  an  influence  as  an  actual  excess. 
The  nature  of  the  salts  present  must  also  be  taken  into  considera- 
tion, and  Kleniperer  has  shown  that  the  essential  yellow  pigment  of 
urine,  urochrome,  has  an  inhibitory  influence,  so  that  the  crystals 
form  more  readily  in  specimens  in  which  that  pigment  is  but 
scantily  present.  It  is  probable  that  in  the  future,  when  the 
condition  of  calculus  formation  shall  be  better  understood,  we 
may  be  able  to  control  these,  and  possibly  the  good  effects 
obtained  in  the  treatment  of  patients  liable  to  stone  or  gravel  by 
certain  mineral  waters  may  be  in  no  small  measure  due  to  their 
effects  upon  the  urinary  tract.  At  present,  however,  our  efforts  are 
chiefly  directed  to  limiting,  on  the  one  hand,  the  excretion  of  the 
peccant  material,  and,  on  the  other  hand,  to  bringing  about  the 
conditions  favourable  to  its  being  held  in  solution. 

In  the  case  of  uric  acid,  a  limitation  of  output  can  be  effected 
only  by  limiting  the  intake  of  its  parent  substances,  the  nucleo- 
proteins  and  purin  bodies  of  the  diet.  It  is  possible  to  allow  the 
patient  to  have  a  diet  by  no  means  poor  in  proteins,  but  in  which 
the  nucleo-proteins  and  purin s  shall  be  but  sparingly  present. 
Thus,  as  Walker  Hall  points  out,  milk,  butter,  eggs  and  cheese 
contain  no  purin  nor  purin-yielding  substances,  or  quantities  so 
small  that  they  may  be  neglected. 

The  various  forms  of  meat  do  not  differ  widely  in  their  purin 
content,  as  the  figures  on  the  next  page,  given  by  Walker  Hall,  show : 

47—2 


740 


Lithuria. 


(Cod 
I  Plaice 
I  Halibut 
1  Salmon 

Mutton  . 

Veal 

Pork 

(Ribs 

Beef  |  Sirloin 
(Steak 

Chicken  . 

Turkey  . 


Undried  purins  as 
giimmes  per  kilo. 

0-582 

0-795 

1-020 

1-165 

0-965 

1-162 

1-212 

1-137 

1-305 

2-066 

1-295 

1-260 


It  will  be  noticed  that  the  distinction  so  commonly  drawn  between 
red  and  white  meats  finds  no  justification  in  their  respective  purin 
contents.  The  glandular  organs  are  comparatively  rich,  and  thymus 
gland,  included  as  sweetbread,  stands  pre-eminent  as  a  purin-rich 
food,  with  10'063  grammes  of  purin  per  kilogramme. 

The  general  indications  would  seem  to  be  to  take  meat  somewhat 
sparingly  when  a  reduction  of  the  uric  acid  is  aimed  at,  to  avoid 
beef  and  especially  beefsteak,  and  above  all  to  avoid  sweetbread. 
It  must  be  remembered,  however,  that  the  richness  of  a  food  in 
purin  substances  may  be  counteracted  to  some  extent  by  the  fact 
that  it  is  as  a  rule  partaken  of  but  sparingly.  Among  vegetable 
substances  peas,  beans,  oatmeal,  asparagus  and  onions  contain 
purins,  and  the  output  of  uric  acid  is  increased  when  they  are 
taken.  The  same  applies  to  the  various  beers  and  also  to  coffee, 
and  to  a  less  extent  to  tea.  Meat  extracts  should  be  excluded  from 
the  diet  list. 

Speaking  generally,  a  diet  such  as  appears  suitable  for  a  gouty 
subject,  who  has  an  accumulation  of  uric  acid  in  his  blood,  is 
applicable  in  cases  in  which  our  aim  is  to  reduce  the  risk  of 
deposition  of  uric  acid  in  the  urinary  passages  by  limiting  the 
output.  Only  the  exogenous  uric  acid  is  likely  to  be  so  affected  by 
treatment,  and  to  its  reduction  our  efforts  will  be  directed. 

Whereas  from  the  above  standpoint  vegetable  foods  are  for  the 
most  part  less  to  be  objected  to  than  animal,  they  have  the  further 
advantage  that,  by  reducing  the  acidity  of  the  urine,  they  tend  to 
hinder  the  precipitation  of  uric  acid.  Such  reduction  of  acidity 
is  also  readily  brought  about  by  the  direct  administration  of 
alkalies,  as  recommended  by  the  late  Sir  William  Koberts,  who 
specially  advised  the  giving  of  a  large  dose  of  potassium  citrate 
(40  to  60  gr.)  at  bedtime,  to  guard  the  night  hours,  during  which 
the  urine  excreted  is  most  concentrated,  is  more  highly  acid,  and 
stays  longer  in  the  bladder.  However,  experience  shows  that 
whereas  the  administration  of  alkalies  usually  suffices  to  arrest  the 


Melanuria.  741 

formation  of  amorphous  uratic  sediments,  its  effect  upon  the 
deposition  of  crystals  of  uric  acid  often  falls  short  of  our  hopes. 

Roberts  further  advised  that  the  meals  should  so  be  arranged  as 
to  take  full  advantage  of  the  alkaline  tide,  and  too  long  intervals 
should  not  be  allowed  between  meals. 

Water  may  be  freely  drunk,  either  several  glasses  of  hot  water  in 
the  day,  or,  better  still,  certain  mineral  waters,  such  as  those  of 
Contrexeville,  Vittel  or  Wildungen,  which  probably  act  beneficially 
in  other  ways  besides  merely  diluting  the  urine  and  so  hindering 
precipitation.  A  course  of  treatment  at  one  or  other  of  the  above 
spas  will  often  have  a  good  effect,  especially  if  signs  of  calculus 
formation  are  present  or  if  gravel  is  being  passed. 

Gee  has  recommended  the  drinking  of  several  cupfuls  of  whey  in 
the  day,  and  this  empirical  remedy,  for  he  did  not  attempt  to 
explain  its  action,  is  regarded  as  useful  by  not  a  few  sufferers  from 
uric  acid,  sand  and  gravel. 

Piperazine,  which  forms  a  very  soluble  urate,  and  in  aqueous 
solution  readily  dissolves  small  uric  acid  calculi,  loses  its  solvent 
power  when  dissolved  in  urine,  and  there  are  no  grounds  for 
believing  that  this  or  any  other  known  solvent  is  capable  of  effecting 
the  solution  of  a  calculus  in  situ. 

MELANURIA. 

The  name  "  melanuria  "  is  applied  to  the  excretion  of  urine  which 
has  the  following  properties  :  It  is  usually  of  normal  tint  when 
passed,  but  darkens  on  exposure  to  air,  becoming  brown  and  in  the 
end  quite  black.  The  addition  of  a  solution  of  ferric  chloride 
produces  immediate  blackening,  as  also  does  nitric  acid,  even  in  the 
cold.  Bromine  water  produces  a  yellow  or  brown  precipitate  which 
blackens  quickly,  and  the  addition  of  sodium  nitro-prusside  and 
liquor  potassse,  followed  by  acidification  with  acetic  acid,  causes  a 
deep  Prussian  blue  colour  to  develop. 

Melanuria  is  a  symptom  of  melanotic  growths  and  does  not  in 
itself  call  for  treatment,  neither  does  it  afford  an  indication  for 
treatment,  seeing  that  it  is  not  manifested  until  the  viscera,  and 
especially  the  liver,  are  invaded  by  secondary  growths  and  the 
case  is  beyond  the  reach  of  surgery. 

It  is  stated  that  melanuria  may  occur  apart  from  melanotic 
growths,  and  in  connection  with  marantic  conditions,  but  the 
recorded  cases,  upon  which  this  statement  is  based,  are  capable  of 
other  interpretations,  and  were  for  the  most  part  described  before 
the  more  distinctive  tests  for  melanuria  were  known.  Some  of 
them,  at  least,  appear  to  have  been  cases  of  indicanuria. 


742  Oxaluria. 

In  practice,  melanuria  requires  to  be  distinguished  from  indi- 
canuria  on  the  one  hand,  and  from  alkaptonuria  on  the  other. 
Both  these  conditions  are  to  be  recognised  by  simple  and  distinctive 
tests,  and  in  neither  is  the  blackening  with  ferric  chloride,  which  is 
the  most  satisfactory  test  for  melanuria,  to  be  obtained. 

OXALURIA. 

Crystals  of  calcium  oxalate  are  among  the  commonest  of  urinary 
sediments,  and  it  is  to  the  occurrence  of  abundant  deposits  of  such 
crystals  that  the  name  "  oxaluria  "  is  usually  applied.  Strictly  speak- 
ing, the  name  should  indicate  an  excessive  excretion  of  oxalic  acid, 
which  is  a  cause,  but  only  one  of  the  causes,  of  the  formation  of  the 
crystals,  for  they  may  be  present  in  numbers  in  cases  in  which 
the  output  of  the  acid  is  in  no  way  increased. 

The  view  which  was  widely  held  in  the  past  that  excessive 
excretion  of  oxalic  acid  is  the  salient  feature  of  a  metabolic  disorder 
which  gives  rise  to  a  well-defined  group  of  symptoms,  among  which 
acid  dyspepsia  and  mental  depression  take  a  prominent  place,  no 
longer  meets  with  any  general  acceptance.  The  deposition  of 
calcium  oxalate,  which  is  often  associated  with  hyperchlorhydria, 
is  now  regarded  as  a  secondary  event,  and  as  due  to  a  more 
abundant  absorption  of  oxalate  from  the  food  under  the  influence  of 
the  excess  of  hydrochloric  acid  in  the  stomach. 

On  the  other  hand,  our  knowledge  is  still  very  incomplete  of  the 
occurrence  of  excessive  excretion  of  endogenous  oxalic  acid  in 
morbid  states,  and  the  point  upon  which  information  is  chiefly  to 
be  desired  is  whether  there  are  individuals  who,  even  when  oxalic 
acid  is  eliminated  from  their  diet,  continuously  excrete  abnormally 
large  quantities  of  that  substance. 

Seeing  that  calcium  oxalate  is  one  of  the  commonest  constituents 
of  urinary  calculi,  the  conditions  which  determine  the  amount  of 
oxalic  acid  excreted  and  influence  the  solubility  of  calcium  oxalate 
in  the  urine  call  for  careful  consideration  with  a  view  to  their 
control.  Apart  from  stone  formation  oxaluria  has  little  clinical 
importance,  although  when  deposited  within  the  urinary  passages 
the  crystals,  if  abundant,  may  even  excite  haematuria,  as  witness 
the  hsematuria  which  sometimes  follows  the  free  consumption  of 
rhubarb  or  other  articles  of  diet  rich  in  oxalates.  It  may  even  be 
that  the  slight  degree  of  albuminuria,  apart  from  any  other  signs 
of  renal  disease,  which  is  often  associated  with  the  presence  of 
calcium  oxalate  crystals,  may  be  attributable  to  the  mechanical 
irritation  which  they  set  up. 

Some  account  of  what  is  known  of  the  origin  of  the  oxalic  acid  of 


Oxaluria.  743 

urine  forms  a  necessary  introduction  to  any  profitable  discussion  of 
the  treatment  of  oxaluria,  for  in  the  present  state  of  our  knowledge 
we  are  driven  to  rely  upon  theoretical  considerations  rather  than 
upon  actual  experience  of  beneficial  results.  Oxalic  acid  is  a 
constant  constituent  of  normal  urine,  in  quantities  of  from 
0'015  to  0'02  milligramme  daily  in  health  and  upon  an  ordinary  diet. 
It  is  in  part  derived  from  the  food,  but  some  oxalic  acid  is  still 
excreted  by  persons  who  have  been  kept  for  long  periods  upon  an 
oxalate-free  diet,  such  as  milk  alone,  and  it  does  not  wholly  dis- 
appear even  during  periods  of  fasting.  It  has  been  shown  that 
neither  carbohydrates  nor  fats  are  its  parent  substances,  and  the 
endogenous  portion  is  presumably  of  protein  origin.  A  clue  to  its 
source  is  afforded  by  the  fact  observed  by  Lommel  that  feeding 
with  gelatine  increases  the  output  of  oxalic  acid,  and  a  further 
most  important  clue  by  the  demonstration  by  Klemperer  and 
Tritschler  that  glycocol  and  kreatinine  taken  by  the  mouth  cause  a 
conspicuously  increased  excretion. 

Of  the  exogenous  oxalic  acid  the  great  bulk  is  derived  from 
vegetable  foods,  some  of  which  are  rich  in  this  constituent,  but  only  a 
small  part  of  the  oxalic  acid  introduced  into  the  stomach  is  absorbed, 
whereas  the  major  part,  passing  into  the  intestine,  undergoes  destruc- 
tion by  the  action  of  bacteria.  Klemperer  and  Tritschler  found  that  a 
larger  fraction  of  the  oxalic  acid  contained  in  a  foodstuff,  namely 
spinach,  was  absorbed  than  of  oxalic  acid  administered  as  such.  The 
absorption  is  greatly  favoured  by  the  presence  of  hydrochloric  acid 
in  the  stomach,  and  when  this  acid  is  given  together  with  an 
oxalate  the  urinary  output  is  thereby  markedly  increased,  whereas 
an  opposite  effect  is  observed  by  neutralisation  of  the  gastric  juice 
by  an  alkali  when  the  food  is  taken.  Once  absorbed  into  the  lymph 
and  blood  the  oxalic  acid  is  promptly  combined  up  as  a  calcium 
oxalate.  This  compound  undergoes  no  further  change,  but  is 
excreted  as  such. 

It  seems  certain  that  some  patients  excrete  oxalic  acid  in  excess 
apart  from  dietetic  influences,  but  such  abnormal  outputs  cannot  be 
assigned  as  a  constant  symptom  of  any  particular  diseases.  In 
some  cases  of  diabetes  an  unusually  abundant  excretion  has  been 
observed,  whereas  in  others  it  is  wholly  wanting,  nor  have  we  any 
certain  clinical  evidence  of  the  existence  of  a  metabolic  disorder  to 
which  the  name  "oxaluria  "  can  be  applied  in  any  strict  sense.  It  has 
been  commonly  taught  that  the  solution  of  calcium  oxalate  in  the 
urine  is  mainly  determined  by  the  presence  of  acid  sodium 
phosphate  ;  but  other  influences  are  certainly  at  work  and  crystals 
are  sometimes  deposited  from  strongly  acid  urines.  The  influence 


744 


Oxaluria. 


of  excess  of  oxalate  has  already  been  alluded  to,  and  Klemperer  and 
Tritschler  found  that,  even  when  the  other  conditions  are  favourable 
to  solution,  crystals  of  calcium  oxalate  are  deposited  if  more  than  1'8 
milligrammes  of  oxalic  acid  are  present  in  100  cubic  centimetres  of 
urine.  On  the  other  hand,  sediments  of  crystals  are  not  uncommon 
apart  from  any  excessive  output,  and  the  same  observers  have  shown 
that  the  relative  quantities  of  magnesia  and  lime  present  in  the  urine 
play  a  very  important  part  in  this  connection,  magnesium  salts 
inhibiting  and  calcium  salts  favouring  the  throwing  down  of  the 
oxalate  crystals.  Ratios  of  lime  to  magnesia  between  1  :  0'8  and 
1  :  1*2  are  the  least  favourable  to  deposition. 

The  aims  of  our  treatment  in  cases  of  oxaluria  should  obviously 
be  to  diminish,  as  far  as  possible,  the  excretion  of  oxalic  acid  in  the 
urine  and  to  hinder  the  separation  from  it  of  calcium  oxalate  in 
crystalline  form.  Even  if  this  can  only  be  so  far  delayed  that 
the  crystals  will  not  form  until  after  the  urine  has  been  passed, 
the  wished-for  result  will  have  been  obtained.  As  with  uric  acid, 
the  only  means  at  our  disposal  for  limiting  the  output  of  oxalic 
acid  is  the  restriction  of  the  intake  in  the  food.  The  effect  of  an 
abundant  intake  is  clearly  seen  in  the  copious  deposition  of  crystals, 
which  is  wont  to  follow  free  consumption  of  oxalate-rich  vegetables, 
such  as  rhubarb  and  spinach.  It  is  therefore  desirable  to  be 
acquainted  with  the  oxalic  acid  content  of  various  articles  of  diet, 
and  such  information  is  supplied  as  regards  many  such  by  the 
following  table  compiled  from  Esbach's  analyses,  which  were,  it 
should  be  mentioned,  carried  out  by  methods  of  estimation  less 
satisfactory  than  those  in  use  nowadays. 

Oxalic  Acid  in  Foodstuffs.     (Extracted  from  Esbach's  Table.) 
Quantities  contained  in  1  Kilogramme,  Raiv,  as  delivered  to  the  Consumer. 


Black  tea    . 

3-75 

Cabbage    . 

.     0-003 

Cocoa  . 

3 

52  to  4-5 

Beetroot    . 

.     0-39 

Chocolate    . 

0-9 

Salsify       . 

.     0-07 

Pepper 

3-250 

Tomatoes  . 

0-002  to  0-052 

Chicory  coffee 

0-795 

Carrots 

.     0-027 

Haricots  blancs 

0-312 

Celery 

.     0-025 

Potatoes 

0-046 

Haricots  verts 

0-06  to  0-21 

Bread  (good  qua 

ity) 

0-047 

Dried  figs  . 

.     0-27 

Crust  . 

0-130 

Gooseberries 

0-130  to  0-07 

Barley  flour 

0-039 

Plums 

.     0-120 

Maize  flour 

0-033 

Raspberries 

.     0-06 

Sorrel 

2 

74  to  3-63 

Oranges     . 

.     0-03 

Spinach 

1 

91  to  3-27 

Lemons     . 

.     0-03 

Ehubarb      . 

2-46 

Cherries    . 

.     0-025 

Brussels  sprouts 

0-02 

Strawberries 

.     0-012 

Lentils,  rice,  cauliflower,  green  peas,  artichokes,  cucumbers  mushrooms, 
onions,  lettuce,  apples,  pears,  apricots  and  peaches,  contain  traces  of  oxalic  acid 
or  none  at  all. 


Oxaluria. 


745 


The  second  factor  which  has  to  be  taken  into  consideration  in 
prescribing  a  diet  for  a  patient  with  oxaluria  is  the  relation  of  lime 
to  magnesia  in  the  several  foodstuffs,  and  an  ideal  diet  should 
consist  of  the  materials  which  are  at  the  same  time  poor  in  oxalic 
acid,  relatively  rich  in  magnesia  and  poor  in  lime. 

The  following  table,  extracted  from  that  of  Klemperer  and 
Tritschler,  and  based  upon  analyses  of  vegetable  foods  by  Liebig 
and  of  animal  products  by  Bunge,  will  be  found  useful  in  this 
connection : 

(a)  Percentage  in  Ash  of  Magnesia  and  Lime  in  Vegetable  Foods. 

(Liebig.) 


- 

Ash  in  100  parts 
of  dry  substance. 

Of  Magnesia. 

Of  Lime. 

Cocoa 

4-9 

15-9 

2-8 

Rice 

0-67 

13-4 

0-8 

Nut  kernels 

— 

13-3 

8-6 

Wheat  flour 

2-3 

10-9 

2-2 

Apple 
Coffee  extract 

1 

0-27 
3-4 

8-7 
8-6 

4-0 
3-6 

Peas 

2-8 

8-1 

5-1 

Tea  extract 

3-1 

6-8 

1-2 

Potato     . 

5-0 

2-5 

0-8 

Grapes    . 

2-25 

8-8 

36-9 

Cherries  . 

0-4 

5-5 

7-5 

Plums 

0-31 

4-7 

4-9 

Asparagus 

6-4 

6-3 

15-9 

Pineapple 

— 

8'8 

12-5 

Spinach  . 

2-03 

5'3 

13-1 

Cauliflower 

8-8 

Traces. 

21-7 

Cabbage  . 

11-6 

3-7 

12-6 

Cucumber 

4-9 

3-0 

6-9 

Gooseberries 

0-4 

5-8 

12-2 

Lentils    . 

2-1 

1-9 

5-1 

Beans 

3-1 

6-5 

8-6 

Sorrel 

—  . 

8-3 

31-6 

Pears 

0-4 

5-2 

7-9 

Strawberries 

— 

Traces. 

14-2 

Carrots    . 

5-4 

2-3 

5-6 

Beef 


(b)  Animal  Foodstuffs.     (Bunge.) 
In  (sentiyrammes  in  the  Dry  Substance. 

Magnesia. 
15-2 


White  of  egg 
Human  milk 
Yolk  of  egg 
Cow's  milk    . 


13-0 
5-0 
6-0 

20-0 


Lime. 

2-9 

13-0 

24-3 

38-0 

151-0 


Milk  and  eggs,  in  which  lime  is  so  abundant  a  constituent,  will 
be  excluded  from  the  optimum  diet  in  these  cases,  and  some 
vegetables,  such  as  cabbage  and  cauliflower,  which  might  escape 
condemnation  on  the  score  of  oxalic  acid  alone,  will  be  excluded 


746  Phosphaturia. 

because  they  contain  too  much  lime  and  relatively  too  little 
magnesia. 

Meats,  on  the  other  hand,  fulfil  all  the  required  conditions,  as  do, 
among  vegetables,  cereals  and  leguminous  seeds,  peas  and  beans, 
and  apples. 

Taking  the  several  factors  into  account  we  may  prescribe  for 
oxaluric  patients  such  a  diet  as  the  following : 

Meat  of  all  kinds,  including  fowl,  game  and  fish,  meat  extracts, 
bread,  rice,  and  farinaceous  foods  of  all  kinds,  potatoes,  peas,  beans, 
and  apples.  Coffee  should  be  taken  in  place  of  tea  or  cocoa. 

Green  vegetables  and  root  vegetables  are  better  avoided,  as  are 
most  fruits,  except  apples,  and  milk,  eggs  and  jellies,  on  account 
of  the  power  which  gelatine  has  of  increasing  the  oxalic  excretion. 
Tea,  cocoa,  rhubarb,  spinach,  sorrel  should  be  rigorously  excluded 
from  the  diet,  and  some  of  these  substances  are  not  only  rich  in 
oxalic  acid  but  are  also  relatively  rich  in  lime. 

In  some  cases  oxaluria  occurs  in  patients  whose  purin  intake  also 
calls  for  restriction.  In  such  circumstances  resort  must  be  had 
to  a  diet  of  compromise,  from  which  the  foods  which  contain  the 
larger  quantities  of  purins  and  of  oxalic  acid  respectively  are 
excluded. 

In  order  further  to  increase  the  magnesium  of  the  urine  small 
doses  of  magnesium  sulphate,  such  as  2  drachms  in  the  day,  may 
be  administered,  and  the  free  drinking  of  water,  by  diluting  the 
urine,  will  tend  to  check  the  deposition  of  calcium  oxalate. 

Maguire  has  recently  advocated  the  administration  of  acid  sodium 
phosphate,-  with  a  view  to  increasing  the  acidity  of  the  urine,  a 
result  which,  as  R.  Hutchison  showed,  is  more  readily  obtained  with 
this  substance  than  by  the  administration  of  free  acids.  He  recom- 
mended that  \  oz.,  1  oz.,  or  even  2  oz.  of  the  acid  phosphate  should 
be  dissolved  in  100  oz.  of  distilled  water,  and  that  the  solution 
should  be  drunk  at  intervals  throughout  the  day.  By  such  means 
he  claims  to  have  effected  the  solution  of  an  oxalate  calculus  within 
the  urinary  passages. 

Lastly,  it  should  be  mentioned  that  mineral  waters,  such  as 
those  of  Contrexeville,  Vittel  and  Wildungen,  which  have  a  reputation 
in  connection  with  the  treatment  of  calculous  disorders,  are  believed 
to  be  valuable  in  cases  of  oxaluria,  as  well  as  in  those  in  which  uric 
acid  is  the  stone-forming  material. 

PHOSPHATURIA. 

When  a  patient  habitually  passes  urine  which  is  amphoteric  or 
alkaline  in  reaction  and  turbid  from  a  precipitate  of  earthy 


Phosphaturia.  747 

phosphates,  although  free  from  ammoniacal  decomposition,  he  is 
said  to  suffer  from  phosphaturia.  On  standing,  such  urine  deposits 
a  bulky  sediment  and  the  supernatant  liquid  may  become  quite  clear. 
The  sediment  consists  of  the  basic  phosphates  of  calcium  and 
magnesium  with  usually  a  small  admixture  of  carbonates. 

The  name  "  phosphaturia  "  is  a  misnomer,  and  as  such  is  apt  to 
mislead,  for  whereas  the  condition  may  be  due  either  to  an  increase 
of  bases  or  a  diminution  of  acids,  it  never  has  its  origin  in  an 
excessive  output  of  phosphoric  acid.  Indeed  such  an  excess  would 
have  an  opposite  effect  upon  the  urine,  would  cause  an  increase  of 
acidity  and  so  prevent  any  deposition  of  earthy  phosphates. 

Phosphaturia  may  result  from  widely  different  causes,  and  is  not 
a  manifestation  of  a  single  definite  morbid  state.  Healthy  persons 
often  pass  such  turbid  urine  two  or  three  hours  after  a  full  meal,  and 
especially  one  rich  in  protein,  during  the  period  of  the  so-called 
alkaline  tide  which  is  due  to  diminution  of  acidity  during  the 
secretion  of  hydrochloric  acid  in  the  course  of  gastric  digestion. 
In  the  same  way  gastric  lavage,  repeated  vomiting  or  even  hyper- 
chlorhydia,  may  give  rise  to  phosphaturia. 

A  physiological  phosphaturia  may  also  result  from  an  excessive 
excretion  of  fixed  alkali,  such  as  follows  the  free  drinking  of  alkaline 
mineral  water  or  results  from  a  vegetarian  diet.  Vegetivorous 
animals  habitually  excrete  turbid  alkaline  urine. 

"When  it  occurs  as  a  persistent  symptom,  apart  from  the  action  of 
any  such  recognised  causes,  phosphaturia  is  less  easily  explained. 
It  certainly  has  a  close  clinical  relationship  to  neurasthenic 
symptoms,  and  especially  to  the  sexual  variety  of  neurasthenia. 
Perhaps  because  they  are  neurasthenic,  the  patients  are  wont  to 
attach  an  altogether  exaggerated  importance  to  these  symptoms, 
and,  by  exciting  alarm,  the  condition  of  the  urine  tends,  in  a  vicious 
circle,  to  aggravate  their  neurasthenia. 

The  researches  of  Soetbeer,  Tobler  and  others  have  brought  to 
light  the  fact  that  in  a  considerable  number  of  cases  of  phosphaturia, 
and  especially  of  cases  occurring  in  children,  the  symptom  is  due  to 
an  excessive  excretion  of  calcium  in  the  urine.  This  excess  of 
calcium  leads  to  the  presence  of  basic  phosphates  in  undue  propor- 
tion, and  so  to  diminution  of  the  acidity  of  the  urine  and  to 
phosphaturia.  The  increase  is  not  of  the  total  phosphoric  acid 
output,  but  merely  of  the  basic  calcium  compound.  The  ratio 
CaO  :  Pa05  is  conspicuously  disturbed,  and  may  be  changed  from  a 
normal  ratio  of  about  1 :  12  to  that  of  1  :  4. 

As  is  well  known,  the  bulk  of  the  calcium  excretion  of  the 
organism  is  effected  by  way  of  the  intestinal  wall,  only  a 


748  Phosphaturia. 

comparatively  small  fraction  of  the  total  output  appearing  in  the 
urine,  and  the  investigators  referred  to  have  further  shown  that,  in 
cases  of  the  class  under  discussion,  the  excretion  of  calcium  is  not 
increased  as  a  whole,  but  that  the  excess  in  the  urine  is  balanced  by 
a  corresponding  decrease  of  the  calcium  in  the  faeces.  Such  a 
diminution  of  the  excretive  power  of  the  intestine  for  calcium 
suggests  that  some  morbid  condition  of  the  alimentary  canal  is  at 
the  bottom  of  the  whole  matter  and  that  the  phosphaturia  is  merely 
a  secondary  effect  thereof.  Soetbeer  ascribes  it  to  a  catarrh  of  the 
colon,  and  evidences  of  the  existence  of  such  a  catarrh  have  been 
present  in  some  at  least  of  the  observed  cases. 

What  proportion  of  cases  of  phosphaturia  are  of  this  nature  is  not 
yet  known.  It  appears  certain  that  the  condition  is  occasionally 
to  be  met  with  among  adults,  but  on  the  other  hand  Langstein's 
observations  show  that  by  no  means  all  phosphaturic  children 
belong  to  this  class ;  and  it  is  not  improbable  that  further  observa- 
tions may  show  that  the  matter  is  not  quite  so  simple  as  has  been 
supposed. 

In  the  cases  of  Soetbeer's  type,  or  of  calcaruria,  to  employ  the 
somewhat  uncouth  designation  which  he  suggests  for  them,  the 
results  of  treatment  have  been  encouraging,  and  dietetic  measures 
have  sufficed  to  control  the  trouble.  The  aim  of  dieting  is  to 
limit  the  introduction  of  calcium  in  the  food,  since  there  is  difficulty 
in  excreting  this  substance  by  the  ordinary  path.  From  the  diet 
prescribed  foodstuffs  rich  in  calcium  should  be  excluded,  and  above 
all  milk  and  eggs,  whereas  meats  of  all  kinds,  farinaceous  foods, 
bread  and  vegetables  fulfilling  the  required  condition,  such  as  potatoes 
and  apples,  may  be  allowed.  In  prescribing  such  a  diet  the  table 
showing  the  calcium  content  of  foodstuffs,  given  on  p.  745,  will  be 
found  of  use.  If,  however,  an  intestinal  disorder  underlies  the  trouble 
our  treatment  should  be  directed  to  the  improvement  of  the  condition 
of  the  bowel  wall,  at  the  same  time  as  we  aim  at  removing  the 
calcaruria  by  a  suitable  dietary. 

In  the  ordinary  cases,  in  which  phosphaturia  is  associated  with 
neurasthenia  of  greater  or  less  degree,  attempts  to  restore  the 
natural  acidity  of  the  urine  by  the  administration  of  acids  or  by  a 
diet  rich  in  proteins  are  not  unfrequently  attended  with  little  success. 
Various  acids  are  given  by  the  mouth,  such  as  lactic  or  hydrochloric, 
but  R.  Hutchison  recommends  the  administration  of  acid  sodium 
phosphate  and  has  had  decidedly  better  success  therewith  than  with 
free  acids.  It  may  be  given  in  doses  of  30  to  60  gr.  every  three 
hours,  or  2  drachms  may  be  dissolved  in  a  pint  of  water  and  the 
patient  directed  to  drink  small  quantities  from  time  to  time. 


Bence  Jones  Protein.  749 

As  a  rule,  treatment  directed  to  the  general  condition  of  the 
patient,  such  as  change  of  air  and  scene,  rest  and  general  massage, 
together  with  tonic  medicines,  prove  more  beneficial  than  specialised 
methods  of  treatment  directed  against  the  alkalinity  of  the  urine. 

PNEUMATURIA. 

Except  in  the  uncommon  cases  in  which  a  fistulous  opening  has 
been  formed  between  the  lower  bowel  and  the  urinary  tract,  usually 
in  connection  with  a  malignant  growth,  the  escape  of  gas  with  the 
urine  is  a  result  of  bacterial  infection.  In  most  instances  the 
subjects  of  such  gas  formation  are  diabetics  whose  bladders  have 
been  infected,  and  the  gas  passed  is  carbon  dioxide  formed  by 
fermentation  of  the  glucose  contained  in  the  urine.  There  is, 
however,  another  class  of  cases,  which  has  been  specially  studied 
by  Adrian  and  Hann,  in  which  the  urine  contains  no  sugar  and 
the  phenomenon  is  due  to  the  action  of  the  bacillus  lactis  aerogenes. 
Pneumaturia  of  these  latter  kinds  calls  for  treatment  of  the  urinary 
infection,  and  in  cases  of  diabetes  affords  an  additional  indication 
for  dietetic  treatment  in  the  hope  of  bringing  about  the  cessation 
of  glycosuria. 

PYURIA. 

The  presence  of  pus  in  the  urine  indicates  a  morbid  condition  of 
the  kidneys  or  urinary  tract,  and  may  have  such  different  causes  as 
tuberculous  disease  of  the  kidney,  calculous  pyelitis,  rupture  of  an 
adjacent  abscess  into  the  urinary  passages,  cystitis  or  gonorrhoeal 
urethritis.  The  quantity  of  pus  present  may  be  very  small  or  it 
may  form  a  thick  deposit  at  the  bottom  of  the  containing  vessel. 
The  reaction  of  the  urine  may  be  acid  or  alkaline,  being  to  a  great 
extent  dependent  upon  the  nature  of  the  infecting  micro-organism, 
and  its  appearance  will  largely  depend  upon  its  reaction.  Alkaline 
urine  containing  pus  remains  turbid,  and  is  viscid  when  poured  from 
one  vessel  to  another,  whereas  from  acid  urine  the  pus  tends  to 
settle  into  a  well-defined  layer,  leaving  the  supernatant  liquid  clear. 

The  cause  of  the  pyuria  can  usually  be  determined  by  the 
patient's  symptoms,  by  physical  examination  and  by  microscopic 
and  bacteriological  examination  of  the  urine,  and  the  treatment 
employed  will  be  directed  to  the  underlying  morbid  condition. 

THE   BENCE  JONES  PROTEIN  IN  URINE. 

The  excretion  in  the  urine  of  the  peculiar  protein  first  detected 
by  Bence  Jones,  and  always  called  by  his  name,  is  a  phenomenon 
of  much  interest  and  of  great  diagnostic  value.  Jt  is,  in  almost  all 


750  Bence  Jones  Protein. 

cases  if  not  in  all,  a  symptom,  and  as  a  rule  the  earliest  symptom, 
of  a  disease  of  the  bone  marrow  known  as  multiple  myeloma.  The 
amount  of  Bence  Jones  protein  in  the  urine  is  usually  large, 
and  it  is  recognised  by  the  low  temperature,  50°  to  60°  C., 
at  which  coagulation  occurs,  and  by  the  fact  that  the  bulky 
flocculent  coagulum,  which  clings  to  the  walls  of  the  test  tube, 
disappears  almost  entirely  before  the  boiling  point  is  reached, 
especially  if  a  drop  of  acetic  acid  has  been  added,  and  reappears  on 
cooling.  However,  this  clearing  on  further  heating,  which  is  largely 
determined  by  the  conditions  of  solution  in  urine,  is  not  always 
well  seen. 

Unfortunately  no  treatment  has  hitherto  had  any  effect  upon  the 
course  of  the  disease,  or  upon  the  excretion  of  the  protein,  the  mode 
of  formation  and  parent  substance  of  which  are  still  unknown. 


A.  E.  GARROD. 


EEFERENCES. 


Acetonuria. — Spriggs,  E.  I.,  "  Critical  Eevievr  on  Acidosis,"  Quart.  Journ. 
Med.,  1909,  II.,  p.  325.  Bainbridge,  F.  A.,  Lancet,  1908,  I.,  p.  911. 

Albuminiiria. — Wright,  Sir  A.,  and  Eoss,  G.  W.,  Lancet,  1905,  II.,  p.  1164. 

Cystinuria. — Alsberg,  C.,  and  Folin,  G.,  Ainer.  Journ.  Physiol.,  1905,  XIV., 
p.  54.  Wolf  and  Shaffer,  Journ.  of  Biological  Chemistry,  1908,  TV.,  p.  444. 
Garrod,  A.  E.,  "  Inborn  Errors  of  Metabolism,"  1909,  pp.  82  et  seq. 

Lithuria. — Klemperer,  G.,  "  Verhandl.  des  Kongress,  f.  innere  Med.,"  1902, 
XX.,  p.  219.  Walker  Hall,  I.,  "The  Purin  Bodies  and  Foodstuffs,"  1903. 
Eoberts,  Sir  William,  "  Croonian  Lectures,"  Lancet,  1892,  I.,  p.  1399. 

Oxaluria. — Klemperer,  G.,  und  Tritschler,  F.,"Zeitschr.  f.  klin.  Med.,"  1902, 
XLIV.,  p.  337.  Esbach,  G.,  "Bull.  Generate  de  Therap.,"  Par.,  1883,  CIV., 
p.  385.  Dunlop,  J.  C.,  Journ.  Path,  and  Bacterio.,  Edinb.,  1896,  HI.,  p.  389. 
Maguire,  E.,  "  Proc.  Eoyal  Soc.  Med.,"  1909,  III.,  Med.  Sect.,  p.  1. 

Phosphaturia. — Soetbeer,  Fr.,  und  Krieger,  H.,  "  Deuteches  Archiv.  f. 
klin.  Med.,"  1902,  LXXIL,  p.  553.  Tobler,  L.,  "Arch.  f.  exper.  Path,  ii 
Pharmakol.,"  1905,  LH.,  p.  116.  Langstein, "  Med.  Klinik.,"  1906,  II.,  p.  406. 
Peyer,  A.,  "  Die  Phosphaturie,"  Volkmann's  "  Saminlung  klinischer  Vortriige," 
Leipzig,  1886—90,  Innere  Med.,  No.  112,  p.  3031.  Hutchison,  E.,  Brit.  Med. 
Journ.,  1903,  I.,  p.  1256. 


BACILLURIA. 

A  NUMBEK  of  micro-organisms  are  found  in  the  urine  under 
different  conditions.  It  is  probable  that  in  most,  if  not  all,  instances 
when  organisms  gain  access  to  the  blood-stream  they  also  gain 
access  to  the  bladder.  This  is  certainly  true  of  the  typhoid  bacillus 
and  in  some  cases  of  tuberculosis.  In  such  cases  there  is  not  neces- 
sarily any  local  disease  of  the  bladder,  and  consequently  this  sym- 
ptom is  usually  dealt  with  adequately  by  means  of  urinary  anti- 
septics, such  as  urotropin  (gr.  7^  to  10)  three  times  a  day. 

In  other  cases  the  urine  may  contain  large  numbers  of  organisms 
without  the  existence  of  any  disease  outside  the  urinary  tract. 
What  local  disease  is  present  is  frequently  confined  to  the  bladder. 
In  some  cases  there  may  be  no  decomposition  of  the  urine  and  no 
cystitis.  In  others  we  may  have  marked  cystitis,  which  may  lead 
to  acute  general  symptoms,  or  we  may  have  slight  cystitis  with 
symptoms  of  sub-acute  toxaemia,  such  as  lassitude  and  want  of  energy. 
In  many  of  these  instances  the  offending  micro-organism  is  the 
Bacterium  coli  comrnunis.  In  all  instances  urotropin  or  other  urinary 
antiseptic  should  be  freely  used,  and,  if  necessary,  pushed  to  the 
limits  of  tolerance. 

In  addition,  an  autogenous  vaccine  of  the  causal  organism 
should  be  used  (see  Vaccine  Therapy,  Vol.  III.).  In  many  of 
the  acute  cases  vaccine  therapy  gives  brilliant  results.  In  a 
number  of  the  more  chronic  cases  the  relief  of  the  symptoms 
afforded  by  this  method  of  treatment  is  apt  to  be  less  marked. 
In  addition,  the  patient's  life  should  be  regulated  in  accordance 
with  the  severity  of  the  symptoms.  The  diet  should  be  of  a  non- 
irritating  character.  It  is  important  that  the  bowels  should  be  kept 
thoroughly  open,  and  sometimes  the  Plombiere  method  of  washing 
out  the  bowel  is  of  service.  In  all  cases  the  patient's  general  health 
should  be  brought  to  as  high  a  level  as  possible,  and  he  should 
carefully  guard  against  the  possibility  of  fatigue. 

ARTHUR  LATHAM. 


752 


ANEURYSM  OF  THE  RENAL  ARTERY. 

Treatment. — The  condition  will  usually  be  discovered  in  the 
course  of  an  exploratory  operation  undertaken  for  a  swelling  in 
the  loin  which  has  followed  an  injury. 

Morris  warns  against  opening  up  the  sac.  Only  a  small 
opening  should  be  made,  sufficient  to  recognise  the  laminated 
character  of  the  contents. 

In  breaking  down  adhesions  severe  haemorrhage  has  taken 
place,  and  necessitated  plugging  with  gauze. 

In  such  a  dilemma,  and  in  the  case  where  diagnosis  has  pre- 
viously been  made,  a  vertical  incision  should  be  made  in  the 
semi-lunar  line  and  the  peritoneal  cavity  opened. 

The  peritoneum  is  divided  along  the  outer  side  of  the  colon 
and  reflected  inwards.  The  pedicle  of  the  kidney  is  exposed  and 
ligatured.  It  is  sometimes  very  broad,  and  requires  a  series  of 
ligatures.  The  aneurysmal  sac  and  kidney  are  then  removed. 

Results. — Albert,  Hahn  and  Keen  have  each  operated  success- 
fully in  one  case.  All  the  other  patients  in  whom  the  aneurysms 
caused  a  tumour  died.  The  aneurysms,  which  were  very  small, 
had  caused  no  symptoms,  and  were  discovered  accidentally  post- 
mortem, the  patient  having  died  from  other  causes. 

J.  W.  THOMSON  WALKER. 


753 


RENAL  CALCULUS. 

PROPHYLACTIC  TREATMENT. 

THE  prophylactic  treatment  of  stone  consists  in  the  treatment  of 
oxaluria,  of  lithiasis,  of  phosphaturia,  and  the  removal  of  local 
conditions  which  may  assist  the  formation  of  stone.  The  subject 
usually  comes  under  discussion  when  a  patient  has  passed  a  stone 
or  undergone  an  operation  for  stone,  and  an  attempt  is  to  be  made 
to  prevent  recurrence. 

(1)  The  treatment  of  oxaluria  is  discussed  elsewhere. 

(2)  When  the  patient  passes  acid  concentrated   urine   with   uric 
acid  crystals,  it  is  advisable  to  limit  the  quantities  of  nitrogenous 
food,  but  it  is  unwise  to  cut  off  meat  entirely.     Beef  and  mutton 
should  be  taken  sparingly.     Cellular  organs,  such  as  brain,  sweet- 
breads, kidney  and  liver,  contain  excessive  quantities  of  nuclein 
from  which  uric  acid  is  derived,  and  should  be  avoided.     White 
meat  is  less  harmful  than  red,  but  veal  and  pork  are  unsuitable 
articles  of  diet.     Duck  and  goose  among  poultry,  and  high  game 
should  be  avoided.     Fish  may  be  taken,  except  salmon,  mackerel, 
lobster  and  crab.     Bread,  all  the  cereals,  roots,  fruits  and  green 
vegetables  should  form  part  of  the  diet.      Butter,  milk  and  eggs 
may  be  taken.     Tea  and  coffee,  if  taken,  should  be  weak.     Sugar 
and  fats  are  harmful,  and  should  be  eaten  sparingly.     It  is  better 
to  avoid  wine  altogether  ;  but  should  it  appear  necessary  to  permit 
some  wine,  the  lighter  Moselle  and  white  French  wines  or  a  light 
claret  should  be   selected.       Heavy   wines,    such   as    Burgundy, 
Australian   and   Californian  wines,  are  especially  harmful.     Port 
and  champagne  should  be  interdicted.     New  port  is  slightly  less 
pernicious   than  old.     Whisky  may  be  allowed  in  very  moderate 
amount. 

Careful  attention  must  be  paid  to  regular  action  of  the  bowels, 
and  a  course  of  waters  containing  sulphates  of  soda  and  magnesia, 
such  as  Hunyadi  and  Friederickshall,  is  beneficial.  Half  a 
tumblerful  or  more  should  be  taken  on  waking,  and  followed  by  a 
tumblerful  of  hot  water.  Courses  of  three  or  four  weeks  with 
intervals  of  two  or  three  weeks  may  be  prescribed.  Watson  speaks 
highly  of  calomel,  given  in  doses  of  J  to  \  gr.  at  bedtime  for  a 
week  at  a  time. 

The  urine  should  be  diluted  and  the  acidity  reduced.  A  large 
glass  of  hot  water  should  be  taken  in  the  early  morning  and  at 

S.T.— VOL.  ii.  48 


754 


Renal  Calculus. 


night.  Aerated  distilled  waters,  such  as  Salutaris,  are  bene- 
ficial. Alkalies,  and  especially  those  which  are  also  diuretic, 
are  useful.  The  citrate  and  acetate  of  potash  should  be  given  in 
doses  of  30  to  60  gr.  four  times  daily,  or  the  carbonate  or  citrate 
of  magnesium  or  lithium.  The  boro-citrate  of  magnesia  (in  doses 
of  15  gr.  thrice  daily)  is  well  borne.  Alkaline  mineral  waters,  such 
as  Contrexeville  (Pavilion),  Vittel  (Grande  Source)  and  Evian 
(Cachet),  should  be  given,  and  a  visit  to  one  of  these  spas  is  often 
beneficial. 

The  most  powerful  effect  is  obtained  by  drinking  the  water  after 
fasting.  For  this  reason  a  large  draught  should  be  taken  in  the 
early  morning  and  another  in  the  late  afternoon. 

Uric  acid  solvents  should  be  administered  by  the  mouth.  The 
following  is  a  selection  : 


Name. 

Composition. 

Method  of  Action. 

Dose. 

1.  Piperazine    . 

Diethylene  -diamine 

Forms  soluble  urates 

4  to  15  gr. 

with  uric  acid 

2.  Sidonal 

Piperazin  quinate 

Quinic  acid  encour- 

H gr- 

ages   excretion  of 

precursors  of  uric 

acid 

3.  Hex  a  methyl  ene- 

Contains  Formalde- 

Solvent    action     on 

5  to  15  gr. 

tetramine.  Syno- 

hyde 

uric  acid,  and  urin- 

nyms :     Urotro- 

ary antiseptic 

pine,        Forrnin, 

Cystamine,  Cys- 

togen,  .     Metra- 

mine,  Uritone 

4.  Helmitol 

New  urotropine 

Do. 

15  gr. 

5.  Hetraline 

Contains  60  per  cent. 

Do. 

7i    to    30 

of  hexamethylene- 

gr. 

tetramine 

6.  Cystopuriu    . 

Hexamethy  lene  -  te  - 

Do. 

30  gr. 

tramine    and    so- 

dium acetate 

7.  Chinotropine 

Urotropine  quinate 

Do.    See  also  Sidonal 

Up   to    90 

gr. 

8.  Urocedin 

Lithium  and  sodium 

Eeduces    acidity    of 

15  gr. 

citrates  and  sodium 

urine 

sulphate 

9.  Uraseptin 

Combination  of  uro- 

Uric acid  solvent  and 

4  drachms 

tropine,  benzoate 

urinary  antiseptic 

of  soda  and  lithia 

piperazine        and 

lead  acetate 

Turpentine,  an  old  remedy,  is  of  undoubted  benefit.  It  should 
be  given  in  10-minim  doses  in  capsules  thrice  daily  for  a  week  or 
ten  days. 


Renal  Calculus.  755 

Exercise,  bathing  and  Turkish  baths,  and  radiant  heat  baths 
are  important  adjuncts  to  treatment. 

(3)  The  treatment  of  pkosphaturia  has  already  been  discussed. 

(4)  Treatment  of  local  conditions  which  assist  the  formation  of 
stone. — These  consist  in  urinary  infection  and  obstruction.     For 
the  treatment  of  chronic  renal  and  pelvic  infections  the  reader  is 
referred   to   the  chapter   on   these   diseases.      The   treatment    of 
chronic  vesical  infection  and  obstruction  will  be  discussed  later. 

TREATMENT  OF  CERTAIN  SYMPTOMS. 

Renal  Colic. — The  pain  of  renal  colic  varies  greatly  in 
severity.  In  severe  attacks  the  following  measures  should  be 
adopted  :  The  patient  is  placed  in  a  hot  bath  and  a  hypodermic 
injection  of  morphine  sulphate  (J  to  ^  gr.)  with  atropine  sulphate 
(200  81'-)  given.  On  his  return  to  bed  hot  poultices  or  fomentations  are 
applied  over  the  loin  and  abdomen.  The  pain  usually  subsides  in 
about  half  an  hour  after  the  injection.  Occasionally  it  is  necessary 
to  repeat  the  hypodermic  injection  after  some  hours.  Rarety  it  is 
found  necessary  to  administer  chloroform  and  to  keep  the  patient 
lightly  under  its  influence  for  an  hour  or  more.  If  this  becomes 
necessary  and  the  stone  is  known  to  lie  at  the  upper  end  of  the 
ureter,  a  ureteric  catheter  may  be  passed  and  the  stone  pushed  back 
into  the  renal  pelvis.  The  injection  of  a  small  quantity  of 
sterilised  oil  into  the  ureter  has  facilitated  the  passage  of  a 
descending  calculus. 

Renal*  Haematuria. — Haematuria  is  seldom  alarming  in  renal 
calculus,  but  may  be  severe  after  exertion  or  a  fall  or  blow.  The 
patient  should  rest  in  bed  with  an  ice-bag  over  the  kidney.  Ergot 
may  be  given,  but  is  of  doubtful  value.  A  hypodermic  injection  of 
morphia  should  be  given,  and  10  or  15  gr.  of  calcium  lactate 
administered  by  mouth  every  four  hours.  For  persistent  severe 
hsematuria  operation  is  necessary. 

Calculous  Anuria. — The  following  points  are  of  importance 
in  regard  to  operative  interference  in  calculous  anuria. 

Calculous  anuria  may  occur  under  the  following  conditions : 

(1)  The  ureter  of  a  single  functional  kidney  is  blocked  by  stone. 
The  second  kidney  is  absent  (six  in  forty-three  cases),  atrophied, 
or  completely  destroyed  by  disease.    This  is  the  most  common  form. 

(2)  The  ureters  of   two   functional   kidneys  are  simultaneously 
blocked    by    calculi  (twelve    in     forty-three     cases,    Donnadieu). 
This  is  a  less  common  form. 

(3)  The  ureter  of  one  functional  kidney  is  blocked  by  stone  and 
the  function  of  the  second  kidney  is  suppressed  by  reflex  influences 

48—3 


756  Renal  Calculus. 

(uretero-renal  reflex).     The  second  kidney  is  always  diseased,  and 
this  renders  it  more  susceptible  to  reflex  influences. 

If  symptoms  of  calculus  have  been  present  on  both  sides,  the 
side  on  which  symptoms  were  last  present  is  that  of  the  active 
kidney. 

The  recently  active  kidney  is  frequently  tender  and  may  be 
enlarged.  There  is  often  rigidity  of  the  abdominal  muscles  over  the 
side  where  other  symptoms  are  absent.  Radiography  may  assist 
the  diagnosis  and  locate  the  position  of  the  calculus.  Extensive 
shadows  in  one  kidney  will  point  to  this  organ  being  inactive  or 
feebly  functional,  and  a  shadow  of  a  calculus  in  the  opposite  ureter 
would  indicate  and  localise  the  cause  of  the  anuria.  A  calculus 
may  be  felt  in  the  lower  ureter  per  rectum  or  per  vaginam. 
Cystoscopy  may  show  absence  of  a  ureteric  orifice,  or  there  may  be 
signs  of  a  stone  impacted  low  down  in  the  ureter  on  .the  recently 
active  side. 

The  ureteric  catheter  will  give  no  useful  information  in  regard 
to  the  side  affected  or  the  position  of  the  offending  calculus. 
Calculous  anuria  is  sometimes  incomplete,  a  few  ounces  of  urine 
being  passed  each  day  or  at  intervals,  or  complete  anuria  may  be 
interrupted  by  the  escape  on  one  or  several  occasions  of  large 
quantities  of  urine.  These  variations  cannot  be  regarded  as 
indicating  that  a  fatal  issue  will  not  take  place.  There  is  usually 
a  latent,  silent  or  tolerant  stage,  which  may  last  as  long  as  ten 
days,  but  more  usually  seven  or  eight  days.  This  is  followed 
by  a  uraemie  stage.  The  patient  may  die  without  developing 
ursemic  symptoms.  Death  occurs  rapidly  after  symptoms  of 
ursemia  appear  ;  rarely  it  is  delayed  one  or  two  days.  Death 
usually  occurs  about  the  tenth  or  eleventh  day  in  unrelieved  cases. 
Spontaneous  recovery  has  occurred  in  28'5  per  cent,  of  recorded 
cases.  Legueu  found  sixteen  unoperated  cases  out  of  fifty-six 
recovered.  The  date  of  spontaneous  relief  of  the  anuria  was  the 
third  day  in  one,  fifth  to  tenth  day  in  ten,  thirteenth  day  in  one, 
fourteenth  day  in  one,  and  fifteenth  day  in  one,  and  in  two 
cases  later  than  the  fifteenth  day. 

The  obstructing  calculus  is  situated  at  the  upper  end  of  the 
ureter  in  most  cases,  less  frequently  at  the  lower  end  of  the  ureter, 
and  rarely  in  the  middle  portion. 

Huck  found  the  following  numbers  at  the  different  levels : 
Pelvis  and  upper  ureter,  80  ;  middle,  5  ;  lower  ureter  11. 

Indications  for  Operation. — Operation  should  be  performed  at 
the  earliest  possible  moment  in  all  cases  of  calculous  anuria. 

It  has  been  held  that  operation  may  be  delayed  until  the  fifth  or 


Renal  Calculus.  757 

sixth  day  as  uraemia  symptoms  do  not  supervene  before  this  time. 
This  delay  could  only  be  justified  by  a  large  proportion  of 
spontaneous  recoveries.  Such  fortunate  results  do  not  obtain. 
Death  does  not  take  place  as  a  result  of  the  operation,  but  as  a 
result  of  the  condition  for  which  it  is  performed. 

Huck's  statistics  show  that  the  mortality  rises  each  day  that 
the  operation  is  delayed. 

Operations  before  the  fourth  day  have  a  mortality  of  25   per  cent. 
„  „         fifth       ,,  „  „  30'7       „ 

sixth      ,,  „  „  42-1       „ 

Operation  should  therefore  be  performed  as  soon  as  anuria  is 
established  and  the  -  diagnosis  clearly  made.  The  presence  of 
urseniic  symptoms  does  not  contra-indicate  operation.  Successful 
cases  of  operation  under  these  conditions  have  been  recorded. 

The  Xaturc'  of  the  Operation. — The  nature  of  the  operation  will 
to  some  extent  depend  upon  the  position  of  the  obstructing  stone, 
the  possibility  of  accurately  localising  it,  and  the  ease  or  difficulty 
with  which  it  can  be  removed.  The  operation  for  calculous  anuria 
is  one  of  emergency  performed  under  the  worst  possible  conditions, 
and  it  should  be  realised  that  it  is  more  important  to  relieve  the 
obstruction  and  do  it  quickly  than  to  carry  out.  an  operation  for  the 
removal  of  calculus  of  the  ureter.  Nephrotomy  should  be 
performed  when  the  stone  is  localised  to  the  renal  pelvis,  when  no 
accurate  localisation  of  the  stone  has  been  possible,  and  when  the 
stone  has  been  localised  in  the  ureter,  but  its  position  is  such  as  to 
necessitate  a  prolonged  operation,  which  the  patient  is  considered 
unfit  to  undergo. 

If  the  stone  is  found,  it  should  be  removed  ;  if  it  is  not  found,  a 
large  drainage  tube  should  be  placed  in  the  pelvis,  and  the  wound 
in  the  kidney  lightly  packed  with  gauze.  After  the  anuria  has 
been  relieved  an  operation  for  the  removal  of  the  obstructing 
calculus  will  be  undertaken. 

Ureterotomy  should  be  performed  when  the  obstructing  calculus 
has  been  accurately  localised  and  is  easily  accessible,  as  in  the 
lateral  vaginal  fornix,  or  in  the  middle  or  upper  segments  of  the 
ureter. 

The  nature  of  the  operation  in  forty-nine  cases  collected  by 
Morris  was  :  Nephrotomy,  thirty- four  ;  pyelotomy,  five;  ureterotomy, 
seven. 

Results. — Morris  gives  the  following  statistics  from  collected 
cases : 

(1)  Forty-eight  cases  not  operated  gave  thirty-eight  deaths  and 
ten  recoveries. 


758  Renal  Calculus. 

(2)  Forty-nine  cases  operated  gave  twenty-four  deaths  and 
twenty-five  recoveries. 

That  is  20*8  per  cent,  of  unoperated  cases  and  51  per  cent,  of 
operated  cases  recovered.  Huck  has  shown  that  the  mortality  of  cases 
operated  before  the  fourth  day  is  25  per  cent.  These  results  are 
sufficiently  striking  to  give  strong  support  to  the  surgeon  in  urging 
immediate  operation  in  all  cases.  In  the  future  these  figures  will 
be  greatly  improved  when  the  necessity  for  early  operation  is  fully 
realised. 


OPERATIVE  TREATMENT  OF  RENAL  CALCULUS. 

Cases  Unsuitable  for  Operation. — (1)  Extensive  bi-lateral  cal- 
culous  disease,  either  aseptic  with  signs  of  progressive  failure  of 
the  renal  function,  or  when  there  is  widespread  sepsis  and  ursemic 
symptoms  are  present  or  are  easily  induced  by  exposure  or  other 
causes.  These  patients  are  in  the  last  stage  of  calculous  disease. 
Operation  would  certainly  be  followed  by  death  from  anuria  or 
uraemia.  Without  operation  life  may  be  prolonged  for  some  time. 

(2)  Cases  in  which  small  calculi  are  frequently  passed,  and  the 
X-rays  do  not  show  a  large  single  shadow,  or  a  collection  of  small 
shadows  in  the  kidney.  These  cases  are  suitable  for  diuretic 
treatment. 

In  all  other  cases,  when  a  small  stone  is  shown  by  the  X-rays, 
a  trial  of  diuretic  and  medicinal  treatment  may  be  given,  but 
this  should  not  be  unduly  prolonged.  Two  or  three  months  should 
be  the  limit  set  to  medicinal  treatment. 

The  following  points  should  be  borne  in  mind  in  considering 
operation  : 

(1)  A  small  stone  may  become  engaged  in  the  renal  pelvis  and 
cause  hydronephrosis  by  obstructing  the  outflow  of  urine. 

(2)  A  small  stone  in  its  passage  down  the  ureter  may  become 
arrested  at  some  part  at  which  its  removal  by  operation  is  very 
difficult. 

(3)  Arrest  of  a  stone  in  the  ureter  frequently  causes  dilatation  of 
the  ureter  and  hydronephrosis. 

(4)  Hfematogenous  infection  of  the  urinary  tract  occurs  in  the 
majority  of  cases  of  renal  and  ureteral  calculus.     Pyelonephritis 
or  pyonephrosis  results. 

(5)  Calculi  remaining  in  the  kidney  increase  in  size  and  destroy 
the  organ  by  pressure  and  chronic  inflammation. 

(6)  The  second  kidney  becomes  affected  with  calculus  in  50  per 
cent,  of  cases. 


Renal  Calculus.  759 

(7)  The  removal  of  a  calculus  from  the  kidney  reduces  the  risk 
of  disease  in  the  second  kidney. 

(8)  The   absence  of   pain   does   not   indicate  that  the  calculus 
has  ceased  to  increase  in  size,  or  that  the  destruction  of  the  kidney 
tissue  has  been  arrested.     The  largest  renal  '  calculi  are  usually 
painless. 

The  following  information  should  be  in  the  possession  of  the 
surgeon  before  commencing  an  operation  for  the  removal  of  stone 
in  the  kidney  : 

(1)  The  position   and  number  of   calculi.     The   whole   urinary 
tract  must  be  examined  by  the  X-rays,  both  kidneys,  ureters,  the 
bladder  and  the  urethra  being  included.     The  X-ray  examination 
must  be  made  within  a  short  time  of  the  operation.     The  assistance 
of   an  opaque  bougie   in   the   ureter   is    sometimes   necessary   to 
distinguish  doubtful  shadows.     Sounding  of  the  ureter  is  often  of 
assistance   in   accurately  localising   ureteric   stone.     The   bladder 
must  be  examined  by  the  cystoscope. 

(2)  The  presence  of  a  second  kidney  and  its  functional  state. 
This  is  ascertained  by  the  examination  of  the  ureteric  orifice  and 
the  observation  of  an  efflux,  by  catheterisation  of  the  ureters,  and 
the  examination  of  the  urine  drawn  from  each  kidney,  and  the  use 
of  the  tests  for  the  renal  function. 

This  information  is  absolutely  necessary  when  there  is  a 
possibility  of  nephrectomy  being  performed. 

The  operations  which  may  be  performed  are :  Nephrolithotomy ; 
pyelolithotomy  ;  nephrectomy. 

Nephrolithotomy. — In  nephrolithotomy  the  kidney  is  exposed 
by  a  lumbar  incision  and  separated  from  its  fatty  capsule  as  far  as 
the  hilum.  It  is  then  carefully  palpated  for  a  hard  nodule  which 
would  indicate  the  presence  of  a  stone.  The  pelvis  is  also  examined 
and  the  finger  pressed  into  the  sinus  of  the  kidney.  The  further 
procedure  will  depend  upon  whether  a  hard  nodule  is  discovered  or 
not.  If  a  nodule  is  felt  in  the  substance  of  the  kidney  it  should  be 
exposed  either  by  an  incision  on  the  convex  border  of  the  organ, 
or  if  it  is  near  the  anterior  or  posterior  surface  it  may  be  cut 
upon  directly. 

Needling  the  kidney  or  a  nodule  felt  in  its  substance  is  an 
unnecessary  procedure,  for  the  reason  that  if  the  nodule  is  a  stone  it 
must  be  cut  upon,  and  if  it  is  not  a  stone,  and  also  if  no  nodule  can 
be  felt,  the  surgeon  cannot  rest  content  with  the  meagre  information 
afforded  by  passing  a  needle  into  the  kidney  substance,  but  will 
proceed  to  explore  the  organ  by  a  free  incision. 

If  nothing  has  been  felt,  the  kidney  should  be  explored.      The 


760  Renal  Calculus. 

ureter  is  first  separated  from  the  vessels  at  the  hilum,  and  the 
vessels  are  compressed  with  the  finger  and  thumb,  or  with  a  rubber 
band  fixed  with  a  pair  of  pressure  forceps.  An  incision  is  made  in 
the  convex  border  of  the  kidney  4  millimetres  behind  the  most 
prominent  line.  The  incision  is  placed  in  the  middle  of  the 
organ  and  extends  for  2  inches  or  more.  The  cut  surfaces  are 
separated  and  the  finger  introduced  into  the  renal  pelvis,  and  with 
this  and  a  metal  sound  a  careful  search  is  made  for  the  calculus. 
Instead  of  making  a  single  large  incision,  a  smaller  incision  may 
be  made  into  each  pole  of  the  kidney,  and  by  this  means  the 
extremities  of  the  organ  are  searched  and  the  portion  intervening 
between  the  incision  is  easily  examined.  If  a  stone  is  felt  in 
the  pelvis  or  a  calyx,  the  incision  should  be  extended  so  that  it  is 
exposed.  By  means  of  forceps,  or  a  fine  scoop  and  the  forefinger, 
the  calculus  is  removed.  In  some  cases  when  there  is  a  short 
pedicle,  or  in  a  stout  or  muscular  patient  with  a  narrow  loin,  the 


FIG.  1. — Thomson  Walker's  stone  forceps. 

kidney  can  only  be  partly  brought  into  the  wound.  In  such  cases 
I  use  long,  fine  forceps  with  an  angled  grasping  extremity,  which 
can  be  passed  along  the  forefinger  and  grasp  the  calculus  just 
beyond  its  tip.  (Fig.  1.) 

A  search  for  multiple  calculi  should  be  carefully  made. 
Each  calculus  should  be  examined  for  facets,  and  for  each  facet  a 
calculus  must  be  found.  A  good  radiogram  is  of  great  assistance, 
and  should  be  before  the  surgeon  at  the  operation.  In  isolated 
scattered  calculi  it  is  of  especial  value.  A  number  of  small  stones 
lying  close  together  frequently  appear  as  a  single  shadow.  Small 
seed-like  calculi  or  soft  phosphatic  material  are  removed  by  a 
copious  stream  of  warm  lotion  from  an  irrigator,  after  packing  the 
peri-renal  space  with  gauze. 

Having  removed  the  stones  from  the  kidney,  the  ureter  should 
be  carefully  examined.  The  upper  portion  is  easily  palpated  with 
the  finger  as  far  as  the  brim  of  the  pelvis.  A  long,  fine,  gum- 
elastic  bougie  of  even  calibre  is  now  passed  down  the  ureter  into 


Renal  Calculus.  761 

the  bladder.  Should  this  be  arrested  at  any  part  of  the  ureter,  the 
finger  is  passed  along  the  outside  of  the  ureter,  and  at  the  end  of 
the  bougie  a  calculus  may  be  discovered. 

A  complete  radiographic  examination  of  the  urinary  tract, 
together  with  sounding  the  ureter  before  the  operation,  will  shorten 
this  part  of  the  operation.  After  removal  of  the  calculi  the  kidney 
wound  should  be  closed  with  sutures.  Soft  catgut  sutures  are  most 
suitable — catgut  preserved  in  iodine  and  chromic  catgut  are  too 
hard  and  cut  out.  The  sutures  are  introduced  with  round,  straight 
needles  and  are  passed  about  1  inch  from  the  edge  of  the  wound. 
They  are  placed  about  \  inch  apart,  and  five  or  six  interrupted 
sutures  usually  suffice.  '  They  are  tied  slowly  and  not  too  tightly 
lest  they  cut  out  through  the  friable  kidney  substance.  When 
the  kidney  substance  has  not  been  destroyed  these  sutures  will 
suffice,  but  occasionally  it  is  necessary  to  introduce  a  mattress 
suture  to  control  bleeding  from  a  large  vessel.  If  mattress 
sutures  are  used,  a  second  row  of  interrupted  sutures  nearer  the 
edge  of  the  wound  will  be  required,  as  the  lips  of  the  renai  wound 
become  everted. 

When  the  kidney  substance  has  been  much  reduced,  there  is 
more  difficulty  in  closing  the  wound  satisfactorily.  The  thin  lips 
become  everted  or  inverted  and  there  is  some  danger  of  the  sutures 
tearing  out.  In  the  cases  in  which  I  have  had  to  remove  the 
kidney  for  severe  haemorrhage  continuing  some  days  after 
nephrolithotomy,  the  bleeding  almost  invariably  took  place  from  a 
suture  having  penetrated  into  a  dilated  calyx  and  either  cut  and 
allowed  a  vessel  to  bleed,  or  having  been  tied  too  tight  it  had  torn 
through  a  vessel. 

When  there  is  sepsis  and  dilatation  of  the  kidney,  drainage  of 
the  intra-renal  cavity  is  necessary,  and  this  is  provided  by  a  rubber 
tube  of  moderate  size,  which  is  retained  in  the  kidney  cavity  by  a 
catgut  stitch  passed  through  the  edges  of  the  kidney  incision.  The 
peri-renal  space  should  also  be  drained. 

The  treatment  of  calculous  hydronephrosis  and  pyonephrosis 
is  discussed  elsewhere. 

Dangers  of  Nephrolithotomy. — The  dangers  of  nephrolithotomy 
are  haemorrhage  and  septic  infection. 

Cases  have  been  recorded  where  at  the  end  of  the  operation  of 
nephrolithotomy  very  severe  haemorrhage  occurred  from  a  large 
vessel  and  necessitated  nephrectomy.  These  cases  are,  however, 
very  rare,  and  there  is  usually  no  difficulty  in  controlling  the 
haemorrhage  by  sutures  so  long  as  the  fibrous  capsule  is  intact.  If 
the  capsule  has  been  stripped  from  the  kidney,  the  sutures  cut  out 


762  Renal  Calculus. 

very  easily.  Bleeding  may,  however,  commence  after  the  operation 
and  the  blood  escapes  into  the  pelvis  and  causes  hsematuria.  This 
post-operative  haematuria  may  assume  serious  proportions  and 
clotting  may  occur  in  the  bladder,  or  it  may  persist  and  cause 
profound  anaemia  and  even  death. 

When  post-operative  hasmaturia  is  moderate,  treatment  by 
absolute  rest  and  the  application  of  an  icebag  together  with  small 
doses  of  morphia  and  the  administration  of  calcium  lactate  (10  to 
15  gr.  every  four  hours  for  two  days)  may  be  tried.  Should  this 
fail  to  arrest  the  bleeding,  operation  should  not  be  too  long  delayed. 
And  further,  if  the  haemorrhage  is  alarming  from  the  first,  operation 
should  be  performed  at  once. 

The  kidney  should  be  rapidly  exposed  and  the  previous  incision 
opened.  Usually  a  quantity  of  blood  escapes  under  tension.  A 
stream  of  hot  lotion  should  be  directed  into  the  cavity  and  then  a 
medium-sized  rubber  tube  introduced  into  the  renal  pelvis. 
Around  the  tube  long  strips  of  aseptic  gauze  are  packed. 

The  patient  may  be  infused  on  the  table  and  continuous  rectal 
infusion  commenced  on  returning  to  bed.  This  treatment  usually 
suffices  to  control  the  haemorrhage,  and  after  three  days  the  packing 
is  removed  and  if  necessary  renewed. 

Rarely  it  becomes  necessary  to  remove  the  kidney  in  order  to 
control  post-operative  haemorrhage. 

Sepsis  may  arise  from  a  kidney  already  infected  or  may  be 
introduced  at  the  operation.  Septic  pyelonephritis  sometimes 
follows  nephrolithotomy,  and  frequently  causes  severe  haamaturia. 

Post-operative  haematuria  combined  with  elevation  of  the 
temperature  is  usually  due  to  this  cause.  Peri-renal  suppuration 
may  occur.  The  infection  usually  subsides,  and  only  very  rarely 
is  there  an  infection  of  the  lumbar  wound,  necessitating  opening 
it  up. 

Results. — The  results  are  influenced  by  the  presence  or  absence 
of  sepsis  previous  to  the  operation.  Some  authorities,  notably 
Morris,  regard  only  such  cases  as  nephrolithotomy  in  which  the 
kidney  is  healthy  and  there  is  no  infection.  Most  surgeons  look 
upon  all  cases  of  removal  of  calculi  from  the  kidney  as  cases  of 
nephrolithotomy.  The  results  of  nephrolithotomy  in  cases  un- 
complicated by  sepsis  or  dilatation  show  a  very  small  death- 
rate.  Watson  collected  185  such  cases  with  three  deaths  (2'2  per 
cent.). 

Rovsing  collected  115  cases  of  neprolithotomy  in  non-infected 
cases  with  seven  deaths  (6'08  per  cent.). 

In  infected  cases  the  mortality  is  high.     Schmieden  collected  211 


Renal  Calculus.  763 

cases  with  forty-three  deaths  (20'3  per  cent.),  and  the  statistics  of 
Kiister  show  251  cases  with  50  deaths  (19'9  per  cent.)- 

After  nephrolithotomy  the  wound  usually  heals  rapidly  even 
when  mild  infection  has  been  present.  In  infected  cases  a  fistula 
may  persist,  and  this  is  occasionally  due  to  calculi  having  been  left 
in  the  kidney  or  to  ureteral  or  pelvic  obstruction. 

In  Schmieden's  cases  (infected)  a  fistula  followed  the  operation  in 
22*2  per  cent.  In  Watson's  collection  (infected  and  non-infected) 
there  were  8'1  per  cent,  of  fistula. 

Pyelolithotomy. — By  this  is  understood  the  removal  of  a 
calculus  through  an  incision  in  the  pelvis  of  the  kidney. 

The  posterior  wall  of  the  pelvis  is  incised  so  that  the  renal 
vessels  in  relation  to  the  anterior  wall  are  avoided.  A  posterior 
branch  of  the  renal  artery  and  irregular  vessels  must  be  avoided. 
The  kidney  is  drawn  out  of.  the  lumbar  wound.  The  organ  is 
grasped  in  the  left  hand  of  the  operator  and  turned  forwards  and 
upwards,  so  that  the  posterior  aspect  of  the  pelvis  is 
exposed.  The  fat  covering  the  pelvis  is  removed  with 
dissecting  forceps.  If  a  stone  is  felt  in  the  pelvis,  it  is  made 
prominent  by  pressure  of  the  fingers  from  the  front  of  the  pelvis 
and  a  longitudinal  incision  made  upon  it  through  the  posterior  wall. 
The  stone  is  then  removed  with  forceps.  If  a  stone  is  not  felt,  the 
kidney  is  given  to  an  assistant  to  hold  and  the  posterior  surface  of 
the  pelvis  exposed  by  dissecting  away  the  fat.  A  longitudinal 
incision  is  then  made  in  this  about  three-quarters  of  an  inch  in 
length  and  a  fine  catgut  suture  passed  through  each  lip  and  the 
wound  held  open  by  these.  A  probe  is  now  introduced  and  the 
pelvis  and  calyces  are  explored.  If  a  calculus  is  felt,  the  probe  is 
held  in  position  and  a  pair  of  fine  forceps  slipped  along  it,  the 
stone  grasped  and  removed. 

After  removal  of  the  stone  the  edges  of  the  wound  in  the  pelvis 
are  brought  together  by  interrupted  stitches  of  fine  catgut.  Over 
this  a  row  of  Lembert's  sutures  may  be  inserted. 

Since  1905  I  have  covered  all  wounds  in  the  renal  pelvis  with  a 
flap  of  the  fibrous  capsule  turned  down  from  the  kidney  and 
stitched  in  place.  This  has  proved  very  successful  in  preventing 
the  escape  of  urine  and  promoting  primary  healing.  A  drainage 
tube  is  placed  behind  the  kidney  and  the  lumbar  wound  closed. 
Usually  there  is  no  escape  of  urine,  but  occasionally  some  urine 
leaks  for  a  few  days.  Barely  this  continues  for  a  fortnight  or 
longer  and  a  urinary  fistula  may  become  established. 

The  cases  which  are  suitable  for  pyelolithotomy  are  small 
unbranched  stones  lying  in  the  pelvis. 


764  Renal  Calculus. 

As  a  method  of  exploration  of  the  kidney  for  stone,  pyelotorny  is 
usually  considered  inferior  to  nephrotomy.  The  relative  methods 
of  these  operations  will  be  discussed  later. 

Results. — In  Schmieden's  statistics  there  are  fifty-four  cases  of 
pyelolithotomy,  of  which  thirty-six  (66'7  per  cent.)  were  completely 
healed,  twelve  (22*2  per  cent.)  recovered  with  a  fistula,  and  six 
(ll'l  per  cent.)  died. 

These  operations  were  performed  only  on  uncomplicated  cases. 

The  Relative  Merits  of  Nephrolithotomy  and  Pyeloli- 
thotomy.— By  nephrolithotomy  all  calculi  which  are  not  so 
extensive  or  so  fixed  as  to  require  nephrectomy  can  be  removed. 

Pyelolithotomy  can  only  be  performed  for  small  or  moderate  sized 
calculi  occupying  the  renal  pelvis  or  calyces,  and  it  is  only  in 
regard  to  these  cases  that  the  relative  merits  of  the  two  operations 
can  be  discussed. 

In  cases  where  there  is  a  short  pedicle  and  a  deep  loin  pyelo- 
lithotomy may  be  impossible  where  nephrolithotomy  presents  no 
insuperable  difficulty. 

In  nephrolithotomy  the  incision  through  the  renal  tissue  causes 
some  destruction  of  renal  tissue,  and  the  sutures  introduced  to 
control  haemorrhage  cause  further  destruction.  Each  suture  is  a 
sclerotic  centre  and  fibrosis  may  extend  for  some  distance  around 
it.  In  pyelolithotomy  there  is  no  destruction  of  renal  tissue  by 
incision,  tearing  or  suture. 

In  nephrolithotomy  there  is  some  immediate  and  remote  danger 
of  haemorrhage ;  in  pyelolithotomy  a  retro-pelvic  vessel  may  be 
wounded,  but  there  is  little  probability  of  severe  haemorrhage.  In 
an  exploration  of  the  kidney  for  stone  which  cannot  be  felt  in  the 
pelvis,  pyelotomy  is  looked  upon  as  inferior  to  nephrotomy.  In  a 
single  large  pelvis  (ampullary  pelvis)  Legueu  looks  upon  both 
operations  as  being  equally  efficient. 

When  there  is  a  branched  pelvis  (ramified  pelvis),  nephro- 
lithotomy is  the  better  operation,  as  it  is  difficult  to  explore  all  the 
calyces  satisfactorily  with  an  instrument  and  the  small  calibre 
makes  the  introduction  of  the  finger  impossible. 

The  exploration  in  nephrotomy  is  also  difficult  in  many  cases. 
After  incising  the  kidney  the  finger  may  pass  through  the  wound 
into  the  sinus  of  the  kidney  without  entering  the  pelvis  at  all, 
and  a  probe  appears  at  the  hilum  alongside  the  pelvis.  The 
sounding  of  each  calyx  with  an  instrument  when  the  pelvis  is  much 
branched  is  less  likely  to  be  successful  through  a  nephrotomy  than 
through  a  pyelotomy  wound.  In  cases  where  a  small  radiographic 
shadow  is  present  and  the  stone  is  not  felt  in  the  renal  pelvis,  and 


Renal  Calculus.  765 

when  the  kidney  can  be  brought  out  of  the  wound,  I  usually  explore 
the  pelvis  first  by  pyelotomy  and  thorough  sounding  with  a  probe, 
and  if  this  fails,  open  the  kidney  and  explore  the  calyces  through 
both  incisions  simultaneously. 

Urinary  fistula  is  stated  to  occur  more  frequently  after  pyeloli- 
thotomy  than  after  nephrolithotomy,  and  the  statistics  of  a  number 
of  cases  support  this  view. 

The  danger  of  a  fistula  following  pyelolithotomy  has  been  over- 
stated. The  probability  of  post-operative  fistula  is  slight,  if  care  is 
taken  to  remove  any  obstruction  to  the  flow  of  urine  along  the 
ureter  and  with  accurate  suturing  of  the  pyelotomy  wound.  In 
cases  of  moderate  sized  unbranched  calculi  in  the  renal  pelvis,  and 
for  many  small  stones  concealed  in  the  calyces,  pyelolithotomy  is 
preferable  to  nephrolithotomy,  as  it  is  more  easily  performed,  there 
is  no  danger  of  haemorrhage,  and  the  kidney  is  not  damaged. 

Nephrectomy.  —  It  is  an  indispensable  preliminary  to 
nephrectomy  that  the  presence  and  functional  activity  of  the 
second  kidney  should  be  proved  before  the  operation. 

Primary  nephrectomy  is  rarely  practised  for  calculus.  Under 
the  following  conditions  it  may  become  necessary :  (1)  Severe  un- 
controllable haemorrhage  during  nephrolithotomy  ;  (2)  when  the 
kidney  is  atrophied  or  destroyed  by  suppuration  or  dilatation; 
(3)  when  calculi  are  so  numerous  and  large  that  they  cannot  be 
removed  without  destroying  the  kidney ;  (4)  a  malignant  growth 
has  been  found  with  renal  calculi  and  necessitated  nephrectomy. 

Secondary  nephrectomy  may  be  called  for  :  (1)  When  there  is 
urinary  fistula  causing  great  discomfort  irremediable  by  other 
means  ;  (2)  recurrence  of  stone  with  an  atrophied  kidney ;  (3)  pro- 
longed renal  suppuration. 

The  operation  may  be  very  difficult  on  account  of  extensive 
adhesions  to  the  peritoneum,  colon,  liver,  aorta  and  vena  cava. 
An  intra-capsular  operation  is  often  impossible  from  the  adhesion 
of  the  kidney  to  the  capsule,  or  a  portion  of  the  kidney  may 
be  shelled  out,  while  the  rest  of  the  organ  is  firmly  adherent. 
Watson  collected  the  following  statistics  :  Primary  nephrectomy, 
136  cases,  forty-one  died  (30*1  per  cent.);  secondary  nephrectomy, 
thirty-three  cases,  six  died  (18'1  per  cent.). 

Bilateral  Calculi. — It  is  unwise  to  remove  the  stones  from 
both  kidneys  at  the  same  operation.  The  best  kidney  should  first 
be  operated  on  in  case  it  may  become  necessary  to  perform 
nephrectomy  on  the  second  kidney  later.  Nephrolithotomy  should 
be  performed  on  both  sides  whenever  possible. 

Kuster    collected    twenty    double    operations,   and    found    ten 


766  Renal  Calculus. 

successful  cases,  three  recovered  with  fistulas  and  seven  died,  the 
fatal  result  being  usually  caused  by  uraemia. 

Calculus  in  a  Solitary  Kidney. — A  conservative  operation  is 
here  a  necessity.  Pyelolithotomy  is  preferred  to  nephrolithotomy 
whenever  possible.  Both  operations  have  been  successfully 
practised.  The  same  limitation  applies  to  calculus  in  a  horseshoe 
kidney. 

J.  W.  THOMSON  WALKER. 


76y 


RENAL  AND  PERI-RENAL  FISTUL/E. 

PERI-RENAL  FISTULA  may  be  connected  with  the  kidney  or  ureter, 
or  arise  apart  from  the"  urinary  organs. 

Those  unconnected  with  urinary  organs  take  origin  in  a  peri- 
nephritic  abscess,  which  may  be  secondary  to  an  empyema,  to  an 
appendix  abscess  or  some  other  cause. 

Urinary  fistulee  are  spontaneous  or  post-operative. 

Spontaneous  urinary  Jistuhe  may  result  from  the  rupture  of  an 
untreated  pyonephrosis  on  the  surface  of  the  body,  or  into  a 
bronchus,  the  stomach  or  elsewhere. 

Post-operative  Jistuhe  open  in  the  lumbar  region.  The  fistula 
may  be  intentionally  produced,  as  in  the  operation  of  nephrostomy, 
or  it  may  follow  the  operations  of  nephrolithotomy,  nephrotomy, 
pyelotorny,  or  nephrectomy. 

Before  operating  upon  a  fistula  in  the  lumbar  region  it  is 
necessary  to  obtain  the  following  information  : 

(1)  What  is  the  origin  of  the  fistula,  and  is  it  connected  with  the 
urinary  tract  ? 

The  history  of  the  case  will  point  either  to  a  renal  origin  or  to 
an  empyema  or  appendix  abscess.  The  absence  of  changes  in  the 
urine  and  the  presence  of  a  healthy  kidney  on  the  fistulous  side  is 
shown  by  cystoscopy,  and  the  examination  of  the  urine  drawn  from 
the  kidney  by  the  ureteral  catheter  will  show  that  the  fistula  is  not 
urinary.  The  discharge  from  the  fistula  should  also  be  examined 
for  urea,  which  can  be  detected  if  even  a  small  quantity  of  urine  is 
present. 

After  an  mtra-muscular  injection  of  methylene  blue  the  discharge 
will  be  tinged  with  blue  if  the  fistula  is  urinary. 

By  injecting  a  solution  or  emulsion  of  bismuth  into  the  fistula 
and  obtaining  a  radiograph  the  course  of  the  track  can  be  followed, 
and  a  cavity  in  the  thorax  or  elsewhere  may  be  demonstrated. 
There  is  frequently  a  peri-renal  cavity  which  is  not  necessarily 
connected  with  disease  in  the  kidney. 

(2)  In  a  urinary  fistula  is  the  ureter  patent  ? 

This  information  is  obtained  by  catheterisation  of  the  ureter. 

(3)  What  is  the  functional  power  of  the  fistulous  kidney  ? 

The  urine  from  both  kidneys  is  withdrawn  by  catheter,  examined 
and  compared,  and  the  discharge  from  the  fistula  is  also 


y68 


Fistulae,   Renal  and  Peri-Renal. 


examined.  The  phloridzin  and  methylene  blue  tests  of  the  renal 
function  should  be  used. 

Treatment. — In  non-urinary  peri-renal  fistulae  extensive 
operations  may  be  required,  such  as  the  exploration  of  the  peri- 
nephritic  tissue,  the  search  for  a  diseased  retro-caecal  appendix,  or 
the  obliteration  of  a  cavity  in  the  pleura  by  resection  of  ribs. 

When  a  permanent  renal  fistula  is  intentionally  produced,  the 
treatment  will  consist  in  the  provision  of  an  efficient  apparatus 


Flo.  1. — Drainage  apparatus  for  renal  fistula. 

to  collect  the  urine  discharged  and  prevent  it  from  soaking  the 
clothes. 

A  modification  of  Irving' s  supra-pubic  drainage  apparatus  is  the 
best  for  this  purpose  (Fig.  1).  It  consists  of  a  shallow  celluloid 
cup  with  rolled-over  edge,  and  a  flat  detachable  bottom  which  is 
perforated.  A  rubber  drain  opens  on  the  dependent  part  of  the 
wall  and  leads  to  a  receptacle.  The  apparatus  is  held  in  position 
by  rubber  bands  which  pass  round  the  body. 

When  a  lumbar  fistula  follows  nephrectomy,  the  cause  is  usually 
a  septic  ligature.  The  fistula  usually  penetrates  deeply  to  the 
renal  pedicle.  It  may  be  scraped  and  cleaned  out  by  means  of  a 
plug  of  gauze  rolled  round  sinus  forceps.  If  it  persists,  the  track 
should  be  dissected  out  and  pockets  opened  up. 


Fistulas,   Renal  and  Peri-Renal.  769 

In  urinary  fistula,  when  the  ureter  is  patent,  Albarran  recom- 
mends drainage  by  a  catheter  en  demeure  in  the  ureter. 

In  order  to  get  a  large  catheter  into  the  ureter  he  introduces  by 
means  of  a  cystoscope  a  large  stilette  (70  centimetres),  which  is 
flexible  for  the  first  6  centimetres.  Over  this  stilette  a  catheter  with 
a  terminal  eye  is  passed,  and  ascends  the  ureter  to  the  renal  pelvis. 

The  catheter  is  held  in  place  and  the  stilette  removed.  The 
catheter  is  left  in  the  ureter  for  four  or  five  days,  and  then  changed 
after  passing  the  stilette  as  a  guide.  Eventually  a  No.  13  F. 
catheter  may  thus  be  passed.  The  renal  pelvis  is  washed  daily  with 
silver  nitrate  solution  (1  in  1,000).  This  continuous  catheterisation 
is  maintained  for  three  weeks. 

Should  this  fail  or  be  impracticable,  a  plastic  operation  should 
be  performed  upon  the  renal  pelvis. 

If  the  ureter  is  impassable  and  the  kidney  has  been  shown  to 
retain  a  considerable  proportion  of  its  function,  a  plastic  operation 
on  the  renal  pelvis  is  necessary  ;  but  should  the  functional  value 
of  the  kidney  be  low  and  that  of  the  second  kidney  adequate, 
nephrectomy  should  be  performed. 

J.  W.  THOMSON  WALKER. 


S.T. — VOL.  II.  49 


770 


HYDRONEPHROSIS. 

THE  following  points  are  important  in  the  treatment  of  hydro- 
nephrosis : 

(1)  Unilateral  hydronephrosis  is  usually  due  to  obstruction  at 
the  upper  end  of  the  ureter,  but  occasionally  a  stone,  new  growth, 
stricture,   or   other  cause  of  obstruction  may  be  situated  at  the 
lower  end  of  the  ureter  or  at  some  intermediate  part. 

(2)  Obstruction   at  the   uretero-pelvic  junction  may  be  due  to 
stone,  valves,  stricture,  pressure  of  an  aberrant  vessel,  to  kinking 
from  undue  mobility  of  the  kidney. 

(3)  The  removal  of  a  stone  may  not  relieve  the  obstruction,  for  a 
stricture  may  co-exist. 

(4)  The   presence  of    an   aberrant   renal    artery   in   a   case   of 
hydronephrosis  cannot  be  accepted  without  further   evidence,  as 
the  cause  of  the  hydronephrosis. 

(5)  The  seat  of  the  obstruction  may  be  above  or  below  the  level 
of  crossing  of  the  aberrant  artery,  in  which  case   the  artery  is 
unconnected  with  the  obstruction. 

(6)  If  the  artery  crosses  the  ureter  at  the  level  of  obstruction,  it 
may  be  accepted  as  the  primary  cause,  but   there  may  also   be 
stenosis  at  this  level. 

(7)  Hydronephrosis  in  a  movable  kidney  may  be  due  to  kinking  of 
the  ureter,  but  there  may  be  a  valve  or  stenosis  at  the  junction  of 
the  pelvis  and  ureter,  which  is  the  true  cause  of  the  obstruction. 

(8)  In  intermittent  hydronephrosis  the  kidney  and  renal  pelvis 
do  not  contract  and  return  to  the  normal  conditions  between  the 
attacks  of  distension.     They  form  a  slack,  partly  filled  sac,  which 
is  too  soft  to  be  felt  on  abdominal  palpation. 

(9)  The  obstruction  is  usually  incomplete  even  in  the  largest 
hydronephroses.     The  urinary  tension  never,  except  in  the  latest 
stages,    becomes    so   great    that    the   renal    secretion    is   entirely 
abolished. 

Until  a  late  stage  there  is  polyuria  on  the  obstructed  side.  I 
have  observed  the  following  differences  in  the  quantity  of  urine 
secreted  in  the  two  sides  during  the  same  time  : 

Diseased  Side.  Healthy  Side. 

Case     I.     Early  stage        .         .         .     82'6  c.c.  68*4  c.c. 

,,      IL     Advanced  stage         .         .     45  c.c.  213      c.c. 

,,    III.     Complete  block          .         .     No  urine.  158'5  c.c. 

,,    IV.  No  urine.  150     c.c. 


Hydronephrosis.  771 

(10)  After  relief  of  the  obstruction  the  kidney  does  not  return 
to  normal.     In  the  early 'stage  of-  hydronephrosis  the  damage  is 
slight  and  the  functional  value  of  the  organ  is  little  impaired.     In 
the  later  stages  the  kidney  tissue  is  extensively  destroyed  and  the 
functional  value  is  much  reduced. 

(11)  Permanent  relief  of   the  obstruction   is   followed   by  con- 
siderable improvement  in  the  function  of  the  kidney. 

(12)  The  functional  value  of  a  hydronephrotic  kidney  is  usually 
much  greater  than  would  be  supposed  on  examining  the  thickness 
of  the  hydronephrotic  sac.    The  renal  tissue,  although  present  in  a 
thin  layer  and  much  damaged  by  interstitial  nephritis,  is  spread 
over  a  large  area. 

(13)  The  work  of  a  hydronephrotic  kidney  may  form  a  large 
proportion  of  the  total  renal  function. 

(14)  The  renal  tissue  is  already  much  damaged  when  the  kidney 
can  be  felt  as  a  hydronephrosis  on  abdominal  palpation. 

(15)  In  order  to  make  an  early  diagnosis  of  renal  retention  the 
capacity  of  the  renal  pelvis  should  be  measured  by  means  of  the 
ureteric  catheter,  and  the  injection  of  a  known  quantity  of  fluid, 
by  radiography  after  the  injection  of  a  non- irritating  fluid  opaque 
to  the  X-rays  and  by  measurement  of  the  size  of  the  radiographic 
shadow  of  the  kidney. 

By  these  means  distension  of  the  kidney  can  be  recognised 
before  enlargement  of  the  organ  can  be  detected  on  abdominal 
palpation. 

(16)  Bilateral  hydronephrosis  is  usually  due  to  ureteral  or  vesical 
disease  or  to  pressure  on  the  ureter  within  the  bony  pelvis.     It 
may  be  due  to  bilateral  renal  or  ureteral  calculus. 

Before  he  commences  treatment  for  hydronephrosis  the  following 
information  must  be  in  the  possession  of  the  surgeon  : 

(1)  Is  the  hydronephrosis  unilateral  or  bilateral,  and  what  is  the 
seat  of  the  obstruction  ? 

Obstruction  in  the  lower  urinary  organs  or  from  some  growth  or 
other  condition  in  the  bony  pelvis  must  be  excluded. 

(2)  What  is  the  condition  of  the  second  kidney  when  one  is 
hydronephrotic  ? 

This  information  is  obtained  by  radiography,  the  examination  of 
urine  drawn  from  this  kidney  by  the  ureteric  catheter,  and  the  use 
of  the  tests  for  the  renal  function. 

If  the  case  is  one  of  calculus  hydronephrosis,  the  radiogram  will 
show  the  position  of  the  obstructing  calculus. 

The  passage  of  a  ureteric  catheter  will  show  the  position  of  the 
obstruction. 

49—2 


772  Hydronephrosis. 

The  question  as  to  whether  the  hydronephrosis  is  unilateral  or 
bilateral  is  settled  by  the  history  of  the  case,  by  abdominal 
palpation,  by  catheterisation  of  the  ureters,  and,  if  necessary,  by 
pyelography. 

(3)  What  is  the  cause  of  the  obstruction  ?  A  careful  radio- 
graphic  examination  should  be  made  of  the  whole  urinary  tract. 
A  ureteral  calculus  may  be  felt  from  the  vagina  or  rectum. 

A  movable-kidney  may  be  present,  and  have  existed  for  some 
years.  Beyond  these  points  no  further  information  is  likely  to  be 
obtained  in  regard  to  the  cause  before  operation. 

Congenital  Hydronephrosis. — Hydronephrosis  in  the  new- 
born and  infant  is  more  frequently  of  interest  to  the  obstetrician 
than  to  the  surgeon  on  account  of  the  difficulty  in  parturition 
to  which  it  may  give  rise.  The  condition  is  frequently  associated 
with  congenital  malformations,  such  as  harelip,  imperforate  anus, 
etc.,  and  the  child  seldom  survives  birth  for  more  than  a  few 
hours,  occasionally  a  few  months,  and  very  rarely  four  or  five 
years.  Morris  performed  bilateral  nephrotomy  on  a  male  child 
within  twenty-four  hours  of  its  birth,  and  the  child  survived 
ninety-four  days. 

Hydronephrosis  due  to  Obstruction  in  the  Urethra,  Bladder, 
or  Bony  Pelvis. — In  cases  of  urethral  obstruction  from  stricture 
or  enlarged  prostate,  operations  will  be  undertaken  for  the  relief 
of  these  conditions.  The  presence  of  dilatation  of  the  kidneys 
in  these  cases  and  in  cases  of  growths  of  the  pelvic  organs,  such  as 
uterine  and  ovarian  tumours,  greatly  increases  gravity  of  such 
operations. 

In  growths  of  the  bladder  which  involve  one  ureter  causing  a 
moderate  degree  of  hydronephrosis,  but  which  are  in  other  respects 
suitable  for  operation,  removal  of  the  growths  with  transplantation 
of  the  ureter  to  some  other  part  of  the  bladder  should  be  under- 
taken. No  direct  operative  treatment  of  the  hydronephrosis  will 
be  necessary  in  these  cases. 

In  nearly  all  these  cases  the  formation  of  a  hydronephrosis  can 
be  prevented  by  early  operation,  and  this  is  especially  true  in  cases 
of  urethral  obstruction  and  of  bladder  growth. 

Movable  Kidney  with  Hydronephrosis.  —  In  cases  where 
hydronephrosis  is  combined  with  undue  mobility  of  the  kidney,  the 
mobility  is  not  always,  at  the  time  of  operation,  the  cause  of  the 
obstruction  ;  strictures,  valves  and  adhesions  may  be  found,  the 
removal  of  which  is  necessary  for  the  relief  of  the  obstruction. 

But  in  many  cases  the  mobility  is  the  direct  cause  of  the 
ureteric  obstruction.  In  cases  of  movable  kidney  hollowing  of  the 


Hydronephrosis. 


773 


organ  with  slight  distension  of  the  pelvis  is  frequently  discovered. 
In  these  cases  nephropexy  will  be  sufficient  to  cure  the  hydrone- 
phrosis. 

The  early  diagnosis  of  these  cases  is  possible  by  the  methods 
described,  and  early  operation  should  be  insisted  upon  in  order  to 
prevent  destruction  of  the  kidney 'tissue. 

In  more  advanced  cases,  even  when  no  sign  of  narrowing  or 
adhesion  or  permanent  kinking  is  found  on  exposure  of  the 
kidney,  the  renal  pelvis  must  be  opened  and  the  patency  of  the 
outlet  and  the  ureter  examined. 

When  a  plastic  operation  has  been  found  necessary  in  such 
cases  nephropexy  must  afterwards  be  performed. 

Hydronephrosis  with  Calculus.  -  When  calculus  in  the 
ureter  or  renal  pelvis 
is  combined  with  hydro- 
nephrosis  the  distension 
of  the  kidney  has  fre- 
quently arisen  from  this 
cause,  but  in  many  cases 
strictures  of  the  ureter 
are  present,  and  have 
either  preceded  the  for- 
mation of  calculus  or 
developed  secondarily. 

In  addition  to  the 
removal  of  the  calculus, 
the  ureter  must  there- 
fore be  examined  for  the 
presence  of  stricture. 

Hydronephrosis 
with  Aberrant  Vessels. — In  cases  where  an  aberrant  vessel  is 
found,  which  bears  no  close  relation  to  the  point  of  obstruction, 
it  need  only  be  divided,  if  it  interferes  with  the  plastic  operation 
for  the  relief  of  the  obstruction.  In  other  cases  it  lies  in  close 
relation  to  the  point  of  obstruction,  and  is  evidently  the  cause  of 
the  obstruction. 

If  it  is  an  unimportant  vessel  passing  to  the  hilum  or  to  the 
peri-renal  tissues  or  an  additional  vessel  arising  from  the  aorta,  it 
should  be  divided  between  two  ligatures  and  the  patency  of  the 
ureter  then  examined,  and,  if  necessary,  a  plastic  operation  per- 
formed. If,  however,  the  aberrant  vessel  is  an  important  artery 
passing  to  the  lower  pole  of  the  kidney,  and  it  is  not  proposed  to 
perform  nephrectomy,  the  vessel  should  be  preserved  and  some 


FIG.  1. — Pyeloplication. 


774 


Hydronephrosis. 


form  of  plastic  operation  carried  out  which  will  circumvent  the 
obstruction  caused  by  it. 

Operations  for  Congenital  and  Acquired  Malformations  of 
the  Ureter.  -  -  (1)  Operations  which  modify  the  form  of  the  renal 
pelvis  : 

(a)  Nephropexy  in  intermittent  hydronephrosis.  The  kidney  is 
not  only  raised  and  fixed,  but  the  pelvis  resumes  its  old  form, 
provided  that  the  distension  has  not  been  too  long  established  and 
led  to  a  weakening  and  sagging  of  the  sac  wall. 

(6)  To    remove   the   pouching  Israel   introduced   an    operation 


FlO.  2. — Resection  of  renal 
pelvis.  Triangular  por- 
tion thrown  down. 


FIG.  3. — Resection  of  renal  pelvis.  Triangular 
portion  removed,  stitching  wall  of  reduced 
pelvis. 


"  pyeloplication,"  by  which  the  redundant  part  of  the  wall  is  folded 
inwards  after  emptying  the  sac  by  puncture.  A  row  of  Lernbert 
sutures  fix  the  fold.  In  addition,  an  operation  may  be  performed 
to  correct  any  malformation  of  the  uretero-pelvic  junction  (Fig.  1). 
(c)  The  writer  resects  a  large  triangular  portion  of  the  renal 
pelvis,  the  apex  of  the  triangle  being  at  the  uretero-peivic  junction, 
and  the  base  at  the  margin  of  the  kidney.  A  plastic  operation  for 
relief  of  any  malformation  of  the  uretero-pelvic  junction  is  then 
performed,  and  the  wound  closed  by  Lembert's  sutures.  A  flap  of 
renal  capsule  is  reflected  and  stitched  over  the  pelvic  wound,  the 
kidney  drained  through  a  nephrotomy  wound  and  fixed  to  the 
posterior  abdominal  wall  (Figs.  2,  3,  4,  5). 


Hydronephrosis. 


775 


(d)  "  Orthopaedic  resection  "  or  capitonnage.     Albarran  removes 
the   pouch   consisting   of    the   portion   of   the  pelvis  and  kidney 


FIG.  4. — Resection  of  renal  pelvis. 
Pelvic  wound  closed,  flap  of  renal 
capsule  marked  by  dotted  line. 


FIG.  5. — Resection  of  renal  pelvis.  Flap 
of  renal  capsule  stitched  over  pelvic 
wound  and  nephrotomy  wound  closed. 


which  lies  below  the  level  of  the  outlet  of  the  pelvis,  and  sutures 
the  opening  (Figs.  6,  7). 

(2)  Pyelo-ureteral  A  nastoinosis  :  (a)  Lateral  anastomosis.     This  is 


FIG.  6. — Orthopaedic  resection, 
incision. 


Line  of 


FIG.  7.— Orthopaedic  resection.  Pouch 
removed,  closing  wound  by  inter- 
rupted sutures. 


the  oldest  plastic  operation  for  hydronephrosis,  and  was  performed 
by  Trendelenberg  in  1886  (Fig.  8).  The  ureter  is  split  longitudi- 
nally on  a  level  with  the  lowest  part  of  the  hydronephrotic  sac  and 


Hydronephrosis. 


a  transverse  incision  is  made  in  the  sac  wall.     The  edges  of  these 
wounds  are  sutured  and  the  kidney  is  drained  and  fixed  (Fig.  9). 


FIG.    8. — Lateral    anastomosis    of    kidney        FIG.  9. — Detail  of  stitching  in  lateral 
and  ureter.  anastomosis  of  kidney  and  ureter. 

(b)  Transplantation  of  the  ureter  into  the  lowest  part  of  the  sac 
(uretero-pyelo-neostomy)  (Fig.  10). 

The  ureter  is  cut  across  transversely  or  obliquely  and  in  addition 


FIG.  10. — Uretero-pyelo-neostomy. 


FlG.  11. — Detail  of  stitching  in  uretero- 
pyelo-neostomy. 


it  may  be  split  longitudinally  to  prevent  stenosis.  An  incision  is 
made  into  the  lowest  part  of  the  sac,  a  small  triangular  portion 
excised  and  the  ureteral  mucous  membrane  is  sutured  to  the  pelvic 
mucous  membrane  (Fig.  11). 


Hydronephrosis. 


777 


(c)  Nephro-cysto- anastomosis  :  This  is  the  direct  anastomosis  of 
a  hydronephrotic  sac  with  a  bladder,  and  has  been  performed  in 
cases  of  displaced  hydronephrotic  solitary  kidney.  The  operation 
is  performed  intra-peritonealiy.  The  sac  is  emptied  by  puncture  and 
the  peritoneum  over  its  lowest  part  incised  and  brought  into  contact 
with  an  incision  in  the  upper  posterior  peritoneal  surface  of  the 
bladder  and  the  edges  sutured. 

(3)  Plastic  Operations  on  Strictures  and  Valves :  (a)  Incision  of 
a  valve.  This  is  performed  through  a  nephrotomy  wound  or  a  large 
opening  in  the  posterior  wall  of  the  dilated  sac.  The  pyelo-ureteral 
opening  is  found  and  one  blade  of  a  pair  of  scissors  introduced  into 
it.  The  valve  is  then  cut  downwrards.  If  it  is  thin  and  formed 


FIG.  12. — Operation  for  pyelo-ureteral 
valve.  Incision  in  posterior  wall  of 
pelvis. 


FIG.  13. — Operation  for  pyelo-ureteral 
valve.  Scissors  in  position  for  cutting 
valve. 


only  of  mucous  membrane,  this  will  suffice ;  usually,  however,  the 
thickness  of  the  pelvic  and  ureteral  walls  are  cut  through  and  these 
are  sutured  to  each  other  (Figs.  12,  13,  14,  15). 

(b)  Uretero-pyeloplasty  :  This  consists  in  making  a  longitudinal 
incision  through  a  stricture  at  the  uretero-pelvic  junction  and 
uniting  the  edges  of  the  wound  transversely  (Fig.  16). 

General  Observations. — (1)  These  operations  are  performed  on 
aseptic  or  on  mildly  infected  hydronephrotic  sacs. 

(2)  When  infection  is  present,  a  preliminary  nephrotomy  with 
drainage  for  some  weeks  should  be  carried  out. 

(3)  The   lumbar   extra -peritoneal   route   is   used   in   all   except 
nephro-cystostomy. 

(4)  Adhesions  of  the  hydronephrotic  sac  and  ureter  should  be 
removed  before  commencing  the  plastic  operations. 


778 


Hydronephrosis. 


(5)  Operations  on  the  renal  pelvis  are  performed  on  the  posterior 
surface.     The  renal  vessels  are  usually  adherent  to  and  stretched 
over  the  anterior  surface. 

(6)  Before  commencing  the  operation  a  catheter  should  be  passed 


FIG.  14. — Operation  for  pyelo-ureteral 
valve.  Valve  cut,  stitching  of  edges 
of  ureter  and  pelvis  commenced. 


FIG.   15. — Operation   for    pyelo-ureteral 
valve.     Stitching  completed. 


up  the  ureter  from  the  bladder  to  ascertain  the  position  of  the 
obstruction  and  assist  in  the  operative  measures. 

(7)  The  pelvic  outlet  may  be  examined  through  a  nephrotomy  or 
pyelotomy  wound  and   the   examination   is   rendered   simpler  by 
everting  this  part  of  the  sac  through  the  wound. 

(8)  The  sac  should  be  drained  through  a  nephrotomy  wound. 


FIG.  16. — Uretero-pyeloplasty.    a.  Longitudinal  incision  through  stricture. 
b,  c.  Edges  united  transversely. 

Some  surgeons  leave  a  ureteric  catheter  in  situ,  but  this  is  not 
necessary  and  may  be  a  source  of  irritation. 

(9)  Nephropexy  is  an  important  part  of  many  of  these  opera- 
tions. 

(10)  Catgut  should  be  used  as  a  suture  material. 


Hydronephrosis. 


779 


Nephrostomy. — Incision  and  drainage  of  the  sac  without  any 
attempt  to  overcome  the  cause  of.  the  obstruction  is  sometimes 
performed.  This  has  been  followed  in  between  30  and  45  per  cent, 
of  cases  by  re-establishment  of  the  flow  of  the  urine  through  the 
ureter  and  healing  of  the  nephrotomy  wound.  In  the  remaining 
cases  a  fistula  persisted. 

Results  of  Plastic  Operations. — Schloffer  collected  eighty-six 
operations,  with  the  following  results  : 


— 

Operations. 

Deaths. 

Failures. 

Section  of  valves  . 

12 

1 

3 

Uretero-pyeloplasty 

18 

1 

4 

Uretero-pyelo-neostomy 

Lateral  anastomosis 

19 
13 

2 
2 

6 
3 

Plastic  operations  on  renal 

pelvis 

1 

— 

1 

Pyelopli  cation 

4 

— 

— 

Orthopaedic  resection   . 
Combined  operations    . 

8 
11 

1 

— 

Total 

86 

7 

17 

To  this  I  can  add  three  personal  cases  treated  by  my  method,  with 
two  successes  and  one  failure  due  to  haemorrhage  into  the  resected 
pelvis.  This  patient  was  submitted  to  nephrectorny  and  recovered. 
I  also  had  a  successful  result  in  a  case  of  pyelo-ureteral  anastomosis. 

Nephrectomy. — Primary  nephrectorny  is  only  indicated  when 
the  sac  is  very  large  and  its  wall  so  thin  and  fibrous  that  no 
renal  tissue  is  present,  and  only  in  cases  when  it  can  be  proved 
that  a  second  kidney  is  present  and  efficient. 

Secondary  nephrectorny  is  required  when  nephrotomy  and  plastic 
operations  have  failed. 

J.  W.  THOMSON  WALKER. 


780 


INJURIES    OF   THE    KIDNEY. 
INJURIES  OF  THE  KIDNEY  WITHOUT  EXTERNAL  WOUND. 

IN  eases  of  slight  and  moderately  severe  uncomplicated  rupture 
of  the  kidney  the  treatment  is  non-operative.  The  side  is  strapped 
with  adhesive  plaster  reaching  to  the  middle  line  in  front  and 
behind  to  prevent  movement,  and  a  broad  bandage  is  applied  over 
this  to  give  pressure.  Ice-bags  should  be  placed  over  and  under 
the  loin,  and  the  patient  kept  absolutely  quiet  in  the  recumbent 
position.  The  food  should  be  fluid.  Haemostatics  are  of  little 
value,  and  those  which  raise  the  blood-pressure,  such  as  ergot,  are 
harmful.  Calcium  lactate  in  doses  of  10  to  15  gr.  every  four  hours 
may  be  tried.  It  should  not  be  continued  longer  than  forty-eight 
hours.  Morphia  should  be  given  hypodermically,  and  serves  the 
double  purpose  of  relieving  pain  and  quieting  the  circulation. 
Shock,  if  not  profound,  should  not  be  too  energetically  treated 
lest  bleeding  be  encouraged.  Warmth  to  the  extremities  and  the 
recumbent  position  will  usually  suffice.  If  the  patient  cannot  pass 
water,  the  bladder  should  be  emptied  by  catheter  under  the  most 
rigid  aseptic  precautions.  Clots,  if  numerous,  may  be  washed  out. 
If  the  bladder  is  distended,. and  on  passing  a  catheter  only  a  little 
bloody  urine  is  drawn,  there  is  an  accumulation  or  clot  in  the 
bladder  which  cannot  be  removed  by  catheter.  An  attempt  may 
be  made  by  means  of  a  large  evacuating  cannula  and  bulb,  such  as 
is  used  after  the  operation  of  lithotrity,  to  remove  the  clots  by 
suction ;  but  this  method  should  not  be  persisted  in  if  it  is  not 
quickly  successful.  The  bladder  should,  in  case  of  failure,  be 
opened  supra-pubically,  the  clots  cleared  out,  and  a  large  rubber 
drainage  tube  introduced.  The  operation  should  be  rapidly  carried 
out.  Should  no  such  complications  supervene,  the  patient  should 
be  kept  in  bed  for  a  fortnight  after  the  haemorrhage  has  ceased 
and  all  local  tenderness  and  swelling  have  disappeared. 

Operative  interference  may  be  required  for  the  following 
conditions  :  (1)  Immediate  severe  haemorrhage ;  (2)  delayed  severe 
haemorrhage ;  (3)  suppuration  of  the  injured  kidney  ;  (4)  septic 
peritonitis ;  (5)  hydronephrosis,  pyonephrosis.  When  there  is  a 
rapidly  increased  swelling  in  the  region  of  the  kidney  or  free  fluid  in 
the  peritoneum  or  severe  persistent  hasmaturia,  and  especially  when 
there  is  progressive  ansemia,  operation  is  necessary  to  control  the 


Injuries  of  the  Kidney.  781 

bleeding.  An  oblique  lumbar  incision  should  be  made  and  the 
damaged  kidney  exposed  ;  clots  are  cleared  away  and  a  careful 
search  made  for  the  bleeding  point.  It  may  be  necessary,  when 
the  haemorrhage  is  free,  to  compress  the  renal  pedicle  with  the 
thumb  and  fingers.  A  single  tear  in  the  kidney  substance  should 
be  closed  by  catgut  sutures  passed  through  the  substance  of  the 
kidney.  If  one  or  several  portions  are  partly  detached  by  a  number 
of  lacerations,  packing  with  strips  of  sterilised  gauze  should  be 
resorted  to,  and  will  successfully  control  the  bleeding. 

When  a  large  branch  of  the  renal  artery  is  the  source  of  haemor- 
rhage it  should,  if  possible,  be  picked  up  in  long  artery  forceps  and 
tied  with  a  silk  ligature.  It  may  be  necessary  to  underrun  the 
vessel  with  a  curved  needle  and  silk  in  order  to  tie  it  securely. 

A  distended  renal  pelvis  should  be  incised  and  the  clots  turned 
out.  If  this  is  followed  by  considerable  haemorrhage,  the  pelvis 
may  be  packed  with  gauze. 

Detached  portions  and  shreds  of  kidney  tissue  should  be  removed, 
and  rents  repaired  as  far  as  possible. 

When  the  kidney  is  injured  so  that  repair  does  not  appear 
possible,  primary  nephrectomy  should  be  performed. 

All  operative  measures  should  be  carried  out  with  the  utmost 
despatch,  and  when  the  haemorrhage  has  been  controlled,  rectal 
and  intra- venous  infusion  of  glucose  solution  (2^  per  cent.)  should 
be  given. 

When  there  is  free  fluid  in  the  peritoneum  and  the  diagnosis  of 
injury  to  the  kidney  is  clearly  established,  the  kidney  should  first 
be  exposed  and  dealt  with,  and  the  peritoneal  cavity  cleared  of  clots 
and  blood  by  an  extension  of  the  lumbar  incision.  When  the 
diagnosis  of  injury  to  the  kidney  is  uncertain,  an  exploratory 
laparotomy  will  be  necessary,  the  abdomen  being  opened  in  the 
middle  line. 

Nephrectomy  is  called  for  when  there  are  recurrent  attacks  of 
haemorrhage  after  injury  to  the  kidney. 

Suppuration  of  the  damaged  kidney  necessitates  lumbar  explora- 
tion. Free  incision,  irrigation  and  drainage  may  be  all  that  is 
necessary,  but  nephrectomy  should  be  performed  if  there  is 
extensive  destruction  of  the  kidney  tissue. 

Laparotomy  and  drainage  of  the  peritoneal  cavity  will  become 
necessary  if  septic  peritonitis  supervenes. 

Persistent  anuria  should  be  treated  by  nephrotomy  and  packing. 
The  treatment  of  hydronephrosis  and  pyonephrosis  are  discussed 
under  their  proper  headings. 

Results. — Prognosis   is    chiefly   affected   by   haemorrhage    and 


782  Injuries  of  the  Kidney. 

injury  to  other  organs.  Recovery  takes  place  in  70  per  cent,  of 
uncomplicated  cases.  Grawitz  found  that  fifty-eight  out  of  108 
cases  of  injury  to  the  kidney  recovered. 

The  fatal  result  in  fifty  cases  was  caused  by  injury  to  other  vital 
organs  in  eighteen,  immediate  haemorrhage  in  fourteen,  delayed 
haemorrhage  in  eight,  suppuration  in  seven,  and  failure  of  the  renal 
function  in  three.  The  mortality  is  much  higher  in  children  than 
in  adults,  owing  to  the  greater  frequency  with  which  the  peritoneum 
is  ruptured. 

The  results  of  operative  treatment  in  injuries  of  the  kidney 
have  greatly  improved  in  recent  years  since  the  necessity  of  early 
aseptic  operation  has  been  recognised. 

Of  thirteen  cases  of  nephrectomy  performed  on  account  of 
dangerous  haemorrhage  only  four  died,  and  the  six  patients  operated 
on  most  recently  all  recovered  (Guterbock).  Willis  collected 
fourteen  cases  of  nephrectomy  for  injury  to  the  kidney,  with  nine 
recoveries  and  five  deaths. 

Albarran  knows  of  six  cases  of  operation  in  which  packing  of  the 
injured  kidney  was  resorted  to,  and  all  recovered. 

The  operative  interference  in  septic  complications  is  frequently 
postponed  until  too  late  and  the  already  exhausted  patient  succumbs. 
In  seven  nephrectomies  of  this  nature,  four  resulted  fatally. 
Nephrotomy  has  also  a  high  mortality ;  of  eight  cases  four  died 
after  the  operation,  and  another  after  a  second  nephrotomy 
(Guterbock). 

The  following  general  statistics  may  be  quoted  from  Eiese  : 
Of  490  cases  of  uncomplicated  subcutaneous  injuries  to  the 
kidney,  ninety-three  (18'9  per  cent.)  died.  There  were  327  treated 
by  expectant  treatment,  and  of  these  sixty-nine  (21*1  per  cent.) 
died,  forty  of  the  deaths  being  due  to  haemorrhage.  In  eighty-five 
cases  a  conservative  operation  was  performed  (forty-six  times  on 
account  of  bleeding),  and  ten  died  (11'7  per  cent.).  In  seventy-eight 
cases  nephrectomy  was  performed  (fifty-four  on  account  of  bleeding) 
and  fourteen  died  (17'9  per  cent.). 

INJURIES  TO  THE  KIDNEY  WITH  EXTERNAL  WOUND. 

The  external  wound  may  lie  in  the  loin  or  on  the  anterior 
surface  of  the  abdomen  or  over  the  ribs,  and  according  to  the 
site  and  direction  of  the  wound  the  intestine,  liver,  spleen,  or 
pleura  may  be  wounded. 

Any  part  of  the  organ  may  be  affected,  and  portions  may  be 
detached  by  bullet  wounds.  In  the  older  forms  of  bullet,  the  ball 
and  portions  of  clothing  might  be  embedded  in  the  organ  and 


Injuries  of  the  Kidney.  783 

remain  for  considerable  periods.  A  bullet  may  have  a  bursting 
action  on  the  kidney  and  cause  extensive  destruction  of  its 
substance. 

The  blood  escapes  by  the  external  wound,  and  if  the  calices  or 
the  pelvis  of  the  kidney  are  wounded,  urine  escapes  along  with  it. 
There  is  no  peri-renal  accumulation  of  blood,  unless  in  rare  cases 
when  the  wound  is  a  long  sinuous  track. 

The  kidney  may  partly  prolapse  from  a  large  wound. 

The  wound  is  almost  invariably  infected,  so  that  primary  union 
is  very  rare,  and  prolonged  suppuration  is  common. 

Urinary  fistulas  occur,  but  seldom  persist. 

External  haemorrhage  from  stab  wounds  may  be  severe  and 
rapidly  fatal.  In  bullet  wounds  the  haemorrhage  is  seldom  severe, 
but  it  may  be  intermittent,  recommencing  after  an  interval  of 
several  days. 

The  escape  of  urine  seldom  takes  place  at  first.  It  usually 
appears  when  the  bleeding  is  diminishing,  after  a  few  days. 

Septic  complications  occur  about  the  fourth  or  fifth  day. 

Treatment. — If  the  external  haemorrhage  is  moderate  and  dimi- 
nishing, it  will  suffice  to  clean  and  dress  the  wound.  A  careful 
watch  is  kept  for  recurrent  haemorrhage  and  septic  complications. 

If  there  is  any  reason  to  suspect  that  a  foreign  body  is  lodged 
in  the  wound,  the  track  should  be  freely  opened  up  and  the  kidney 
exposed  and  examined. 

If  the  haemorrhage  is  severe  and  persistent,  the  kidney  should  be 
exposed  by  an  oblique  lumbar  incision.  A  single  wound  in  the 
kidney  may  be  closed  with  catgut  sutures.  Detached  portions  of 
the  kidney  may  require  removal,  or  if  the  kidney  is  extensively 
lacerated,  nephrectomy  may  be  necessary. 

When  a  large  vessel  is  wounded  at  the  hilum  it  may  be  very 
difficult  to  control  the  haemorrhage,  and  clamps  must  be  placed 
upon  the  pedicle.  If  the  blood-supply  of  the  kidney  is  entirely 
cut  off  in  this  way,  it  will  be  necessary  to  remove  the  kidney. 

Kiister  advises  that,  when  a  doubt  exists  as  to  the  blood-supply 
being  sufficient  to  nourish  the  kidney,  the  clamps  be  left  on  for  a 
day,  and  then  be  removed  on  the  operating  table. 

If  the  kidney  now  bleeds  when  it  is  pricked,  it  may  be  left 
and  packed  with  gauze.  If  it  fails  to  bleed,  nephrectomy  is 
performed. 

A  kidney  prolapsed  into  a  large  lumbar  wound  is  cleansed, 
examined  and  replaced,  fixing  it  in  position  by  means  of  catgut 
stitches.  The  wound  is  then  cleansed  and  partly  closed,  and  a 
large  drainage  tube  inserted. 


784  Injuries  of  the  Kidney. 

In  complicated  cases,  when  it  is  probable  that  other  organs  are 
wounded,  an  exploratory  laparotomy  will  be  necessary. 

Results, — In  wounds  of  the  kidney  the  prognosis  is  compara- 
tively good,  and  operation  is  frequently  undertaken  with  success. 
Wounds  of  other  organs  increase  the  gravity  of  the  prognosis. 
Tuffier  found  in  thirty-one  cases  eight  died,  and  in  six  of  these  the 
fatal  result  was  due  to  complicating  injuries. 

The  mortality  of  incised  wounds  of  the  kidney  is  as  low  as 
15  per  cent.  (Albarran) ;  but  bullet  wounds  have  a  high  mortality, 
namely,  53  per  cent.  (Kiister). 

The  mortality  of  bullet  and  other  wounds  of  the  kidney  in  the 
American  Civil  War  was  66'2  per  cent. 

The  statistics  are  all  compiled  from  cases  treated  before  the 
development  of  aseptic  wound  treatment  and  abdominal  surgery. 
The  duration  of  healing  varies  from  three  weeks  to  three  months  ; 
rarely  it  may  be  prolonged  to  two  years. 

After  healing  of  the  wound,  sequelae,  such  as  inflammation  in  the 
urinary  track,  fistulae,  etc.,  may  cause  chronic  invalidism.  In 
fifty-two  recently  healed  wounds  of  the  kidney,  Tuffier  found 
twenty-two  with  sequelae. 

Primary  union  is  very  rare,  and  prolonged  suppuration  is 
common.  Urinary  fistulae  occur,  but  seldom  persist.  In  the 
American  Civil  War  there  was  only  one  permanent  fistula  in 
seventy-four  cases  of  bullet  wounds  of  the  kidney. 

When  healing  has  taken  place  the  kidney  is  usually  extensively 
destroyed,  and  presents  irregular  depressed  scars  and  extensive 
adhesions  to  neighbouring  parts. 

J.  W.  THOMSON  WALKER. 


785 


MOVABLE  KIDNEY. 

THE  following  points  are  important  in  considering  the  treatment 
of  movable  kidney : 

(1)  Dilatation  of  the  renal  pelvis  and  kidney  develops  in  varying 
degree  in  the  majority  of  movable  kidneys  from  kinking  of  the 
ureter  or  pressure  upon  it  of  bands,  or  from  other  causes. 

(2)  When  the  hydronephrosis  can  be   detected     by    palpation, 
either   as  intermittent   or  permanent  enlargement  of  the  kidney, 
the  destruction  of  secreting  tissue  of  the  kidney  is  already  extensive, 
and  although  considerable  functional  activity  may  remain,  the  kidney 
is  permanently  damaged. 

(3)  If  the  undue  mobility  is  relieved  in  the  early  stage,  the 
destruction  of  kidney  tissue  is  arrested  or  prevented. 

(4)  The  early  symptoms  of  obstruction  in   movable  kidney  are 
insignificant,  and  are  likely  to  be  overlooked. 

(5)  Dilatation  of  the  kidney  in  the  early  stage  may  be  diagnosed 
by  estimating  the  capacity  of  the  renal  pelvis  after  catheterisation 
of  the  ureters,   by  radiography  after  filling  the  renal  pelvis  with 
an  opaque  fluid,  such  as  collargol  (pyelography) ,  and  by  measure- 
ment of  the  kidney  shadow  on  a  radiographic  plate  (proportional 
renal  mensuration).     These  methods  are  harmless  in  the  hands  of 
an  expert  urinary  surgeon. 

(6)  Some  other  disease,  such  as  stone  or  tuberculosis,  may  be 
present  in  addition  to  the  abnormal  mobility  of  the  kidney. 

(7)  When  the  movable  kidney  is  hydronephrotic,  the  obstruction 
may  be  due  to  some  condition,  such  as  stenosis  of  the  ureter,  or  the 
pressure  of  an  aberrant  vessel,  which  is  not  relieved  by  nephropexy. 

The  Selection  of  Cases. — The  careful  selection  of  cases  for  the 
different  methods  of  treatment  is  the  only  means  of  obtaining  satis- 
factory results.  In  cases  where  no  symptoms  are  present,  and  there 
does  not  appear  to  be  any  change  taking  place  in  the  kidney  itself, 
as  shown  by  enlargement  or  tenderness  of  the  organ,  or  changes 
in  the  urine,  it  will  only  be  necessary  to  limit  violent  exercises, 
such  as  horse-riding,  and  to  warn  the  patient  against  lifting 
heavy  weights.  The  bowels  should  be  carefully  regulated.  Should 
symptoms  appear,  active  treatment  of  the  condition  will  become 
necessary.  In  cases  where  symptoms  are  present  a  choice  will  have 
to  be  made  between  palliative  and  operative  treatment. 

S.T.— VOL.  ii.  50 


786  Movable  Kidney. 

In  certain  cases  palliative  treatment  is  contra-indicated,  and 
operative  treatment  is  imperative  : 

(1)  Where  there  are  signs  that  the  mobility  is  causing  disease  of 
the   kidney.      This   includes  cases  where  the  kidney  is  tender  or 
enlarged,  cases  of  intermittent  hydronephrosis,  cases  where  haerna- 
turia  or  albuminuria  are  present  or  there  are  tube  casts  in  the 
urine,  or  where  slight  or  severe  attacks  of  torsion  of  the  renal  pedicle 
have  occurred. 

(2)  Where  the  kidney  is  exerting  harmful  traction   upon  other 
organs.     This  includes  cases  where  there  are  gastric  and  intestinal 
crises,  and  attacks  of  jaundice. 

(3)  Where   the  kidney   lies  below   the  waist  line,    and    is   un- 
controlled by  any  mechanical  apparatus,  and  when  the  use  of  a 
mechanical  apparatus  causes  pain  and  aggravates  the  symptoms. 

(4)  When  the  patient  is  going  to  reside  in  tropical  or  uncivilised 
countries. 

(5)  When  the  patient  has  to  perform  manual  labour,  and  the 
expense  of   maintaining  an  apparatus  in    good    order  cannot    be 
borne. 

In  all  other  cases  palliative  treatment  may  be  tried  before 
resorting  to  operation. 

In  cei'tain  cases  operative  treatment  is  doomed  to  failure,  and  is 
therefore  contra-indicated  : 

(1)  When  general  enteroptosis  is  present. 

(2)  When  severe  neurasthenia  is  present,  and  no  symptoms  can 
be  referred  to  the  kidney. 

In  a  few  cases  of  movable  kidney  with  neurasthenia,  control  of 
the  renal  movements  by  a  mechanical  apparatus  will  alleviate  or 
cure  the  neurasthenia,  and  in  these  cases  also  fixation  of  the 
kidney  by  operation  will  be  followed  by  a  similar  result.  This 
view  is  generally  held,  but  a  few  writers  go  further  and  advo- 
cate operation  in  all  cases  of  neurasthenia  with  movable  kidney. 

Palliative  Treatment. — (1)  Treatment  by  rest  and  increasing 
the  body  fat. — It  is  claimed  by  a  very  few  writers  that  this  method 
can  bring  about  a  cure  of  the  renal  mobility.  They  hope  by 
increasing  the  general  fat  of  the  body  to  produce  a  simultaneous 
deposit  around  the  kidney  which  will  fix  it  in  position.  Such  a 
result  is  not  obtained  in  practice.  The  method  is,  however,  useful 
in  treating  cases  of  movable  kidney  when  neurasthenic  symptoms 
are  present.  In  these  cases  a  "  rest  cure "  should  be  the  first 
resort,  and  an  operation  the  last. 

The  patient  is  strictly  confined  to  bed,  and  in  severe  cases  full 
Weir-Mitchell  isolation  should  be  exacted.  The  bowels  are  carefully 


Movable  Kidney. 


787 


regulated,  and  the  food  given  with  the  view  of  increasing  the  body 
weight.  Milk  is  given  in  large  quantities,  graduated  according  to 
the  digestive  powers.  General  massage  is  practised,  but  the  kidney 
areas  are  not  subjected  to  manipulation.  The  treatment  will  extend 
over  a  month  or  six  weeks. 

This  is  a  useful  preliminary  to  treatment  by  means  of  a  mecha- 
nical apparatus. 

(2)  Treatment  by  mechanical  apparatus. — Treatment  by  this 
means  is  specially  indicated  when  enteroptosis  is  present.  It  is 


ERNST, 
FIG.  1.— Ernst's  Kidney  Truss. 

suitable  for  any  case  of  movable  kidney,  with  the  exceptions  already 
mentioned. 

I  shall  describe  three  forms  of  apparatus : 

(a)  KIDNEY  TRUSS. — Ernst  makes  the  truss,  of  which  the  follow- 
ing is  a  description  (Treves,  Practitioner,  January,  1905)  :  This 
instrument  consists  of  a  thin,  carefully -padded  metal  plate,  which 
exercises  pressure  upon  the  abdominal  wall  by  means  of  two  springs. 
The  pressure  concerns  the  lower  and  inner  margins  of  the  plate,  so 
that  the  kidney  is  forced  upwards  and  outwards  (Fig.  1).  It  must 
of  necessity  be  applied  when  the  patient  is  lying  down.  The  truss 
must  be  very  carefully  fitted,  and  the  patient  trained  and  practised 
in  its  proper  adjustment. 

50—2 


y88 


Movable  Kidney. 


Treves  found  that  the  truss  proved  absolutely  efficient  in  90  per 
cent,  of  cases.  The  kidney  was  kept  in  place  and  the  symptoms 
disappeared.  The  patient  was  able  to  take  active  exercise. 

(b)  KIDNEY  BELT. — A  kidney  belt  is  an  abdominal  belt  which  is 
specially  adapted  for  the  relief  of  movable  kidney  (Fig.  2). 

The  belt  consists  of  a  broad  band  of  jean  or  cotil,  which  surrounds 
the  waist  and  comes  down  over  the  iliac  crests  and  is  accurately 
moulded  to  the  hips.  The  lower  border  follows  the  curve  of  the 
groin  along  Poupart's  ligament,  and  in  the  middle  line  in  front  it 
slightly  overlaps  the  pubic  bones.  The  upper  border  is  about  the 
level  of  the  umbilicus.  The  belt  is  stiffened  by  whalebone  or 
light  steel  busks.  It  is  laced  in  front  and  behind.  At  each  side 


FIG.  2.— Kidney  Belt. 


FIG.  3.— Pad  for  Kidney  Belt. 


there  is  a  broad  inset  of  silk  elastic.  There  are  two  perineal  straps 
to  prevent  the  belt  from  riding  upwards. 

A  kidney  pad  (Fig.  3)  is  added  with  the  view  of  exerting  pressure 
upon  the  movable  kidney  and  retaining  it  in  place.  This  may  be 
horseshoe-shaped  or  oval.  The  pad  may  be  fixed  in  the  lining  of 
the  belt,  and  consist  of  a  rubber  bag  with  a  fine  tube,  which  pierces 
the  belt  and  has  a  turncock  ;  or  the  pad  may  be  a  closed  air  sac  or  a 
rubber  bag  containing  glycerine,  and  fits  into  a  pocket  in  the  lining 
of  the  belt.  The  belt  must  be  put  on  when  the  patient  is  lying 
down,  and  is  worn  over  a  silk  or  fine  woollen  undervest. 

A  belt  of  similar  construction  can  be  fitted  to  the  lower  part  of 
a  corset,  and  by  this  means  the  perineal  straps  which  are  irksome 
become  unnecessary. 

The  pads  which  are  used  in  these  belts  do  not  control  the  move- 
ments of  the  kidney;  were  they  sufficiently  large  and  firm  to  do  so, 
they  would  exert  injurious  pressure  upon  the  bowel.  Their  use 
appears,  however,  to  give  a  feeling  of  security  to  the  wearer,  and 
for  this  reason  they  may  be  worn. 


Movable  Kidney.  789 

(c)  CORSET  FOR  MOVABLE  KIDNEY  (GALLANT).  —  The  corset  is 
made  from  measurements  taken  from  each  patient.  At  the  bottom 
the  front  steels  must  overlap  the  upper  half-inch  of  the  symphysis 
pubes  and  fit  very  snugly  over  the  hips,  stretching  tightly  from  one 
to  the  other  to  flatten  and  reduce  the  hypogastrium.  The  circum- 
ference must  be  equal  to  the  natural  waist,  but  there  must  be  well- 
marked  incurving  of  the  sides,  so  that  the  clothing  is  supported, 
the  corset  prevented  from  slipping  upward,  and  a  fashionable 
outline  afforded  to  the  figure.  At  the  back  and  sides  the  upper 
portion  must  accurately  fit  the  thorax,  while  in  front  ample  room 
must  be  provided  for  the  replaced  stomach.  Below  the  waist  the 
corset  must  be  inflexible  and  inelastic,  and  the  portion  above  the 
waist  must  permit  free  play  to  the  motions  of  the  trunk  and 
thoracic  walls.  If  the  hips  are  poorly  developed,  pads  should  be 
stitched  inside  the  lower  part  of  the  corset  to  give  rotundity  to  the 
figure  and  avoid  painful  pressure  on  the  iliac 'crests  and  anterior 
spines.  One  lace  begins  at  the  eyelet  above  the  waist-line,  and 
is  continued  down  to  the  bottom  of  the  corset.  In  the  upper 
part  a  thin,  flat,  hat-elastic  is  loosely  threaded  so  as  to  keep  the 
corset  in  contact  with  the  thorax,  ;but  not  so  tight  as  to  cause 
pressure. 

The  following  directions  must  be  followed  in  putting  on  the 
corset :  The  lower  lacing  is  freely  loosened  and  the  corset  applied 
to  the  body  over  a  fine  woollen  or  silk  vest.  The  patient  lies  on 
her  back  on  a  bed,  and  the  legs  are  flexed  to  a  right  angle. 
The  abdomen  is  massaged  by  stroking  upwards  for  ten  minutes. 
The  corset  is  then  drawn  well  down  over  the  hips  and  fastened 
in  front,  beginning  with  the  lowest  hook.  Without  lowering  the 
thighs  the  lace  behind  is  drawn  as  tight  as  possible  and  tied. 
The  corset  must  not  be  drawn  down  after  the  front  has  been 
fastened. 

The  lower  part  above  the  pubes  must  fit  so  snugly  that  the  fingers 
can  barely  be  inserted  between  the  corset  and  the  pubes  when  lying 
down.  On  rising,  sitting,  or  walking  the  corset  should  not  slip 
upwards. 

Gallant  holds  that  from  90  to  95  per  cent,  of  movable  kidneys 
with  symptoms  are  cured  of  the  symptoms  by  wearing  this 
corset. 

Operative  Treatment. — The  usual  incision  is  an  oblique  incision, 
extending  from  the  angle  of  the  last  rib  and  the  erector  spinse 
muscle  downwards  and  forwards  towards  the  anterior  superior  iliac 
spine.  A  vertical  posterior  incision  along  the  outer  border  of  the 
erector  spinae  muscle  is  used  by  Edebohls,  and  has  the  advantage 


7QO  Movable  Kidney. 

of  slight  disturbance  of  the  muscles.  A  disadvantage  is  that  the 
exposure  is  limited.  An  anterior  incision  has  been  used  by  some 
surgeons  (Harlan,  Stanmore  Bishop).  The  incision  runs  from 
the  anterior  edge  of  the  latissimus  dorsi  forwards  for  4  inches 
parallel  with  the  costal  margin. 

The  great  majority  of  operations  are  extra-peritoneal.  The  fatty 
tissue  around  the  kidney  is  carefully  removed.  The  kidney  is  fixed 
by  sutures  of  catgut,  silk,  kangaroo  tendon  or  a  strip  of  tendon 
from  the  erector  spinae  muscle  of  the  patient.  Strong  catgut  and 
kangaroo  tendon  are  the  best.  The  sutures  may  be  passed  through 
the  fibrous  capsule  of  the  kidney  alone  or  through  the  kidney 
substance,  or  the  fibrous  capsule  may  be  stripped  and  clipped  away, 
leaving  the  denuded  organ  in  contact  with  the  muscles  of  the 
posterior  abdominal  wall.  After  decortication  the  capsule,  instead 
of  being  clipped  away,  may  be  used  to  sling  the  kidney  by  sutures 
passed  through  it  and  then  through  the  parietes.  If  nephrotomy 
has  been  performed,  I  close  the  nephrotomy  wound  with  thick 
catgut  sutures  passed  through  the  kidney  substance,  and  then 
decapsulate  the  kidney,  leaving  an  area  of  capsule  round  the 
nephrotomy  wound  to  prevent  the  stitches  cutting  out.  The  stitches 
which  close  the  nephrotomy  wound  are  then  used  to  fix  the 
kidney. 

In  place  of  suturing,  a  fibrous  sling  may  be  formed  at  the  lower 
end  of  the  kidney  by  packing  the  wound  with  strips  of  gauze 
placed  below  the  lower  pole  of  the  kidney,  and  thus  promoting 
granulation. 

Stanmore  Bishop  forms  a  shelf  of  peritoneum  by  exposing  the 
kidney  by  an  anterior  incision  through  the  peritoneum,  and  passing 
sutures  through  the  peritoneum  below  and  internal  to  the  lower 
pole.  The  sutures  pass  through  the  muscles  of  the  posterior 
abdominal  wall,  and  are  tied  behind  after  division  of  the  skin. 

Watson  Cheyne  exposes  the  kidney  by  an  anterior  incision  and 
pushes  aside  the  peritoneum.  Flaps  of  capsule  are  stripped  from 
the  lower  pole  and  stitched  to  the  muscles,  so  that  a  shelf  of  fibrous 
capsule  is  formed  below  the  kidney. 

Results. — The  operative  mortality  is  stated  at  1  per  cent.,  but  it 
is  lower  than  this  in  the  practice  of  most  surgeons.  The  statistics  in 
regard  to  the  success  of  operation  vary.  Keen  found  that  in  116  cases 
examined,  not  less  than  three  months  after  operation  57'8  per  cent, 
were  cured,  12*9  per  cent,  improved  and  19'8  per  cent,  failed. 
Failure  may  be  shown  by  recurrence  of  the  mobility  or  persistence 
of  pain.  In  forty-two  cases  examined  by  Me  Williams  twenty-two  were 
cured,  eight  greatly  benefited,  seven  somewhat  relieved,  and  five 


Movable  Kidney.  791 

unrelieved  of  symptoms.  Improvement  in  many  cases  was  only 
seen  some  months  after  the  operation.  There  were  48  per 
cent,  of  cures  where  parenchymatous  sutures  were  employed. 

Wilson  and  Howell  examined  forty-one  cases  after  nephrotomy 
had  been  performed  at  St.  Bartholomew's  Hospital,  and  found  twelve 
cured,  eight  greatly  improved,  twelve  improved,  and  nine  unaffected 
by  the  operation. 

J.  W.  THOMSON  WALKER. 


792 


ACUTE  NEPHRITIS  (ACUTE  BRIGHT'S  DISEASE). 

THIS  is  seldom  primary  except  as  a  sequela  of  an  acute  fever, 
such  as  scarlatina.  Most  cases  so  labelled  are  exacerbations  of  a 
chronic  condition. 

The  patient  should  be  in  bed.  So  long  as  the  urine  is  scanty,  and 
hsematuria  with  lumbar  pain  persists,  or  any  fever  is  present,  the 
diet  should  be  of  milk  and  farinaceous  food.  The  presence  of 
hsematuria  alone  does  not  forbid  a  richer  diet.  It  often  persists  for 
a  long  time. 

No  drugs  directly  influence  renal  congestion  or  inflammation. 
The  point  is  to  keep  the  patient  in  the  condition  most  favourable 
to  its  subsidence. 

The  chief  symptoms  that  need  attention  are  in  the  usual  order 
of  their  occurrence,  oliguria,  haematuria,  alUuminuria,  nausea  and 
vomiting,  dropsy  and  uraBmia. 

The  diminution  of  urine  sometimes  amounts  to  complete 
suppression.  Occasionally,  when  slight,  a  milk  diet  is  sufficient 
to  relieve  it.  If  not  recourse  must  be  had  to  diuretics.  These  are 
of  three  kinds.  The  first  are  the  organic  salts  of  the  alkalies 
(Pot.  citrat.,  Pot.  tartr.  ac.,  Pot.  acet.,  Sod.  bicarb.,  Sod.  citrat., 
Liq.  ammon.  acetatis),  which  are  gentle  stimulants  of  the  renal  cells. 
Their  excess  in  the  blood  leads  to  their  excretion  by  the  epithelium 
of  the  tubules,  and  they  draw  with  them  a  certain  amount  of  water. 
A  good  method  of  using  them  is  the  Imperial  drink,  a  lemonade 
made  with  a  drachm  of  acid  tartrate  of  potash  to  the  pint.  When, 
as  sometimes  happens,  the  situation  is  partly  due  to  cardiac 
weakness,  tonics  of  the  digitalis  group  are  needed  (Tr.  digitalis, 
strophanthi  [U.S.P.,  irtl  to  3] ,  vel  convallariae,  ni5  to  15 ;  Infus. 
digitalis,  jij  to  5iv  [U.S. P.,  5j  to  5ij] ;  Sulphate  of  sparteine,  gr.  £ 
to  1 ;  Nativelle's  crystalline  digitaline,  gr.  aio)-  I  think  myself  the 
infusion  of  digitalis  acts  best.  A  third  class  of  diuretics  is  formed 
by  the  alkaloids  caffein  and  theobrornin,  with  their  salts  and 
preparations  (Caffein.  citrat.,  gr.  5  to  10 ;  Theobrornin.,  gr.  1  to  5  ; 
Agurin=Theobr.  sod.  acet.,  gr.  5  to  15;  Diuretin =Theobr. 
sod.  salicylat.,  gr.  5  to  15 ;  Theocin.  sod.  acet.,  gr.  2  to  4),  which 
act  on  both  kidneys  and  heart.  I  always  use  diuretin  of  these 
drugs,  and  combine  it  with  digitalis  (Infus.  digit.,  5iv  [U.S.P.,  5ij] ; 
Diuretin,  gr.  10  ex.  Aq.).  Caffein  is  not  so  good  a  diuretic.  It  is 


Acute  Nephritis.  793 

better  not  to  use  these,  which  are  stronger  stimulants  than  the 
alkalies,  unless  the  latter  fail. 

At  the  same  time  the  kidneys  may  be  relieved  by  acting  on  the 
bowels  or  on  the  skin.  For  the  latter  purpose  hot  baths,  hot  air 
baths,  hot  packs,  and  injections  of  pilocarpin  nitrate  may  be  given. 
The  latter  should  not  be  given  in  doses  greater  than  £  gr,,  as  it 
may  produce  collapse  and  diminish  the  secretion  of  urine  (for 
hot  air  bath  see  Uraemia). 

But  if  oliguria  is  very  severe  it  is  advisable  to  deplete  the  kidney 
locally.  I  have  known  half  a  dozen  leeches  to  each  loin  completely 
relieve  a  case  of  suppression.  Cupping  is  a  similar  but  less  effective 
method.  Mr.  Reginald  Harrison  recommended,  when  symptoms 
pointed  to  extreme  congestion,  to  cut  down  upon  the  kidney  and 
relieve  internal  pressure  by  splitting  the  capsule  open.  I  have 
never  had  to  do  this,  but  it  seems  reasonable.  Edebohls  has 
practised  complete  removal  of  the  capsule.  That  is  in  my  opinion 
unreasonable. 

Hsematuria  usually  clears  up  spontaneously ;  but  it  occasionally 
persists  though  the  other  symptoms  improve.  If  the  blood  is  in 
large  quantity  leeches  to  the  loin  sometimes  stop  it  altogether. 
More  often  it  is  slight  in  amount.  I  have  never  found  iron  or  gallic 
or  tannic  acid  of  any  use.  Hamamelis  is  recommended,  but  I  have 
not  used  it,  and  as  its  action  is  only  due  to  the  gallic  acid  it 
contains  I  should  not  expect  it  to  be  useful.  I  have  known  ergot 
effective,  and  once  or  twice,  when  other  drugs  failed,  I  have  given 
oil  of  turpentine  in  10  or  15  min.  doses  successfully. 

Albuminuria  is  due  chiefly  to  the  damaged  glomeruli.  It  decreases 
as  the  inflammation  subsides,  but  hardly  ever  disappears  if  the 
patient  is  past  childhood.  No  drugs  seem  to  affect  it.  The  impor- 
tant thing  to  remember  is  that  its  presence  does  not  contra- 
indicate  a  flesh  diet.  Repeated  analysis  has  shown  me  that  it 
is  not  increased  by  a  change  from  milk  to  fish  diet,  or  from  fish 
to  meat.  A  temporary  increase  may  appear  with  any  change  of 
diet,  even  if  in  the  reverse  direction,  but  it  is  transient. 

Nausea  and  vomiting  can  be  treated  with  ordinary  bitters  and 
alkalies.  Sometimes  minim  doses  of  Tr.  iodi,  given  hourly,  succeed 
if  these  fail.  Cerium  oxalate  was  at  one  time  recommended,  but 
I  have  never  known  it  useful.  A  good  formula  is  Acid,  hydrocyan. 
dil.,  irj.iv  ;  Sod.  bicarb.,  gr.  5  ;  ex.  Aq. ;  given  at  short  intervals  for 
a  few  doses. 

Dropsy  is  discussed  under  chronic  diffuse  nephritis  and  uraemia 
under  its  own  heading. 

W.  P.  HERRINGHAM. 


794 


CHRONIC  INTERSTITIAL  NEPHRITIS. 

THIS  is  common  after  forty  years  of  age.  Probably  more  than 
a  third  of  all  patients  over  this  age  show  some  renal  fibrosis.  It 
is  generally  accompanied  by  sclerosis  of  the  arteries. 

At  first  it  produces  no  symptoms.  Systematic  examination  with 
the  microscope  of  kidneys  from  the  'post-mortem  room  proves  this. 
Later  the  symptoms  are  chiefly  due  to  cardiac  dilatation,  hyper- 
trophy and  eventual  failure,  which  result  rather  from  the  arterial 
than  from  the  renal  disease. 

But  many  such  cases  are  complicated  with  parenchymatous 
changes  as  well.  Either  a  parenchymatous  nephritis  has  developed 
fibrosis,  or  a  kidney  in  which  interstitial  changes  have  been  at 
first  uncomplicated,  has  been  subsequently  affected  by  parenchy- 
matous inflammation  (see  Chronic  Diffuse  Nephritis). 

In  many  cases  the  patient  complains  chiefly  of  shortness  of 
breath.  On  examination  the  lungs  are  found  to  be  normal,  and 
the  symptoms  are  clearly  due  to  changes  in  the  heart  and  arteries 
(see  Arterial  Sclerosis),  in  the  course  of  which  the  heart  has  become 
unequal  to  its  work.  The  first  indication  is  to  lessen  its  labour 
by  rest.  Such  patients  should  be  put  to  bed  for  a  time,  and  when 
allowed  to  get  up  must  be  warned  that  any  effort  which  produces 
either  shortness  of  breath  or  palpitation  is  a  strain  upon  the  heart, 
which  it  is  unsafe  to  allow.  Digitalis  is  seldom  of  much  use 
in  this  condition,  probably  because  it  increases  the  peripheral 
resistance  as  much  as  it  increases  the  stroke  of  the  heart.  But 
convallaria,  strophanthus  and  sparteine,  though  they  belong  to  the 
same  group,  are  said  to  act  more  on  the  heart  than  on  the  arteries, 
and  to  be  better,  in  this  condition,  than  digitalis. 

In  some  cases  a  pure  milk  diet  relieves  symptoms  rapidly.  A 
patient  of  this  kind  has  been  in  my  wards  occasionally  during  the 
last  three  years,  and  has  each  time  been  relieved  by  this  treatment. 
He  has  no  albuminuria,  and  is  a  thin,  florid  man,  with  extreme 
arterial  degeneration.  A  woman  of  the  same  build  and  with  the 
same  symptoms,  seen  in  consultation,  has  been  much  less  subject 
to  attacks  of  dyspnoea  and  palpitation  since  taking  tablets  of 
alkaline  salts  (Sod.  Chlorid.,  gr.  150  ;  Sod.  Sulph.,  gr.  15  ;  Sod. 
Garb.,  gr.  6 ;  Sod.  Phosph.,  gr.  5 ;  Magnes.  Phosph.,  gr.  6 ;  Calc. 
Glycero-phosph.,  gr.  5  ;  make  25  tablets ;  dose,  two  tablets,  thrice 


Chronic  Interstitial  Nephritis.  795 

daily)  made  in  imitation  of  Trunesek's  "  inorganic  serum."  The 
effect  may  be  due  to  suggestion.  Bleeding  may  be  necessary  in 
some  cases. 

In  the  intervals  between  the  attacks  the  diet  of  these  patients 
must  be  light  and  digestible,  for  any  mechanical  interference  with 
the  heart,  such  as  indigestion  may  produce,  will  bring  on  an 
attack  at  once.  The  bowels  for  the  same  reason  must  be  well 
regulated.  But  there  is  not  the  same  urgent  need  for  diminu- 
tion of  the  food  as  in  cases  complicated  with  parenchymatous 
change.  Indeed,  as  the  symptoms  are  due  chiefly  to  cardiac  weak- 
ness, a  physician  hesitates  to  reduce  the  food  to  a  low  level.  It  is 
better  to  try  to  treat  the  patient  like  a  man  in  training,  giving 
him  a  fair  amount  of  plain  proteid  food  and  using  exercises 
with  passive  resistance,  and  general  massage  to  take  the  place  of 
ordinary  muscular  work.  Some  of  these  patients  declare  them- 
selves better  after  a  course  of  Nauheim  baths.  Later  uraemia  may 
appear  (see  Uraemia). 

W.  P.  HERRINGHAM. 


796 


CHRONIC  DIFFUSE  PARENCHYMATOUS  NEPHRITIS. 

PRIMARY  acute  nephritis  is  rare.  Most  cases  of  nephritis  begin 
insidiously.  But  they  are  liable  to  fresh  attacks  of  inflammation 
with  haematuria,  lumbar  pain  and  oliguria.  These  furnish  most 
of  the  cases  of  what  is  called  acute  nephritis,  and  their  treatment 
is  discussed  under  that  heading. 

In  the  mildest  form  the  chronic  disease  produces  slight  albu- 
minuria,  anaemia  and  a  trace  of  oedema.  For  these  the  chief  aim  of 
treatment  is  (1)  to  cure  the  anaemia ;  (2)  to  prevent  the  inflamma- 
tion spreading  or  recurring. 

(1)  For  the  anaemia  the  lighter  forms  of  iron  are  the  best,  such 
as  the  tartrate  or  the  citrate  of  iron  and  quinine.      When  digestion 
is  not  affected  the  perchloride  or  the  sulphate  can  be  given. 

(2)  The  chief  part  of  the  treatment  is  preventive. 

(a)  Chill  must  be  avoided.     Many  of  these  patients  are  young, 
and  for  them  the  chief  danger  is  chill  after  sweating.     Exercise 
does  not  hurt  them,  but  they  must  not  stand  about  when  hot,  as, 
for  instance,  after  a  game  of  lawn  tennis.     Dancing  is  never  safe. 
Clothing  should  be  warm.     I  think  loose  cotton  fabrics  are  better 
than  flannel.     Damp  cold  is  dangerous.     A  dry  climate,  even  if 
cold,  allows  evaporation  through  the  skin  and  relieves  the  kidneys. 
In  the  Riviera  or  North  Africa  special  care  should  be  taken  to 
escape  the  sunset  chill  and  cold  winds.     The  Grand  Canary  and 
Southern  India  are  the  two  best  winter  climates  that  I  know. 

(b)  The   kidneys   are    permanently    damaged,  for   albuminuria 
rarely  disappears  if  the  patient  has  passed  childhood,  and  therefore 
must  be  spared  as  much  as  possible.     This  is  almost  entirely  a 
question  of  diet,  and  especially  of  the  proteid  intake.      The  work  of 
the  kidney  consists  chiefly  in  the  excretion  of  proteid  products  and 
of  salts.     These  latter,  again,  are  contained  in  large  amount  in  the 
proteids.     The  amount  of  proteid  in  the  standard  diet  of  an  ordinary 
man  is  about  120  grammes.     Many  eat  a  great  deal  more.     It  has 
been  shown  by  Chittenden  that  about  half  this  amount  is  sufficient 
to  preserve  health  and  strength.     In  making  up  a  diet  it  may  be 
remembered  that 

Milk  contains  about     3'5  per  cent,  of  proteid. 

Meat,  fish  or  poultry    „         „       20'0         „         „         „ 

Bread  „         „         6'5 

Macaroni  „         „        lO'O 

Oatmeal  „         „        14'0 

An  egg  „         „          3'6  grammes ,,         „ 


Chronic  Diffuse  Parenchymatous  Nephritis.    797 

Therefore  a  pint  of  milk  (=  600  grammes  =  21  grammes 
proteid)  +8  oz.  of  meat,  fish  or  poultry  (=  90  grammes  =  18 
grammes  proteid)  +  6  ozs.  of  bread  (=  180  grammes  —  12 
grammes  proteid)  contain  51  grammes  of  proteid,  to  which  can  be 
added  vegetables,  fruit,  jams,  farinaceous  puddings,  cream,  butter, 
bacon  and  other  fats,  without  much  increasing  the  renal  labour. 

Alcohol  and  condiments  are  renal  irritants.  Salt  should  be 
taken  sparingly. 

With  care  such  patients  live  for  many  years.  But  in  cases 
which  are  neglected  the  disease  progresses  in  one  of  two  directions  : 

(1)  By     fibrosis    to     the    contracted     kidney,    which    ends    in 
uraemia  (q.r.). 

(2)  By  epithelial  degeneration  to  the  large  white  kidney  which 
ends  in  general  dropsy,  oedema  of  the  lungs,  and  cardiac  failure. 
In  this   form  it  is  almost  impossible,   owing  to  the  state  of  the 
kidneys,  to  increase  the  amount  of  urine,  either  by  renal  or  cardiac 
stimulation,    but  both    should  be  tried.      Sometimes    dropsy  can 
be  relieved  to  some  extent  by  sweating  or  purging,  but  most  often 
it  must  be  drained  directly  by  tapping.     All  these  methods  are 
described  under  Acute  Nephritis  (p.  792). 

W.  P.  HERRINGHAM. 


798 


SURGICAL  TREATMENT  OF   NON-SUPPURATIVE 
NEPHRITIS. 

Acute  Nephritis. — In  1896  Reginald  Harrison  suggested 
operative  interference  in  certain  cases  of  acute  nephritis.  He 
operated  on  cases  of  scarlatinal  nephritis,  nephritis  complicating 
influenza,  traumatic  nephritis,  and  nephritis  which  had  followed 
a  chill.  The  operations  were  undertaken  on  account  of  one  or 
more  of  the  following  symptoms :  Diminished  secretion  of  urine, 
pain,  haematuria. 

He  recommended  operation  in  cases  of  acute  nephritis  where 
convalescence  was  delayed,  and  albumen  and  casts  did  not  disappear 
from  the  urine;  also  in  cases,  such  as  the  malignant  type  of 
scarlatinal  nephritis,  where  suppression  occurred ;  and,  lastly, 
where  cardiac  and  circulatory  complications  were  present.  The 
operation  was  performed  with  the  object  of  setting  aside  'the 
dangerous  symptoms,  and  also  of  preventing  the  sequence  of 
chronic  nephritis. 

Harrison  suggested  incision  of  the  renal  capsule  and  puncture  of 
the  kidney  to  relieve  the  renal  tension  in  these  cases.  Other 
observers  (Pel  and  Rosenstein)  recommend  nephrotomy  in  acute 
nephritis  when  oliguria  is  present  and  medical  treatment  has 
failed.  Confusion  in  regard  to  statistics  has  been  caused  by  the 
publication  of  cases  of  suppurative  nephritis  under  the  same 
category  as  those  referred  to  above. 

All  Harrison's  cases  recovered,  but  the  after-history  is  un- 
recorded. 

Chronic  Bright's  Disease.  (1)  Acute  Exacerbations  in  Chronic 
Bright's  Disease. — Edebohls,  Pousson,  Casper  and  others  have 
treated  the  acute  exacerbations  of  chronic  Bright's  disease  by 
surgical  operation.  In  these  cases  surgical  interference  is  supple- 
mentary to  medical  treatment.  Where  there  are  symptoms  of 
uraemia,  diminished  secretion  of  urine  and  oedema,  operation  may 
be  of  service  when  medical  treatment  has  failed.  Cases  where 
advanced  car dio- vascular  changes  and  pulmonary  complications  are 
present  are  unsuitable  for  operation. 

Decapsulation  and  nephrotomy  are  the  operations  recommended. 
Except  in  the  rare  cases  when  the  disease  can  be  proved  to  be 
unilateral,  decapsulation  should  be  rapidly  performed  on  both 


Surgical  Treatment  of  Chronic  Nephritis.     799 

sides.  Pousson  recommends  that  nephrotomy  should  be  performed 
on  one  side  and  only  decapsulation  on  the  other. 

The  immediate  results  give  a  mortality  of  25  per  cent.  (Pousson) 
some  part  of  which  is  due  to  the  patient  being  moribund  when  the 
operation  was  performed. 

Of  ninety-two  patients  who  survived  the  operation,  eight  are 
considered  as  cured.  The  others  died  after  a  temporary  relief, 
lasting  from'  some  months  to  one  or  two  years  in  a  few  cases. 

In  the  writer's  experience  of  decapsulation,  and  nephrotomy  in 
these  cases  and  in  large  white  kidney,  very  striking  improvement 
may  be  observed ;  but  this  is  temporary,  and  relapse  soon  occurs. 

(2)  Chronic    Interstitial    \e)>liriti#    irith    Hd-maturia. — There    is 
a  class   of   cases   where   the   symptoms  of  chronic   nephritis   are 
insignificant,  and  intermittent  profuse  haernaturia  occurs.     These 
cases    have     been    classed     under    the    heading    of     "  Essential 
Haematuria,"    along   with    other    conditions   which   give    rise   to 
renal    haematuria    without    other    symptoms,   and    without   gross 
changes  in  the  kidneys.     The  haematuria  is  accidental,  and  is  due 
to   pressure   of  a  patch  of  sclerosis   on  a  vein.     Nephrotomy  is 
followed  by  disappearance  of  the  haematuria,  which  does  not  recur, 
except  in  the  rarest  instances. 

(3)  Chronic    \e)>hritia    irith     Pain. — Legueu     described     these 
cases  under  neuralgia  of  the  kidney.     In  a  few  cases  the  renal 
condition  is  that  of  chronic  Bright's  disease,  but  in  many  cases 
there  has  been  a  renal  calculus  at  some  previous  date,  while  in 
others  there  is  a  history  of  trauniatism. 

The  kidney  shows  chronic  nephritis,  and  there  is  thickening  and 
adhesion  of  the  fibrous  capsule  and  fibrosis  of  the  fatty  envelope. 
The  pain  may  be  localised  to  the  kidney,  and  may  be  spontaneous, 
constant,  and  unaffected  by  movement,  or  there  may  be  attacks  of 
renal  colic.  There  may  be  a  trace  of  albumen  with  hyaline  and 
granular  casts. 

Nephrectomy,  nephrotomy,  capsulotoniy,  decapsulation  or  simple 
freeing  of  the  kidney  from  surrounding  adhesions  have  been  practised. 

The  great  majority  of  patients  have  been  relieved  by  operation, 
and  the  relief  is  known  to  have  lasted  for  some  years.  If  there 
has  been  a  diminution  in  the  quantity  of  urine  and  albuminuria 
these  symptoms  disappear. 

The  operation,  like  that  for  haematuria  in  chronic  nephritis, 
usually  takes  the  form  of  an  exploratory  nephrotomy,  and  to  this 
decapsulation  may  be  added. 

(4)  Treatment    of  Oinmic  Briyltt's  Disease    by  Decapsulation. — 
In     1899     Edebohls    suggested     nephrotomy    as     a    method    of 


8oo     Surgical  Treatment  of  Chronic  Nephritis. 

treatment  of  chronic  nephritis  in  cases  of  chronic  nephritis  in 
movable  kidney.  Newman,  of  Glasgow,  had  previously  treated 
two  cases  of  this  nature  by  nephropexy. 

In  1901  Edebohls  proposed  decapsulation  of  the  kidney  with 
the  object  of  curing  chronic  Bright's  disease.  He  held  that 
the  thickened  fibrous  capsule  prevented  the  establishment  of  a 
collateral  circulation,  and  if  this  barrier  were  removed  a  free  flow  of 
blood  through  the  kidney,  which  the  diseased  vessels  were  unable 
to  supply,  was  provided  by  anastomosis  with  the  parietal  vessels. 
By  this  means  the  increased  interstitial  tissue  would  be  absorbed, 
pressure  on  the  tubules  removed,  and  a  regeneration  of  renal 
epithelium  would  take  place. 

Experimental  enquiry  into  this  hypothesis  has  shown  that  no 
damage  is  done  to  the  kidney  by  decapsulation,  and  that,  although 
the  fibrous  capsule  invariably  re-forms  in  a  few  weeks,  the  new 
capsule  is  composed  of  loose  connective  tissue  which  does  not 
compress  the  kidney.  A  parietal  anastomosis  has  actually  been 
observed  which  was  not  strangled  by  contraction  of  the  new  capsule. 
The  kidney  has  also  been  transplanted  into  the  peritoneal  cavity 
and  formed  adhesions  with  the  serous  membrane  or  with  the 
omentum.  Conflicting  statements  have  been  made  in  regard  to  the 
results,  found  post-mortem,  after  decapsulation  in  human  beings. 

Results. — Pousson  gives  a  mortality  of  5  per  cent.  Of  fifty-five 
cases,  thirty-six  survived  more  than  three  months  after  the 
operation. 

Of  ten  cases  of  nephritis  withnephroptosis,  there  were  nine  greatly 
improved,  three  of  which  were  said  to  be  cured  ;  while  of  sixteen 
cases  of  nephritis  without  nephroptosis,  three  were  improved,  four 
much  improved,  four  greatly  improved,  and  five  cured.  The  five 
cases  of  cure  were  under  observation  for  eleven  years,  six  and  a  half 
years,  five  and  one-third  years,  two  years,  and  one  year. 

It  will  be  seen,  therefore,  that,  although  the  course  of  the  disease 
is  uninfluenced  in  a  considerable  proportion  of  cases,  improvement 
is  undoubted  in  some,  and  it  is  possible  that  a  cure  may  be  brought 
about  in  a  few  cases.  The  cases  of  movable  kidney  with  albumi- 
nuria  and  tube  casts  should  be  carefully  separated  from  the  others, 
for  the  prognosis  without  operation  is  very  different  from  that  of 
chronic  Bright's  disease,  and  the  effect  of  nephropexy  alone  is  to 
cure  most  of  these  cases. 

In  cases  of  chronic  Bright's  disease  the  results  might  be 
improved  by  operation  performed  at  an  earlier  date  than  is  usually 
the  case. 

).  W.  THOMSON  WALKER, 


8oi 


PERINEPHRITIC  ABSCESS. 

PRIMARY  PERINEPHRITIC  ABSCESS  may  follow  injury  to  the  kidney, 
suppuration  occurring  immediately  or  after  months  or  years,  or 
it  develops  during  the  course  of  some  fever,  such  as  typhoid, 
scarlatina,  measles,  or  pneumonia,  or  when  the  patient  is  suffer- 
ing from  tonsillitis  or  boils. 

Secondary  perinephritic  abscess  complicates  suppuration  in 
some  neighbouring  organ,  such  as  the  kidney  (25  per  cent.),  liver, 
gall-bladder,  appendix,  pelvic  organs  or  vertebrae. 

Tuberculous  perinephritic  abscess  is  usually  found  with  tuber- 
culous disease  of  the  vertebrae ;  very  rarely  with  tuberculosis  of 
the  kidney.  Pus  from  an  empyema  or  an  abscess  of  the  lung  may 
track  through  the  costo-lumbar  hiatus  of  the  diaphragm,  and  form 
a  perinephritic  abscess. 

Early  operation  is  the  only  successful  method  of  treatment. 

The  kidney  is  exposed  by  an  oblique  incision  and  the  abscess 
drained.  The  cavity  should  be  explored  in  all  directions,  so  that 
no  pockets  are  left  undrained.  Subphrenic  collections  of  pus  and 
those  in  the  iliac  fossa  are  searched  for  and  opened  up.  Counter- 
openings  may  be  necessary  in  the  loin  or  elsewhere  to  ensure  free 
drainage.  If  the  kidney  is  the  seat  of  abscess,  pyelonephritis,  or 
pyonephrosis,  it  should  be  freely  incised  and  drained.  If 
nephrectomy  is  necessary,  it  should  be  postponed  to  a  later 
date. 

When  the  abscess  has  originated  in  an  empyema,  this  also  should 
be  drained. 

In  old-standing  cases  when  sinuses  have  persisted,  a  diseased 
kidney  or  an  imperfectly  drained  empyema  may  necessitate 
nephrectomy,  resection  of  portions  of  ribs,  or  other  secondary 
operations. 

Results. — Good  results  are  obtained  by  prompt  operation  .in 
primary  cases.  The  longer  the  operation  is  delayed,  the  worse  the 
prognosis.  The  prognosis  in  secondary  perinephritic  abscess 
depends  upon  the  original  cause.  Kiister  collected  230  cases  at  a 
period  when  the  importance  of  early  operation  was  imperfectly 
understood,  and  found  151  (65'6  per  cent.)  recovered.  Fistula? 
persisted  in  six  of  these  cases. 

S.T.— VOL.  ii.  51 


802  Perinephritic  Abscess. 

Watson  compared  two  series  of  cases  where  perinephritic 
suppuration  had  followed  injuries  to  the  kidney. 

In  twenty-one  cases  treated  without  operation,  seventeen  died 
(80  per  cent.),  while  in  twenty-eight  cases  treated  by  operation, 
two  died  (7'1  per  cent.). 

J.  W.  THOMSON  WALKER. 


8o3 


PYELITIS. 

THE  intimate  relation  between  the  kidney  and  its  pelvis  makes  it 
impossible  for  severe  inflammation  to  be  wholly  confined  to  one  or 
the  other.  At  the  same  time,  there  are  cases  when  the  brunt  of 
the  inflammation  falls  upon  the  pelvis  and  the  kidney  is  but 
slightly  involved.  These  are  cases  of  mild  subacute  or  chronic 
inflammation,  which  may  either  follow  upon  an  acute  attack  of 
pyelonephritis  or  arise  de  novo. 

Diseases  of  the  lower  urinary  organs  which  cause  obstruction 
and  inflammation,  such  as  enlarged  prostate,  stricture,  stone  in  the 
bladder,  gonorrheea,  bladder  growths,  etc.,  are  the  most  frequent 
causes. 

In  some  cases  a  calculus  is  present  in  the  renal  pelvis  which  may 
either  be  the  cause  or  the  result  of  the  pyelitis. 

Diagnosis. — (1)  In  a  case  of  cystitis  from  any  cause,  is  pyelitis 
present  ? 

When  the  signs  of  pyelitis  are  overshadowed  by  cystitis,  the 
diagnosis  "depends  upon  the  observation  of  a  cloudy  efflux  from  the 
ureteric  orifice,  the  appearance  of  the  orifice  and  the  'examination 
of  the  urine  of  each  kidney  obtained  from  the  ureteric  catheter. 

(2)  Is  the  kidney  involved  ? 

The  history  of  a  severe  acute  onset  points  to  renal  inflammation, 
and  so  do  tenderness  and  enlargement  of  the  organ,  an  excessive 
quantity  of  albumen,  the  presence  of  tube  casts  and  proofs  of  an 
inadequate  renal  function  shown  by  the  methylene  blue  and 
phloridzin  tests. 

(3)  Is  there  a  calculus  in  the  renal  pelvis  ? 

A  calculus  is  readily  discovered  by  the  X-rays,  but  this  method 
of  examination  may  not  be  used,  for  there  may  be  no  pain  or 
haBmaturia  and  no  history  of  stone,  and  the  possibility  of  stone 
being  present  may  not  be  suspected.  It  should  be  a  rule,  there- 
fore, that  all  cases  of  persistent  pyelitis  should  be  examined  by  the 
X-rays. 

The  first  indication  for  treatment  is  to  remove  any  local  irritant 
in  the  renal  pelvis  or  any  cause  of  back  pressure  or  sepsis  in  the 
lower  urinary  organs. 

The  removal  of  a  calculus  from  the  renal  pelvis  may  suffice  to 
cure  the  pyelitis. 

51  —  2 


804  Pyelitis. 

Enlarged  prostate  and  stricture  must  be  treated.  If  the  pyelitis 
is  of  long  standing,  and  there  is  reason  to  suspect  that  the  kidney 
is  involved,  it  may  be  necessary  to  drain  the  bladder  by  supra- 
pubic  cystotomy  for  a  fortnight  or  more  before  proceeding  to  the 
operation  for  radical  cure  of  the  prostatic  obstruction. 

The  treatment  of  the  pyelitis  consists  in  the  administration  of 
urinary  antiseptics  (urotropine,  hetraline,  helmitol,  metramine,  etc.) 
and  diuretics  (Contrexeville,  Evian,  Vittel,  and  other  alkaline 
diuretic  waters). 

Vaccine  treatment  should  be  tried  in  chronic  cases  (see 
Pyelonephritis). 

Installations  of  argyrol  and  other  silver  preparations  have  been 
made  through  a  ureteric  catheter.  The  method  is  not  free  from 
the  danger  of  obstruction  resulting  from  swelling  of  the  mucous 
membrane  at  the  outlet  of  the  pelvis,  and  should  be  practised  with 
the  utmost  caution,  and  should  not  be  used  if  there  is  any 
elevation  of  the  temperature.  Kelly  and  Casper  have  used  this 
method  in  cases  of  gonorrhceal  pyelitis  with  success.  They  used 
instillations  of  10  to  15  cubic  centimetres  of  silver  nitrate  solution 
(1  or  2  per  cent.),  or  washed  the  pelvis  with  silver  nitrate  solu- 
tion (1  in  500  to  1  in  1000).  Stockmann  recommended  the  use  of 
this  method  in  chronic  pyelitis  of  any  origin.  Albarran  dilated 
the  ureter  in  order  to  introduce  larger  ureteral  catheters. 

Should  these  methods  fail,  in  severe  cases  the  kidney  may  be 
exposed  and  the  pelvis  washed  out  and  drained  through  a  nephro- 
tomy  or  a  pyelotomy  wound.  I  have  used  this  method,  tying  in 
a  small  rubber  tube  in  the  renal  pelvis  through  a  nephrotomy 
wound  and  washing  the  pelvis  daily  with  silver  nitrate  solution 
for  ten  days,  and  then  allowing  the  wound  to  close.  This  was 
successful  where  other  measures  had  failed. 

J.  W.  THOMSON  WALKER. 


8o5 


PYELITIS  OF  INFANCY  AND  CHILDHOOD. 

A  FORM  of  acute  pyelitis  occurs  in  infants  and  children. 

Constipation  is  frequently  present,  or  there  may  be  attacks  of 
diarrhoea. 

There  is  a  tendency  to  spontaneous  recovery,  but  the  condition 
sometimes  ends  fatally.  The  cases  improve  rapidly  under  treat- 
ment. Bacteria  may,  however,  persist  in  the  urine. 

Treatment. — The  acidity  of  the  urine  is  reduced  by  the  adminis- 
tration of  alkalies,  and  the  urine  is  kept  neutral.  Citrate  of  potash 
is  given  in  doses  of  24  gr.,  or  in  severe  cases  36  to  48  gr.  per  day  in 
infusion  of  digitalis,  and  continued  till  danger  of  a  relapse  is  past. 

Urotropine  (5  to  10  gr.  daily)  and  salol  may  be  given  in  addition 
to  the  alkaline  treatment. 

The  nurses  should  be  warned  not  to  wipe  soiled  diapers  against 
the  urethra. 

Operative  measures  are  very  rarely  necessary.  If  the  child  is 
steadily  losing  ground  under  medicinal  treatment  and  the  symptoms 
are  unilateral,  nephrotoniy  may  be  performed. 

J.  W.  THOMSON  WALKER. 


8o6 


PYELITIS  (PYELONEPHRITIS)  OF  PREGNANCY. 

WHEN  pyelonephritis  is  already  present,  the  effect  of  pregnancy 
is  to  aggravate  the  disease.  Pyelonephritis  may  however  commence 
during  pregnancy,  and  in  such  cases  the  pregnancy  is  the  predis- 
posing cause  of  the  disease.  The  bacillus  coli  is  present  in  82  per 
cent,  of  cases.  In  some  cases  the  disease  follows  the  passage  of  a 
catheter,  but  it  also  occurs  apart  from  instrumentation.  Premature 
labour  occurs  in  25  per  cent,  of  cases.  If  the  infection  occurs  late 
in  pregnancy,  there  is  usually  fever  during  the  puerperium.  If  the 
pregnancy  is  interrupted,  the  child  dies  in  one-third  of  cases. 

If  the  attack  occurs  late  and  the  pregnancy  goes  on  to  full  term, 
the  child  is  usually  healthy. 

After  parturition  the  pyelonephritis  may  subside  and  the  urine 
become  sterile,  but  bacilluria  usually  persists  and  pyelonephritis 
recurs  during  succeeding  pregnancies. 

Treatment. — Prophylaxis  consists  in  careful  asepsis  in  catheter- 
isation,  and  in  the  treatment  of  constipation  during  pregnancy. 
If  bacilluria  exists,  or  there  has  been  a  previous  attack  of  pyelo- 
nephritis, this  should  be  energetically  treated  and  the  patient 
warned  of  the  danger  of  becoming  pregnant. 

The  production  of  abortion  or  the  induction  of  premature  labour 
is  seldom  necessary,  but  it  may  be  called  for  in  a  severe  case. 
Urinary  antiseptics  are  not  likely  to  influence  the  course  of  the 
disease. 

Operative  Treatment. — Nephrotomy  has  given  good  results,  and 
according  to  Legueu  is  specially  indicated  when  the  pyelonephritis 
is  unilateral.  In  bilateral  pyelonephritis  premature  labour  should 
be  induced.  Nephrectomy  is  a  more  severe  operation,  but  does  not 
affect  the  course  of  the  pregnancy  in  most  cases. 

Cova  collected  twenty-one  cases  of  nephrectomy,  and  found  that 
the  pregnancy  went  on  to  term  in  fifteen,  and  was  five  times  inter- 
rupted spontaneously  and  once  artificially.  The  mortality  is  9*5 
per  cent.  According  to  this  observer,  nephrectomy  is  well  borne  in 
the  early  months  of  pregnancy,  but  less  so  after  the  fifth  month. 

J.  W.  THOMSON  WALKER. 


807 


PYELONEPHRITIS  (INFECTIVE), 

IN  infective  pyelonephritis  there  is  acute  or  chronic  inflammation 
of  the  kidney  and  renal  pelvis. 

There  are  two  forms  of  the  disease,  namely,  primary  and 
secondary. 

Primary  or  haematogenous  pyelonephritis  occurs  without  any 
previous  disease  of  the  lower  urinary  tract,  and  is  due  to  blood- 
borne  bacteria. 

Secondary  or  ascending  pyelonephritis  is  a  complication  of 
disease  of  the  lower  urinary  tract.  The  treatment  of  these  two 
forms  will  be  described  separately. 

PRIMARY   OR    HAEMATOGENOUS   PYELONEPHRITIS. 

Haematogenous  pyelonephritis  occurs  in  three  degrees  : 
(1)  Hyperacute  or  fulminating.     (2)  Acute.     (3)  Chronic. 

In  fulminating  pyelonephritis  there  is  sudden  profound  toxaemia, 
with  scanty  bacterial  urine  or  complete  anuria.  The  diagnosis 
must  be  made  from  other  acute  infections,  such  as  infective 
endocarditis,  acute  influenza,  lobar  pneumonia,  or  malaria.  In 
acute  pyelonephritis  the  attack  may  be  mild  or  severe.  There  are 
symptoms  of  septic  absorption  with  signs  of  acute  inflammation  in 
one  kidney,  and  the  urine  contains  bacteria,  pus,  blood  and  casts. 
Bacteria  may  be  found  in  the  blood,  and  there  is  leucocytosis.  In 
chronic  pyelonephritis  the  renal  symptoms  are  insignificant. 
There  are  symptoms  of  cystitis  with  polyuria  and  acid  pyuria. 
There  may  be  oliguria  and  intermittent  attacks  of  anuria.  The 
diagnosis  is  made  by  the  cystoscope  and  by  catheterisation  of  the 
ureters.  Chronic  pyelonephritis  may  be  complicated  by  the 
presence  of  stone  in  the  kidney.  The  lesion  is  usually  unilateral 
in  haematogenous  pyelonephritis. 

The  bacillus  coli  communis  is  the  most  common  cause  of  renal 
infection.  The  next  most  frequent  bacteria  are  the  staphylococcus, 
streptococcus,  proteus,  and  the  bacillus  pyocyaneus.  The  bacillus 
coli  is  usually  found  in  pure  culture,  but  occasionally  in  a  mixed 
infection. 

Prognosis. — In  mild  cases  of  acute  pyelonephritis  the  prognosis 
is  good.  Recovery  without  operation  is  the  rule.  Recurrent 
attacks  occur,  however,  and  in  a  large  percentage  of  cases  bacilluria 


8o8  Pyelonephritis  (Infective). 

and  slight  chronic  pyelitis  or  pyelonephritis  persist.  This  may 
disappear  or  it  may  continue  for  many  years,  and  may  be  the  cause 
of  an  acute  attack  ten  or  twelve  years  after  the  first. 

In  acute  cases  the  prognosis  is  very  grave,  and  operation  will 
frequently  be  necessary.  In  fulminating  cases  the  issue  is 
frequently  fatal.  If  the  diagnosis  has  been  made,  early  operation 
gives  a  more  hopeful  outlook.  Chronic  pyelonephritis  persists  for 
many  years  and  eventually  destroys  the  kidney.  There  is  the 
danger  of  secondary  stone  formation  in  the  kidney  and  bladder  and 
of  ascending  pyelonephritis  of  the  second  kidney. 

The  treatment  is  medicinal,  serum  and  vaccine,  or  operative. 

Medicinal  Treatment  consists  in  confining  the  patient  to  bed 
and  applying  hot  fomentations  to  relieve  pain,  and  turpentine  stupes 
or  dry  cupping  over  the  loins  to  relieve  congestion.  Urinary 
antiseptics  should  be  given,  such  as  urotropine,  metramine, 
hetraline,  or  helmitol  (in  doses  of  5  or  10  gr.  every  four 
hours).  Alkalies  and  diuretics  should  be  freely  administered, 
such  as  potassium  citrate  (in  doses  of  50  or  60  gr.  daily), 
Contrexeville  water  and  distilled  water.  The  bowels  should  be 
freely  opened,  and  calomel  (in  doses  of  ^  to  ^  gr.  daily) 
administered.  This  treatment  is  suitable  for  mild  cases 
and  the  early  stage  of  acute  cases.  If  bacteria  persist  in  the 
urine  when  the  acute  symptoms  have  subsided,  urinary  antiseptic 
treatment  should  be  continued  and  vaccine  treatment  adopted. 

Serum  Treatment. — This  consists  in  the  injection  of  anti-toxin 
serum,  usually  anti-colon  bacillus  serum,  since  the  infection  is  due 
to  the  bacillus  coli  in  the  great  majority  of  cases.  A  dose  of  25  cubic 
centimetres  is  injected  hypodermically  each  day  for  three  days,  and 
at  the  same  time  calcium  lactate  (in  doses  of  20  gr.  thrice  daily)  is 
given  by  the  mouth,  in  order  to  prevent  the  joint  pains  and  rashes 
which  may  result  from  the  serum.  Should  no  effect  be  produced 
in  three  days,  the  treatment  should  be  abandoned. 

Dudgeon  obtained  satisfactory  results  in  most  instances  by  this 
treatment  in  twelve  cases  of  acute  pyelonephritis.  In  five  of  these 
cases  the  effect  was  rapid  and  permanent,  in  four  there  was 
considerable  benefit,  and  in  three  no  benefit.  In  chronic  cases  the 
treatment  has  no  effect. 

Vaccine  Treatment. — This  consists  in  injecting  graduated 
doses  of  dead  bacteria  obtained  from  cultures  of  the  patient's  urine, 
or  of  a  stock  vaccine  should  there  not  be  time  for  the  preparation 
of  an  auto-vaccine.  Small  doses  of  2  or  3  millions  of  bacillus  coli 
should  be  used  at  first,  and  repeated  in  four  or  five  days,  rising 
rapidly  to  10, 15,  20,  25,  30  millions,  and  so  on  to  100  millions,  then 


Pyelonephritis  (Infective). 


809 


150  for  six  doses,  then  200  for  six  or  twelve  doses.  The  injection 
should  then  he  made  once  a  week,  and  should  any  reaction  (shown 
by  a  rise  of  temperature,  malaise  and  headache)  occur,  the  dose 
should  be  reduced  and  a  longer  interval  allowed.  The  opsonic 
index  has  not  proved  a  reliable  guide  to  dosage. 

In  acute  cases  the  results  of  the  vaccine  treatment  have  been 
unsatisfactory.  In  ten  cases  only  one  showed  a  change  in  tem- 
perature (Williamson) ;  in  a  large  number  of  patients  treated  by 
Dudgeon  there  was  "  no  material  improvement  except  in  a  very 
few  instances." 

In  chronic  cases,  with  or  without  acute  exacerbations,  where  no 
complication,  such  as  growth  or  stone,  is  present,  the  treatment 
may  be  of  great  service,  and  bring  about  a  cure  when  all  other 
methods  have  failed.  The  treatment  is  a  long  and  tedious  one,  and 
may  last  for  six  months  or  a  year,  or  even  longer. 

The  doses  must  be  carefully  graduated,  and  a  sudden  large 
increase  of  dose  avoided,  as  an  overdose  is  frequently  followed  by  a 
recurrence  of  symptoms,  and  the  vaccine  appears  to  have  less  effect 
if  this  has  occurred.  In  several  cases  under  the  writer's  care 
the  urine  has  been  rendered  sterile  after  six  or  twelve  months' 
treatment. 

Operative  Treatment. — The  following  operations  have  been 
performed :  Nephrotomy,  decapsulation  and  opening  of  surface 
abscesses,  partial  resection  and  nephrectorny,  but  only  nephrotomy 
and  nephrectomy  need  be  considered. 

I  have  collected  forty  cases  of  operation  in  acute  haematogenous 
pyelonephritis  from  the  literature  with  the  following  results  : 


Operation. 

Cases. 

Recovered  . 

No  change. 

Died. 

Nephrotomy     ...... 
Decapsulation    and   opening  of    surface 

12 

3 

2 

7 

abscesses       .... 

6 

6 

— 

— 

Partial  resection 

2 

2 

-  —  . 

— 

Nephrectomy   .... 

17 

17 

— 

— 

HU'tfcral  operations  : 

Nephrotomy 

2 

2 

— 

— 

Nephrectomy  and  nephrotomy 

1 

1 

~- 

— 

40 

31 

2 

7 

The  results  of  nephrotomy  are  not  quite  so  unsatisfactory  as  this 
table  suggests.     I  have  performed  the  operation  twice  in  the  acute 


8io  Pyelonephritis  (Infective). 

stage,  and  seen  three  cases  in  which  it  had  previously  been 
performed.  All  these  patients  survived.  This  makes  twenty  cases 
of  nephrotomy,  with  seven  deaths.  The  after-results  of  nephro- 
tomy  are  unsatisfactory.  Chronic  pyelonephritis  persists,  and 
nephrectomy  may  be  required  at  a  later  date. 

The  best  results  in  acute  cases  have  been  obtained  by  nephrec- 
tomy. This  should  not  be  too  long  delayed.  If  at  the  end  of  five 
or  seven  days  the  acute  symptoms  persist,  and  the  patient  is 
beginning  to  lose  ground,  nephrectomy  should  be  performed. 

In  chronic  cases,  operation  will  be  called  for  on  account  of 
recurrent  exacerbations  of  acute  inflammation,  or  of  persistent 
cystitis,  or  of  secondary  calculus,  or  sometimes  for  anuria.  If  the 
second  kidney  is  shown  to  be  healthy  by  examination  of  its  urine, 
nephrectomy  should  be  performed.  I  have  found  nephrotomy 
sufficient  when  reflex  oliguria  and  attacks  of  anuria  were  caused  by 
chronic  unilateral  pyelonephritis. 

SECONDARY   OR   ASCENDING   PYELONEPHRITIS. 

This  disease  occurs  as  the  result  of  extension  of  infection  from 
the  lower  urinary  organs.  It  is  the  last  phase  of  many  chronic 
diseases  of  the  bladder  and  urethra,  such  as  malignant  growths, 
stone,  enlarged  prostate,  stricture.  It  frequently  follows  surgical 
interference  in  the  bladder  or  urethra,  such  as  the  passage  of 
instruments,  operations  for  stone,  etc.,  and  has  for  this  reason  been 
termed  "  surgical  kidney." 

Ascending  pyelonephritis  usually  attacks  kidneys  which  are 
already  the  seat  of  chronic  aseptic  pyelonephritis,  due  to  obstruction 
in  the  lower  urinary  tract. 

Ascending  pyelonephritis  is  always  bilateral  in  chronic  cases, 
and  usually  in  acute  cases ;  but  in  acute  cases  the  symptoms 
frequently  point  to  one  kidney  being  affected  alone,  or  one 
kidney  being  severely  affected  while  the  disease  in  the  other  is 
slight. 

The  disease  may  be  acute  or  chronic.  In  acute  ascending 
pyelonephritis  there  is  the  sudden  onset  of  symptoms  of  septic 
absorption,  with  local  signs  of  inflammation  of  the  kidney,  and 
partial  or  complete  suppression  of  urine. 

Chronic  pyelonephritis  may  follow  an  acute  attack,  but  the 
onset  is  frequently  insidious.  The  condition  known  as  "  chronic 
urinary  septicaemia  "  develops.  This  may  be  interrupted  by  acute 
attacks. 

Prognosis. — Many  patients  die  during  the  acute  attack  of 
ascending  pyelonephritis,  and  of  those  that  recover  the  majority 


Pyelonephritis  (Infective).  811 

suffer  from  chronic  pyelonephritis.  Should  the  urinary  obstruc- 
tion be  removed,  the  further  progress  of  the  disease  will  probably 
be  arrested,  but  the  kidneys  are  permanently  damaged. 

Chronic  ascending  pyelonephritis  is  usually  slowly  progressive, 
and  is  eventually  fatal  after  some  years. 

Acute  Ascending  Pyelonephritis.  -  -  Prophylactic  measures 
include  the  sterilisation  of  all  urethral  instruments  and  of  all  basins, 
syringes,  lotions,  etc.,  and  cleansing  of  the  surgeon's  hands  and  the 
patient. 

They  consist  also  in  practising  the  utmost  gentleness  in  all 
manipulations.  Roughness  means  bruising  and  laceration,  and 
this,  together  with  the  damage  produced  by  obstruction,  paves  the 
way  for  sepsis. 

Non-operative  treatment  consists  in  dry  cupping,  hot  fomenta- 
tions, turpentine  stupes,  or  poultices  applied  to  the  loin  to  relieve 
the  renal  congestion.  A  hot  pack  or  hot  vapour  bath  or  radiant 
heat-bath  should  be  given  to  induce  sweating.  Pilocarpin  may  be 
injected  hypodermically,  but  should  be  carefully  watched.  It  is 
important  to  get  the  bowels  opened,  and  to  relieve  the  abdominal 
distension.  A  large  dose  of  castor  oil  or  a  strong  saline  purge 
should  be  given,  but  it  is  frequently  returned  if  the  patient  has 
commenced  vomiting.  Turpentine  and  soap-and-water  enemata,  to 
which  20  min.  of  oil  of  rue  are  added,  help  to  bring  away  flatus, 
and  a  rectal  tube  should  be  introduced  high  up  in  the  rectum. 

If  the  patient  is  able  to  keep  fluids  down,  large  draughts  of 
warm  Contrexeville  water  should  be  given,  and  may  be  combined 
with  theocin  sodium  acetate,  3  to  8  gr.  every  four  hours,  or 
theo-bromine  sodiosalicylate  (diuretin),  10  or  15  gr.  every  four 
hours.  Glucose  solution  should  be  introduced  into  the  subcutaneous 
tissues  in  large  quantities,  several  pints  being  injected  slowly. 

Infusion  of  glucose  solution  into  a  vein  (median  basilic)  is  the 
most  rapid  and  powerful  means  of  re-establishing  the  renal 
secretion. 

Operative  Treatment. — There  are  two  indications  for  operative 
treatment  :  (1)  the  relief  of  urinary  obstruction,  if  present ; 
(2)  the  relief  of  congestion  and  drainage  of  the  kidney. 

Should  the  measures  detailed  above  prove  ineffectual,  and  no 
improvement  be  apparent  in  two  or  three  days,  or  if  the  patient 
appears  to  be  failing  before  this,  operation  will  become  necessary. 

If  there  is  unrelieved  urinary  obstruction,  this  should  first 
receive  attention.  The  operation  which  is  performed  for  the 
relief  of  the  obstruction  is  not  necessarily  that  which  would  have 
been  chosen  had  no  kidney  complication  developed. 


8i2  Pyelonephritis   (Infective). 

The  operation  should  give  the  freest  drainage  with  the  least 
amount  of  shock.  Supra-pubic  cystotomy  and  drainage  with  a  large 
tube  is  the  best  means  of  carrying  this  out.  It  is  a  temporary 
measure.  Operation  for  the  permanent  cure  of  the  obstruction  can 
be  performed  later,  if  the  patient  survives.  For  relief  of  the 
renal  congestion  and  sepsis,  nephrotomy  should  be  performed. 
The  kidney  is  freely  incised  along  the  convex  border,  and  a 
large  rubber  drain  introduced  into  the  pelvis.  If  there  is  free 
haemorrhage,  a  mattress  stitch  may  be  inserted  to  control  it,  and 
the  rest  of  the  kidney  wound  left  open  or  packed  with  antiseptic 
gauze.  Another  large  drain  is  placed  outside  the  kidney  before 
uniting  the  edges  of  the  parietal  wound. 

As  a  result  of  this  operation  the  temperature  will  fall  to  normal, 
and  within  a  few  hours  the  dressings  will  be  flooded  with  urine.  The 
temperature  may  remain  normal,  and  the  progress  to  complete 
recovery  be  uninterrupted,  or  the  temperature  may  rise  again  to 
100  or  101  for  a  few  days,  and  then  gradually  fall.  The  secretion 
of  urine,  however,  is  re-established  and  the  crisis  is  over.  It  is  of 
vital  importance  that  these  operations  should  be  carried  through 
with  the  utmost  celerity.  The  operation  for  obstruction  and  that 
for  relief  of  the  renal  congestion  and  sepsis  are  done  at  one  sitting. 
Glucose  infusion,  rectal  and  intra-venous,  should  be  given  on  the 
return  from  the  operation.  There  is  some  danger  of  haemorrhage 
from  the  kidney  about  the  seventh  or  tenth  day  after  operation. 
Should  this  occur,  the  tube  is  removed  arid  the  kidney  rapidly 
plugged  with  gauze. 

Nephrectomy  is  not  indicated  in  these  cases,  since  nephrotomy 
suffices  to  tide  over  the  crisis  ;  the  shock  is  greater,  the  disease  is 
not  cured  by  nephrectomy,  the  second  kidney,  if  it  is  not  acutely 
septic,  is  damaged  to  an  unknown  degree  by  back  pressure. 
Nephrectomy  may,  however,  be  necessary  in  the  hsemorrhagic  type 
of  pyelonephritis  on  account  of  the  severe  and-  continuous 
haemorrhage. 

Chronic  Ascending  Pyelonephritis.  —  In  the  majority  of 
cases  chronic  ascending  pyelonephritis  is  bilateral,  one  kidney 
being  more  seriously  damaged  than  the  other.  The  prophylaxis  of 
chronic  ascending  pyelonephritis  consists  in  the  early  removal  of 
enlarged  prostate,  the  efficient  treatment  of  stricture,  the  removal 
of  calculi,  and  other  measures  directed  against  the  existence  of 
chronic  obstruction  and  chronic  sepsis  in  the  lower  urinary  organs. 
When  chronic  pyelonephritis  has  become  established,  operative 
interference  in  the  bladder  and  urethra  must  be  undertaken  with 
the  utmost  caution.  When  an  operation  for  enlarged  prostate  is 


Pyelonephritis  (Infective).  813 

proposed,  the  bladder  should  be  opened  supra-pubically  and  drained 
for  a  week  or  more  before  the  prostate  is  removed.  In  the  case  of  a 
stricture,  external  urethrotomy  with  drainage  of  the  bladder  would  be 
preferred  to  internal  urethrotomy  or  dilatation  with  instruments. 
Urinary  antiseptics  (see  under  Chronic  Haematogenous  Pyelo- 
nephritis) and  diuretics  should  be  freely  administered. 

If  the  disease  is  proved  to  be  unilateral,  and  the  second  kidney 
ascertained  to  be  healthy  by  means  of  the  ureteric  catheter  and 
tests  for  the  renal  function,  the  kidney  may  after  removal  of  all 
lower  urinary  obstruction  be  incised  or  removed.  It  is  seldom, 
however,  that  these  circumstances  combine  to  make  this  possible. 

Vaccine  treatment  has  not  given  encouraging  results. 

The  administration  of  renal  extract  has  been  tried  in  these  cases 
and  in  chronic  aseptic  pyelonephritis.  It  does  not  influence  the 
cause,  or,  in  the  cases  I  have  seen  treated  by  it,  modify  the 
progress  of  the  disease. 

J.  W.  THOMSON  WALKER. 


PYONEPHROSIS. 

THE  following  information  should  be  in  the  possession  of  the 
surgeon  before  operating  upon  a  case  of  pyonephrosis  : 

(1)  Are  calculi  present  in  the  kidney  or  ureter,  and,  if  so,  what  is 
their  position  and  number  ? 

This  information  is  obtained  by  the  X-rays,  and  it  is  essential 
that  the  number  of  the  calculi  should  be  shown  in  the  plate.  It  is 
often"  possible  to  distinguish  one  stone  plugging  the  upper  end  of 
the  ureter,  while  other  shadows  are  scattered  over  the  renal  area. 
A  stone  may  be  found  low  down  in  the  ureter  and  be  the  cause  of 
the  pyonephrosis.  I  have  operated  for  and  removed  a  large 
calculus  from  the  lower  end  of  the  ureter  some  years  after  the 
corresponding  kidney  had  been  removed  for  pyonephrosis  by 
another  surgeon. 

(2)  What  is  the  functional  value  of  the  pyonephrotic  kidney  ? 
This  is  ascertained  by  catheterisation  of  the  ureter.     The  urine 

obtained  is  examined,  the  quantitative  estimation  of  urea  and 
chlorides  being  most  important.  The  methylene  blue  and 
phloridzin  tests  for  the  renal  function  are  employed. 

(3)  What  is  the  condition  of  the  second  kidney  ? 
Information  is  necessary  in  regard  to  the  presence  of  calculi  or 

of  nephritis  or  septic  pyelonephritis,  and  it  is  necessary  to  estimate 
the  functional  power  of  this  kidney. 

This  is  obtained  by  the  use  of  the  X-rays,  the  examination  of  the 
urine  of  this  kidney,  and  the  use  of  the  phloridzin  and  methylene 
blue  tests.  The  examination  is  made  simultaneously  with  that  of 
the  other  kidney,  so  that  the  X-ray  examination  includes  the  whole 
urinary  tract,  and  both  ureters  are  catheterised. 

The  following  table  shows  the  information  obtained  in  a  case  of 
calculous  pyonephrosis : 

Right  Kidney  Left  Kidney, 

(pyonephrosis). 
Quantity    .         .  206-5  c.c.  107  c.c. 


Specific  gravity  . 
Freezing  point  (A) 
Colour 
Urea  . 
Chlorides    . 
Methylene  blue . 


1,004  1,011 

—0-18  c.  —0-76  c. 

Pale,  limpid  Fairly  coloured 

0-4  per  cent.  1 '3  per  cent. 

0-977  per  cent.  0-1112  per  cent. 

No  change  Delayed  two  hours.    Small 


quantity ;  lasted  eighteen 
hours. 
Phloridzin  glycosuria         .     0-395  gramme  1  '623  grammes 


Pyonephrosis.  815 

An  X-ray  examination  showed  calculi  in  the  right  kidney,  but 
the  rest  of  the  urinary  tract  free  from  calculi. 

From  this  examination  it  was  inferred  that  the  right  kidney  was 
almost  completely  destroyed,  and  that  the  functional  power  of  the 
left  kidney  was  practically  normal.  Nephrectomy  was  performed, 
and  the  patient  made  a  good  recovery. 

The  following  methods  of  treatment  will  be  discussed  :  (1)  Drain- 
age by  ureteral  catheter  ;  (2)  Plastic  operations ;  (3)  Nephrotomy  ; 
(4)  Partial  nephrectomy ;  (5)  Nephrectomy. 

Drainage  by  Ureteral  Catheter.  -  -  Pawlick  and  Albarran 
have  advocated  this  method  in  selected  cases.  The  ureter  is 
catheterised  daily,  or  less  often  according  to  whether  a  reaction 
occurs.  The  pelvis  is  washed  at  the  same  time.  The  catheter 
may  be  progressively  increased  in  size  until  a  No.  13  F. 
is  reached.  Albarran  has  left  the  ureteral  catheter  in  place  for 
several  weeks,  changing  it  when  it  became  blocked.  He  uses 
boracic  acid,  silver  nitrate  (1  in  1000)  and  permanganate  of 
potash  (1  in  4000  to  1  in  500)  for  washing  the  kidney.  Pawlick 
recommends  massage  of  the  kidney  and  the  application  of  a  firm 
bandage  afterwards.  He  claims  a  cure  in  a  pyonephrosis  of  150  gr., 
and  Albarran  another  in  one  of  60  gr. 

Many  circumstances  combine  to  limit  the  application  of  this 
method  :  an  intolerant  bladder,  febrile  reaction,  stricture  of  the 
ureter,  subdivision  of  the  pyonephrotic  pouch,  the  presence  of 
calculi,  thick  caseous  contents,  etc.,  and  there  can  be  very  few  cases 
when  it  will  possess  an  advantage  over  an  open  operation. 

Plastic  Operations. — In  cases  of  uro-pyonephrosis  plastic  opera- 
tions have  been  undertaken  with  the  object  of  re-establishing  the 
lumen  of  the  ureter.  These  operations  have  been  discussed  under 
Hydronephrosis.  It  is  necessary  to  ascertain  first  the  nature  of 
the  obstruction  and  the  functional  power  of  the  kidney,  and  in 
order  to  do  this  a  preliminary  nephrotomy  is  necessary.  Fre- 
quently the  functional  power  is  so  far  destroyed  that  it  is  not  worth 
while  doing  such  an  operation,  and  the  choice  will  lie  between 
nephrostomy  and  nephrectomy. 

Nephrostomy. — Nephrostomy  may  be  only  the  incision  of  the 
kidney,  or  there  may  be  an  attempt  made  to  re-establish  the  flow 
by  the  ureter. 

The  pyonephrotic  sac  is  opened  by  an  oblique  lumbar  incision. 
The  contents  are  evacuated,  septa  between  saccules  are  broken 
down.  Careful  search  is  made  for  interstitial  abscesses  and  the 
main  cavity,  the  upper  portion  of  the  ureter  and  the  subsidiary 
cavities  are  carefully  examined  for  stone,  and  the  perinephritic 


816  Pyonephrosis. 

tissue  around  the  kidney,  and  especially  at  the  upper  and  lower 
poles,  should  be  explored  for  extra-renal  collections  of  pus. 

Guyon  recommends  that  the  edge  of  the  sac  should  be  stitched  to 
the  skin,  in  order  to  avoid  peri-nephritic  suppuration.  This  is  not 
necessary  if  free  drainage  is  established  by  large  rubber  tubes 
placed  both  inside  and  outside  the  kidney. 

This  operation  has  the  advantages  that  it  is  rapid,  causes  no 
shock,  and  the  remains  of  the  secreting  tissue  are  preserved.  It 
may  therefore  be  performed  in  the  very  worst  cases,  when  the 
patient  is  weak  from  severe  or  prolonged  suppuration,  and  in  cases 
where  it  is  impossible  to  estimate  the  value  of  the  second  kidney, 
or  where  this  organ  is  known  to  be  the  seat  of  advanced  disease. 
The  mortality  of  this  operation  is  from  17  per  cent.  (Kiister)  to 
23-3  per  cent.  (Tuffier). 

After  the  operation  an  improvement  in  the  work  performed  by  the 
second  kidney  is  usually  observed,  and  is  due  to  the  relief  of  the 
depressant  reno-renal  reflex,  and  also  to  the  removal  of  toxins  which 
were  being  absorbed  and  excreted  by  the  second  kidney.  The 
general  health  for  similar  reasons  greatly  improves.  In  27 
per  cent,  of  cases  the  wound  closes,  the  sac  shrinks,  and  the  patient 
is  cured  (Kiister). 

In  a  certain  number  of  cases  septicaemia  persists,  and  the  work 
of  the  second  kidney  is  still  poorly  performed.  This  is  due  to  the 
continued  suppuration  in  a  thick,  fibrous-walled  cavity,  to  unopened 
pouches,  to  abscesses  in  the  walls  and  partitions,  to  stones  being 
left  in  the  sac  (16  per  cent,  of  cases),  and  to  the  persistence  of  the 
ureteric  block  and  ureteritis. 

A  fistula  remains  in  from  45*6  per  cent,  (calculous  pyonephrosis, 
34'2  per  cent. ;  non-calculous,  57'1  per  cent.)  (Tuffier)  to  56  per  cent. 
(Kiister). 

Various  means  have  been  adopted  to  obviate  this,  or  to  cure  the 
fistula  when  it  has  developed. 

At  the  nephrotomy  Bazy  introduced  a  bougie  along  the  ureter, 
and  Doyen  used  a  metal  sound  to  dilate  the  ureter.  There  is 
difficulty,  however,  in  finding  the  opening  of  the  ureter  in  a  large 
multi-locular  sac,  and  Albarran  has  used  the  following  method  : 
Before  the  nephrotomy  he  passes  a  catheter  up  the  ureter  by  means 
of  the  cystoscope.  At  the  operation  this  is  easily  found,  and  to  the 
end  of  it  is  attached  a  catheter  of  No.  10  F.  size.  By  withdrawing 
the  first  catheter  the  No.  10  catheter  is  drawn  down  to  the  bladder. 
This  second  catheter  is  fixed  to  the  skin  of  the  loin  with  a  thread, 
and  the  nephrotomy  is  finished  in  the  manner  described.  The 
ureteric  catheter  is  left  in  place  for  four  or  five  days  and  then  is 


Pyonephrosis.  817 

changed.  A  light,  pliable  stilet  is  passed  along  the  catheter,  and  a 
metal  conductor  attached  to  the  end  of  it.  The  catheter  is  now 
withdrawn  and  replaced  by  another,  which  is  threaded  over  the 
guide.  The  ureteral  drainage  is  continued  for  a  month.  By  this 
means  the  number  of  post-operative  fistulae  have  decreased. 

A  fistula  may  be  cured  by  the  removal  of  its  fibrous  wall,  the 
opening  up  of  the  sac,  removal  of  calculi,  and  the  establishment  of 
free  drainage.  Should  this  fail,  the  patient  has  the  choice  of 
retaining  the  fistula  or  having  the  kidney  removed.  The  presence 
of  a  renal  fistula  does  not  of  itself  necessarily  shorten  life.  Watson 
has  described  a  bilateral  renal  fistula  persisting  for  thirteen  years, 
and  Legueu  has  known  patients  become  pregnant  and  parturition 
proceed  naturally  when  such  fistulae  were  present. 

Secondary  nephrectomy  is  indicated  (1)  when  septicaemia  per- 
sists, (2)  when  it  is  believed,  by  the  inadequate  secretion  of  the 
diseased  kidney  and  the  absence  of  disease  in  the  second  kidney, 
that  a  depressed  renal  function  in  the  latter  will  improve  after 
nephrectomy,  and  (3)  when  the  patient  is  gradually  losing  ground 
from  prolonged  suppuration. 

The  mortality  of  secondary  nephrectomy  is  only  5'9  per  cent, 
(two  in  twenty-five  operations,  eight  calculous  and  seventeen  non- 
calculous)  (Tuffier).  If  this  is  added  to  the  mortality  of  nephrotomy 
(23'3  per  cent.),  the  total  mortality  is  29'2  per  cent. 

Nephrectomy.— (1)  Partial  nephrectomy  is  only  possible  when 
there  is  a  partial  pyonephrosis  with  a  separate  pelvis ;  (2)  Total 
nephrectomy. 

Nephrectomy  is  performed  by  the  lumbar  route.  The  abdominal 
route  has  been  abandoned  owing  to  its  high  mortality  (57  per  cent.) 
(Kiister). 

Subcapsular  nephrectomy  should  be  performed.  The  kidney  will 
usually  shell  out  of  the  great  peri-nephritic  fibro-fatty  mass  with 
comparative  ease,  whereas  the  removal  of  the  thick,  fibro-fatty 
capsule  with  the  kidney  is  fraught  with  extreme  difficulty  and  some 
danger.  It  may  be  necessary  to  puncture  a  very  large  pyonephrosis 
with  a  trocar  and  cannula  and  to  remove  a  large  part  of  its  contents, 
so  as  to  deal  with  the  pedicle  more  easily.  The  wound  should  be 
protected  with  pads,  and  the  purulent  fluid  removed  by  a  rubber 
tube  attached  to  the  cannula  to  avoid  soiling  the  wound.  The 
ureter  should  be  dissected  out  separately,  and  as  much  of  it  removed 
as  possible.  The  mortality  of  this  operation  is  17  percent.  (Kiister). 

Death  may  take  place  from  shock  in  patients  exhausted  by 
severe  or  prolonged  suppuration,  but  the  principal  danger  is  the 
inadequacy  of  the  second  kidney  from  disease  (40  per  cent.). 

S.T.— VOL.  II.  52 


8i8  Pyonephrosis. 

Nephrectomy  should  not,  therefore,  be  undertaken  until  the 
condition  of  the  second  kidney  has  been  ascertained  by  catheter- 
isation  of  the  ureters  and  the  use  of  the  phloridzin  or  methylene 
blue  tests.  By  this  means  only  those  cases  are  submitted  to 
nephrectorny  that  have  a  functionally  adequate  second  kidney,  and 
the  mortality  is  thereby  greatly  reduced.  In  the  remaining  cases 
nephrotorny  is  performed,  and  at  a  later  date  improvement  in 
the  condition  of  the  second  kidney  may  render  nephrectorny 
practicable. 

J.  W.  THOMSON  WALKER. 


819 


TUBERCULOSIS  OF  THE  KIDNEY. 

THE  following  points  are  important  in  considering  the  operative 
treatment  of  tuberculous  kidney  : 

(1)  Tuberculosis  of  the  kidney  is  unilateral  in  the  great  majority 
of  cases  during  the  early  stage  of  the  disease.     It  is  bilateral  in 
only  8  or  9  per  cent,  of  cases  when  the  patient  comes  under  the 
observation  of  the  surgeon. 

In    childhood    the   disease   is    much   more  frequently  bilateral 
(53*3  per  cent.). 

(2)  In  the  late  stage  the  disease  is  bilateral  in  almost  50  per  cent, 
of  cases. 

(3)  The  extent  to  which  the  disease  has  advanced  in  each  kidney 
in  bilateral  tuberculosis  differs  to  a  marked  degree,  and  leads  to  the 
view  that  a  considerable  interval  has  intervened  between  the  infec- 
tion of  the  first  and  the  second  kidney. 

(4)  The  probability  of  the  healthy  kidney  becoming  tuberculous 
increases  as  the  disease  progresses  in  the  diseased  kidney.     The 
number  of  cases  where  the  healthy  second  kidney  becomes  tuber- 
culous after  extirpation  of  its  diseased  neighbour  is  less  than  that 
when  the  diseased  kidney  is  left  unoperated. 

(5)  One  kidney  may  be  destroyed  by  tuberculous  disease  without 
giving  rise  to  pronounced  symptoms,  and  this  kidney  may  not  be 
palpable  or  tender. 

(6)  The  second  kidney  may  be  increased  to  twice  the  normal  size 
by  hypertrophy  without  disease. 

(7)  When  tuberculous  disease  attacks  the  hypertrophied  second 
kidney,   the  patient  may  be  unaware  of   the  disease  of  the  first 
kidney,  and  there  is  nothing  in  the  clinical  history  or  physical 
examination  to  show  that  the  large,  tender,  painful  kidney  is  not  the 
only  seat  of  disease. 

(8)  Chronic  nephritis  without  tuberculous  infection  is  frequently 
present  in  the  second  kidney. 

(9)  Symptoms  of  cystitis  may  be  present  in  tuberculosis  of  the 
kidney  without  disease  of  the  bladder,  and  are  due  to  reflex  irritation 
of  the  bladder  (reno-vesical  reflex).     Symptoms  of  renal  disease 
may  be  absent  in  these  cases. 

(10)  There  is  no  anatomical  proof  that  tuberculosis  of  the  kidney 
ever  heals  spontaneously  or  as  a  result  of  medical  treatment. 

52—2 


82O  Tuberculosis  of  the  Kidney. 

The  following  information  must  be  in  the  possession  of  the  surgeon 
before  he  performs  an  operation  upon  tuberculous  disease  of  the 
kidney  : 

(1)  Is  there  tuberculous  cystitis?     The  cystoscope  is  necessary 
to   distinguish    between  reflex   vesical  irritation    and   tuberculous 
cystitis. 

(2)  The  presence  of  a  second  kidney  must  be  ascertained,  and 
information  must  be  obtained  in  regard  to  the  presence  of  disease 
in  this  kidney  and  its  functional  activity.     These  data  are  obtained 
by  examination  of  the  ureteral  orifice  and  by  catheterisation  of  the 
ureter.     The  tests  for  the  renal  function  are  made,  and  the  urine 
examined  chemically  and  bacteriologically. 

(3)  Are  there  foci  of  tuberculous  disease  in  the  genital  system, 
lungs,  bones,  joints  or  elsewhere '? 

Tuberculin  Treatment. — Tuberculosis  of  One  Kidney  Alone.— 
It  is  impossible  to  speak  with  certainty  in  regard  to  the  effect  of 
tuberculin  upon  the  early  stage  of  renal  tuberculosis  when  one 
organ  only  is  affected,  for  extensive  observations  on  the  subject  are 
wanting. 

The  tuberculin  treatment  to  have  a  fair  trial  must  be  prolonged 
for  two  years  or  even  longer.  In  tuberculosis  of  the  kidney,  where 
the  spread  under  all  other  non-operative  forms  of  treatment  is 
known  to  be  progressive,  where  the  second  kidney  becomes  almost 
certainly  affected  after  a  variable  period  of  time,  the  length  of 
which  cannot  be  estimated  in  any  single  case,  where  the  results  of 
nephrectomy  in  the  early  stage  are  extremely  good,  the  surgeon 
will  hesitate  before  recommending  a  form  of  treatment  the  results 
of  which  are  still  uncertain  and  the  period  of  time  over  which  it 
must  extend  may  well  exceed  the  interval  of  safety  during  which 
the  second  kidney  is  still  unaffected.  It  is  in  cases  where 
operation  has  been  offered,  and  fairly  discussed  and  has  been 
refused,  that  this  treatment  must  for  some  time  to  come  find  its 
application. 

An  exception  may  perhaps  be  made  in  renal  tuberculosis  in 
children.  The  frequency  with  which  the  disease  is  bilateral  in  the 
early  stage  in  young  children  is  much  greater  and  the  difficulties  in 
accurate  diagnosis  by  modern  methods  are  more  formidable.  In 
such  cases  tuberculin  may  be  tried  in  lieu  of  operation. 

Tuberculosis  of  the  Kidney  and  Bladder. — The  indications  for 
tuberculin  treatment  are  the  same  as  when  the  kidney  alone  is 
affected. 

Nephrectomy  is  not  contra-indicated  by  the  presence  of  tubercu- 
losis of  the  bladder. 


Tuberculosis  of  the  Kidney.  821 

In  these  cases  the  chief  application  of  tuberculin  is  the  treatment 
of  the  bladder  after  nephrectomy  has  been  performed. 

In  some  cases  the  cystitis  subsides  without  further  treatment 
after  removal  of  the  kidney,  but  in  the  more  severe  grades  of  tuber- 
culous cystitis  the  disease  persists.  The  administration  of  tuber- 
culin is  indicated  in  such  cases,  and  the  results  obtained  by  its  use 
are  extremely  good. 

Tiil><'irnlo*is  of  l>ot)i  Kidneys. — In  such  cases  operative  inter- 
ference is  contra-indicated,  and  tuberculin  should  be  tried. 

I  have  not  met  with  a  cure  or  any  case  approaching  a  cure  in  this 
class  of  cases.  There  has,  however,  been  undoubted  improvement 
after  the  institution  of  the  tuberculin  treatment. 

When  the  disease  is  so  extensive,  a  considerable  period  of  time 
might  be  expected  to  elapse  before  the  full  effect  of  the  tuberculin 
is  obtained.  Such  a  period,  unfortunately,  is  seldom  afforded  in 
these  cases  before  death  takes  place  from  intercurrent  infection  or 
renal  failure. 

The  treatment  may  be  commenced  with  such  doses  as  ±J00 
milligramme  and  carried  on  with  great  caution,  for  there  is  some 
danger  of  blocking  the  already  obstructed  ureters  if  a  reaction  and 
swelling  of  the  mucous  membrane  takes  place. 

If  the  injections  are  followed  by  renal  pain  or  by  a  rise  of  tempera- 
ture, or  an  increase  of  fever  already  present,  they  should  be  stopped 
or  the  dose  much  reduced. 

Tuberculosis  of  one  Kidney,  iritJi  Tuberculous  Foci  in  other 
/V/>-/x — A  frequent  combination  is  renal  and  genital  tuberculosis. 
Tuberculin  treatment  is  often  of  service  in  these  cases,  either  in 
combination  with  nephrectomy  or  apart  from  operation. 

After  nephrectomy  tuberculin  treatment  of  the  genital  tubercu- 
losis is  likely  to  be  successful. 

Tuberculosis  of  the  kidney  may  occur,  with  active  tuberculosis  of 
the  lungs,  bones  or  joints.  My  experience  of  tuberculin  in  these  cases 
has  not  been  encouraging.  There  was  improvement  in  the  renal 
disease  in  some  of  the  cases,  but  the  extra-renal  foci  were  unaffected 
or  even  appeared  to  increase  under  the  treatment.  When  the  extra- 
renal  disease  was  quiescent,  it  could  be  ignored  in  the  treatment  of 
the  renal  tuberculosis. 

The  method  of  administration  of  tuberculin  is  described  else- 
where. (See  Vaccine  Therapy,  Vol.  III.)  In  renal  tuberculosis  I 
have  used  dose  sconimeucing  at  ^cfeo  or  ^oo  milligramme  (T.  R), 
and  gradually  increased  the  strength  to  jooo  or  noo-  I  have  not 
found  the  tuberculo-opsonic  index  necessary  as  a  routine  guide  to 
dosage.  I  used  it  in  my  earlier  cases  and  found  the  "  negative 


822  Tuberculosis  of  the  Kidney. 

phase  "  described  by  Sir  Almroth  Wright  reproduced  in  these  cases. 
This  period  of  depressed  resistance  lasted  two  or  three  days,  and 
even  if  severe  it  completely  passed  off  before  the  end  of  a  week.  The 
"  negative  phase  "  appeared  in  all  the  cases  examined  for  it  under 
the  influence  of  doses  which  proved  to  be  of  therapeutic  value. 

An  excessive  dose  was  followed  by  a  more  profound  negative 
phase,  but  it  was  also  accompanied  by  symptoms  of  reaction,  such  as 
malaise,  depression,  "  aching  all  over  tfce  body,  "  a  slight  rise  of 
temperature  and  some  pain  or  tenderness  in  the  diseased  organ.  I 
found  that  the  appearance  of  these  symptoms  was  a  sufficient  warn- 
ing, without  the  use  of  the  tuberculo-opsonic  index,  that  the  thera- 
peutic dose  had  been  over-stepped.  The  converse  also  held  good, 
and  in  the  absence  of  these  symptoms  of  reaction  the  doses  which 
were  being  administered  were  within  the  limit  of  safety. 

The  treatment  must  extend  over  one  or  several  years.  A  course 
of  six  or  eight  injections  is  worthless.  I  have  given  tuberculin 
both  continuously  (i.e.,  weekly  or  fortnightly  for  one  or  more  years) 
and  intermittently  in  successive  courses  of  two  or  three  months 
with  intervals  of  rest  of  equal  duration,  the  treatment  lasting  one 
or  more  years.  Of  the  two  methods,  I  am  inclined  to  favour  the 
intermittent  one.  Each  course  must,  however,  be  cautiously  intro- 
duced with  a  small  dose,  and  the  strength  gradually  increased. 

Progress  is  measured  by  the  effect  upon  symptoms  :  the  increase 
or  decrease  of  the  body- weight,  the  general  feeling  of  vigour,  the 
effect  on  pain,  tenderness,  enlargement  of  the  kidney,  and  the  re- 
currence of  attacks  of  haematuria.  Where  vesical  symptoms  are 
present  the  amelioration  of  these  symptoms  frequently  provides  the 
most  striking  demonstration  of  improvement.  The  specific  gravity 
and  the  pigmentation  of  the  urine  increase  as  the  renal  condition 
improves.  The  quantity  of  pus  and  the  presence  or  absence  of 
microscopical  quantities  of  blood  are  also  important  tests. 

The  presence  and  number  of  tubercle  bacilli  are  the  most  critical 
tests  of  the  progress  of  the  disease. 

The  operations  which  may  be  performed  for  tuberculosis  of  the 
kidney  are  partial  nephrectomy,  nephrotomy,  and  total  nephrec- 
tomy. 

Partial  Nephrectomy. — This  operation  consists  in  removal  of 
the  diseased  part  of  the  kidney.  It  has  been  practised  in  isolated 
cases  by  Israel,  Watson,  Morris,  Godlee  and  others,  and  has  been 
recommended  in  the  early  stage  of  renal  tuberculosis. 

In  practice,  however,  it  is  found  that  at  this  early  stage  it  is 
impossible  to  make  certain  how  much  of  the  kidney  is  affected.  On 
surface  inspection  the  organ  may  appear  normal,  or  one  pole  may 


Tuberculosis  of  the  Kidney.  823 

appear  tuberculous  and  the  rest  of  the  kidney  healthy  when  the 
disease  has  already  affected  both  poles. 

For  this  reason  partial  nephrectomy  has  not  been  widely  adopted, 
and  the  opinion  is  practically  universal  at  the  present  time  that 
total  nephrectomy  is  the  only  radical  operation  that  should  be 
practised  for  tuberculosis  of  the  kidney. 

Nephrectomy. — Nephrectomy  in  the  early  stage  of  renal 
tuberculosis  is  the  only  method  by  which  a  cure  can  be  assured, 
and  the  operation  is  indicated  whenever  the  diagnosis  is  made. 

Nephrotomy  is  reserved  for  certain  cases  that  are  unsuitable 
for  nephrectomy,  and  is  a  purely  palliative  operation. 

The  contra-indieations  to  nephreetomy  are  as  follows  : 

(1)  Bilateral  Tubi'inilosis. — When  both  kidneys  are  proved  to 
be  tuberculous,  nephrectomy  cannot  be  recommended  as  a  curative 
operation. 

The  disease  is  always  more  advanced  in  one  kidney  than  in 
the  other,  and  it  may  be  discussed  whether  the  removal  of  the 
organ  in  which  the  disease  is  more  advanced  will  not  prolong 
life.  If  we  set  aside  general  tuberculosis,  which  is  a  very  rare 
accident  in  tuberculous  disease  of  the  kidney,  and  is  not  likely 
to  be  affected  by  the  removal  of  one  of  two  tuberculous  organs,  the 
dangers  to  which  a  patient  with  bilateral  renal  tuberculosis  is 
exposed  are  two : 

(a)  Toxaemia  due  to  absorption  from  the  tuberculous  foci. 

(b)  Anuria  from  destruction  of  the  renal  tissue. 

In  so  far  as  the  general  health  is  suffering  from  the  absorption 
of  toxins  from  the  diseased  area  considerable  benefit  will  accrue  from 
the  removal  of  one  focus  of  disease,  and  it  is  also  certain  that  the 
second  and  the  functionally  more  active  kidney  will  be  relieved  of 
the  irritation  caused  by  the  excretion  of  toxins  from  the  blood.  But, 
on  the  other  hand,  the  period  of  life  remaining  to  the  patient  is 
also  measured  by  the  quantity  of  active  renal  tissue  which  he 
possesses.  By  nephreetomy  of  the  most  diseased  organ  some 
functional  renal  tissue  is  removed  even  when  the  tuberculous 
inflammation  is  far  advanced.  The  whole  work  of  secretion  is 
thus  thrown  upon  the  remaining  kidney.  In  some  cases  the 
removal  of  even  this  small  amount  of  renal  tissue  leaves  the 
patient  with  too  little  active  secreting  tissue,  and  anuria  follows 
the  operation.  In  other  cases  the  patient  survives  the  operation, 
but  after  a  short  period  death  from  anuria  takes  place. 

Unless  it  is  proved  by  the  examination  of  the  urine  obtained 
by  the  ureteric  catheter,  and  by  the  various  tests  of  the  renal 
function,  that  the  disease  of  the  second  kidney  is  in  a  very 


824  Tuberculosis  of  the  Kidney. 

early  stage,  and  unless  it  is  obvious  that  the  health  of  the  patient 
is  suffering  to  a  marked  degree  from  the  absorption  of  toxins, 
nephrectomy  of  the  more  diseased  kidney  in  bilateral  tuberculosis 
is  contra-indicated. 

(2)  Non-tuberculous  Nephritis  of  the  Second    Kidney. — A    slight 
degree   of    chronic    nephritis   is    very    frequently    present  in  the 
second  kidney.     This  is  shown  by  the  presence  of  albumen  and 
granular  and  hyaline  tube-casts  in  the  urine,  and  is  due  to  the 
excretion  of  toxins.     This  does  not  centra-indicate  nephrectomy  of 
the   tuberculous    kidney  unless  the  nephritis  is   advanced.     The 
urine  from  this  kidney  must  be  examined  and  the  tests  of  the  renal 
function  carried  out  in  order  to  ascertain  the  extent  of  the  renal 
disease.     Should  these  prove  satisfactory,  nephrectomy  should  be 
performed. 

(3)  Tuberculous  Lesions   of  the    Bladder. — Tuberculous   cystitis 
does  not  centra-indicate  nephrectomy  if  it  can  be  proved  that  the 
second  kidney  is  healthy. 

This  proof  is  sometimes  very  difficult  to  obtain,  for  the  con- 
tracted and  irritable  state  of  the  bladder  interferes  with  catheterisa- 
tion  of  the  ureters.  With  care  and  perseverance,  however,  this  can 
be  carried  out  by  a  skilled  cystoscopist  in  all  but  the  most 
exceptional  cases. 

The  removal  of  the  tuberculous  kidney  has  usually  a  most 
beneficial  effect  upon  the  disease  of  the  bladder.  The  cystitis 
may  subside  without  further  local  treatment. 

The  use  of  tuberculin  in  these  cases  has  given  most  satisfactory 
results  in  my  hands.  When  the  tuberculous  infection  has  become 
mixed  with  bacterium  coli  or  other  bacteria  the  prognosis  is  not, 
however,  so  good. 

(4)  Tuberculous  Lesions  of  other  Organs. — Obsolete   tuberculous 
foci,  such  as  Pott's  curvature,  ankylosed  joints,  healed  tuberculous 
disease  of  bones  or  glands,  etc.,  do  not  contra-indicate  nephrectomy, 
although  from  anatomical  reasons  the  operation  may  be  rendered 
more  difficult. 

In  active  tuberculous  disease  of  the  genital  system,  nephrectomy 
may  be  performed  if  the  genital  disease  is  not  widespread.  In  a 
case  where  both  epididynies,  both  seminal  vesicles  and  the  prostate 
are  affected,  nephrectomy  would  be  contra-indicated  ;  but  in  less 
extensive  lesions,  such  as  unilateral  tuberculous  epididymitis, 
nephrectomy  and  epididymectomy  may  be  performed.  When  renal 
tuberculosis  is  complicated  by  active  spinal  caries,  psoas  abscess, 
tuberculous  arthritis,  pulmonary  phthisis  and  other  such  serious 
lesions,  nephrectomy  is  contra-indicated. 


Tuberculosis  of  the  Kidney.  825 

(5)  The  General  State  of  the  Patient. — It  is  occasionally 
necessary  to  refuse  primary  nephrectomy  on  account  of  an 
enfeebled  general  state,  apart  from  any  of  the  complications  above 
described. 

Secondary  nephrectomy  may  sometimes  be  possible  in  these  cases 
after  nephrotomy. 

The  Operation. — The  retro-peritoneal  route  is  invariably  chosen 
for  the  removal  of  a  tuberculous  kidney.  An  oblique  lumbar 
incision  gives  the  most  satisfactory  access. 

The  operation  is  simple  or  complicated  according  to  the  absence 
or  presence  of  peri-nephritic  inflammation. 

Nephrectomy  in  an  early  stage  of  renal  tuberculosis  before  the 
peri-nephritic  fat  has  become  dense  and  sclerosed  presents  no 
difficulties  or  unusual  features.  On  exposing  the  organ  the  out- 
ward appearance  may  not  suggest  that  it  contains  any  disease, 
and  palpation  does  not  detect  any  change  in  consistence.  In  such 
a  case  the  value  of  the  previous  examination  of  the  urine  from 
each  kidney  becomes  evident.  The  kidney  is  removed  without 
being  incised,  and  the  danger  of  infecting  the  wound  with  tubercle 
is  avoided. 

The  ureter  is  first  isolated  and  carefully  examined.  Whether  it 
is  thickened  or  not,  it  should  be  cut  across  between  two  ligatures 
and  each  end  seared  with  the  cautery  or  touched  with  pure 
carbolic  acid.  The  pedicle  is  ligatured  and  the  kidney  removed. 
Legueu  recommends  that  the  peri-renal  fat  should  be  dissected 
away,  as  there  are  frequently  tuberculous  deposits  in  it.  To  do 
this  thoroughly  is  often  difficult  and  sometimes  impossible.  In  the 
early  stage  of  tuberculosis  of  the  kidney,  before  peri-nephritis  has 
occurred,  there  is  little  difficulty,  but  in  the  later  stages  it  is  impossible 
to  dissect  away  the  fibro-lipomatous  mass  that  surrounds  the  kidney, 
and  this  applies  also  to  the  adherent  lymphatic  glands  that  are 
sometimes  found  among  the  structures  forming  the  renal  pedicle. 
"When  there  has  been  peri-nephritis  the  fatty  capsule  is  transformed 
into  a  thick,  firm,  adherent  fibro- fatty  mass,  and  a  sub-capsular 
nephrectomy  becomes  necessary.  The  kidney  is  exposed  and 
stripped  from  its  capsule  with  the  forefinger,  great  care  being 
taken  not  to  rupture  the  tuberculous  cysts,  the  walls  of  which  are 
thin  and  easily  torn.  If  the  kidney  is  converted  into  a  large 
pyonephrosis,  it  may  be  advisable  to  tap  it,  and  so  reduce  the  size 
and  diminish  the  possibility  of  rupturing  the  wall  of  the  sac 
during  the  ermcleation.  This  is  seldom  necessary,  however,  and 
if  it  is  done  the  most  stringent  precautions  must  be  observed  to 
prevent  soiling  of  the  wound  with  the  escaping  tuberculous 


826  Tuberculosis  of  the  Kidney. 

material.  The  puncture  is  made  with  a  trocar  and  cannula  after 
protecting  the  wound  with  large  gauze  swabs,  and  the  puncture 
wound  is  closed  by  pressure  forceps  over  gauze  during  the 
remaining  stages  of  the  operation.  After  removal  of  the  kidney 
the  cavity  must  be  drained. 

When  the  ureter  is  normal  in  appearance  it  is  ligatured  and 
dropped  into  the  wound.  When  it  is  thickened  and  tuberculous, 
one  of  three  courses  may  be  pursued  :  (1)  The  upper  end  may  be 
fixed  in  the  lumbar  wound  ;  (2)  the  upper  end  may  be  ligatured, 
cauterised,  and  dropped  into  the  retro -peritoneal  space  after  remov- 
ing the  kidney ;  (3)  the  ureter  may  be  excised. 

(1)  The  upper  end  of  the  tuberculous  ureter  may  be  fixed  in  the 
lumbar  wound. — This  has  been  done  with  a  view  to  ureterectorny 
at  a  later  date.     A  tuberculous  sinus  results,  and  in  one  case  in 
which  I  did  this  the  lumbar  wound  became  extensively  infected 
with  tubercle,  and  only  healed  after  some  months. 

(2)  The  upper  end  is  dropped  into  the  retro-peritoneal  space 
after  being  ligatured   and  cauterised. — In  the  majority  of   cases 
the  tuberculous  process  becomes  quiescent,  and  the  tube  gradually 
becomes  transformed  into  a  fibrous  cord.     Zuckerkandl  found  that 
a  sinus  followed  nephrectomy  more   frequently  when  the  ureter 
had  been  left  intact.      Occasionally,  tuberculous   cystitis  appears 
to    be    kept    up    by    the  persistence   of    tuberculosis    in    such   a 
ureter. 

(3)  The  ureter    is  excised. — In  order  to  do  this    the    oblique 
lumbar    incision    is     prolonged    forwards     beyond    the    anterior 
superior  iliac  spine,  and  runs  parallel  to  Poupart's  ligament  and 
about  1£  inches  above  it  to  about  the  middle  of  its  extent.      The 
patient  should  be  placed  in  the  Trendelenberg  position  in  order 
to  reach  the  pelvic  portion  of  the  ureter.     The  thick  rigid  tube  is 
easily  traced  down  into  the  pelvis. 

The  adhesions  sometimes  give  rise  to  some  difficulty  in  iso- 
lating it.  In  the  male  subject  the  ureter  can  be  traced  to  the 
bladder,  and  then  ligatured  and  cut  across.  In  the  female 
the  pelvic  portion  of  the  ureter  is  concealed  in  the  broad  liga- 
ment, and  the  tube  must  be  cut  across  behind  this.  Kelly  has 
removed  the  lower  portion  of  the  tuberculous  ureter  through  the 
vagina. 

A  portion  of  the  bladder-wall  around  the  lower  end  of  a 
tuberculous  ureter  has  been  excised  along  with  the  ureter. 

The  advisability  of  performing  an  extensive  operation  for  the 
removal  of  the  ureter  at  the  end  of  nephrectomy  will  depend  upon 
the  state  of  the  patient  and  the  duration  of  the  nephrectomy. 


Tuberculosis  of  the  Kidney. 


827 


The  ureterectomy  should  only  be  performed  if  the  nephrectomy 
has  passed  off  smoothly  and  the  patient's  strength  is  well 
maintained. 

Most  authorities  are  content  to  remove  "as  much  as  possible" 
of  the  ureter,  which  means  that  the  ureter  is  traced  over  the  brim 
of  the  pelvis  and  cut  across  in  the  descending  part  of  its  pelvic 
course,  leaving  the  remaining  portion  of  the  pelvic  ureter.  This 
operation  occupies  less  time  and  necessitates  less  extensive  dissec- 
tion than  the  more  complete  removal  of  the  ureter ;  it  protects 
the  lumbar  wound  against  the  possibility  of  infection  from  the 
ureter,  and  the  small  stump  does  not  give  rise  to  any  further 
trouble.  On  these  grounds  it  is  to  be  recommended.  Secondary 
ureterectomy  may  be  required  in  cases  where  the  ureter  has  not 
been  removed  at  the  time  of  the  nephrectomy.  The  operation  is 
necessary  when  a  fistula  connected  with  the  ureter  persists,  and  when 
vesical  symptoms  persist  or  increase. 

Results  of  Nephrectomy  jor  Primary  Tuberculosis  —  Immediate 
Mortality. — The  following  figures  are  given  by  Brongersma  : 


Surgeon. 

Number  of 
Nephrectomies. 

Deaths  from 
Operatiou. 

Per  cent. 

Albarran 

108 

3 

2-77 

Brongersma 

58 

3 

5-17 

Casper  . 

19 

2 

10-50 

Israel    . 

97 

11 

11-34 

Kronlein 

34 

2 

10-70 

Kummel 

69 

3 

4-35 

Pousson 

20 

2 

10-00 

Rafin     . 

40 

5 

12-50 

Eovsing 

47 

3 

6-30 

Ziickerkandl 

23 

3 

13-05 

515 

37 

7-18 

This  gives  an  operative  mortality  of  7*18  per  cent,  in  515  cases. 
During  the  last  twenty-five  years  there  has  been  a  steady  and  rapid 
decrease  in  the  mortality  of  nephrectomy  for  tuberculous  disease  of 
the  kidney. 

The  improvement  in  the  statistics  was  due  in  the  earlier  years  to 
more  perfect  asepsis,  and  to  improved  methods  of  treating  surgical 
shock  and  more  perfect  technique,  as  well  as  to  experience  in  the 
selection  of  cases  suitable  for  operation. 

Recently  the  great  advance  in  the  methods  of  early  diagnosis  and 
examination  of  the  renal  function  afforded  by  catheterisation  of 


828 


Tuberculosis  of  the  Kidney. 


the  ureters  and  the  use  of  the  phloridzin,  methylene  blue  and 
Albarran's  experimental  polyuria  tests  have  led  to  still  further 
reduction  of  the  mortality. 

If  from  the  above  list  only  those  cases  are  selected  where  modern 
methods  of  diagnosis  were  used,  the  mortalit}7  falls  to  2'85  per 
cent.  The  following  are  the  figures  thus  obtained : 


Surgeon. 

Number  of 
Nephrectomies. 

Deaths. 

Per  cent. 

Albarran 

106 

1 

0-94 

Brougersma 

57 

1 

1-75 

Casper  . 

19 

2 

10-50 

Kiimmel 

68 

2 

2-90 

Ra6n    . 

32 

2 

6-50 

JRovsing 

33 

1 

3-38 

315 

9 

2-85 

In  these  cases  not  one  of  the  nine  deaths  was  due  to  renal 
failures. 

After-Results  —  The  after-history  of  369  patients  on  whom 
nephrectorny  was  performed  for  primary  tuberculosis  shows  that 
death  occurred  after  a  considerable  interval  in  fifty-six  cases  (15'2 
per  cent.). 

In  these  cases  the  interval  varied  from  one  or  two  years  to  four- 
teen or  sixteen  years.  The  great  majority  of  these  fatal  cases  died 
within  the  first  two  years.  Thus  of  329  cases  of  nephrectomy, 
thirty-five  (or  10*6  per  cent.)  died  during  the  first  two  years.  In 
these  cases  the  fatal  result  would  be  due  to  spread  of  the  tubercu- 
lous process. 

Of  184  cases  surviving  two  years  after  nephrectomy  from 
tuberculosis  only  six  (3-2  per  cent.)  died  of  tuberculosis  after  that 
interval.  It  may  be  stated,  therefore,  that  there  is  a  risk 
(amounting  to  10'6  per  cent.)  of  the  patient  dying  of  tuberculosis 
during  the  first  two  years,  and  a  risk  of  3'2  per  cent,  of  a  fatal  result 
from  tuberculosis  after  this. 

Nephrotomy. — Nephrotomy  is  a  preliminary  or  a  palliative 
operation  in  tuberculosis  of  the  kidney,  and  is  indicated  under  the 
following  conditions  : 

(1)  When  it  is  impossible  from  the  condition  of  the  bladder  to 
catheterise  the  ureter  and  obtain  information  in  regard  to  the  state 
of  the  second  kidney.  After  an  interval  the  cystitis  subsides 


Tuberculosis  of  the  Kidney.  829 

and  the  examination  can  be  carried  out.  Casper  has  recommended 
that  under  these  very  rare  circumstances  the  diseased  kidney  should 
be  exposed,  its  ureter  compressed,  an  injection  of  indigo  carmine 
given,  and  the  urine  collected  from  the  bladder  by  a  catheter.  By 
this  method  the  functional  power  of  the  second  kidney  is  tested. 

(2)  As  a  preliminary  operation  to  nephrectomy  when  the  general 
condition  of  the  patient  is  much  enfeebled. 

Secondary  nephrectomy  is  performed  after  some  weeks,  when 
the  patient  has  regained  strength. 

(3)  When  both  kidneys  are  tuberculous :  (a)  to  remove  a  collec- 
tion of  tuberculous  material ;  (b)  to  relieve  excessive  haemorrhage 
or  severe  pain  ;  (c)  to  relieve  profound  toxemia. 

The  mortality  of  nephrotomy  is  high.  Pousson  in  his  personal 
statistics  found  an  operative  mortality  of  27*5  per  cent,  for 
nephrotomy,  and  6'54  per  cent,  for  primary  nephrectomy. 

A  fistula  persists  during  the  lifetime  of  the  patient. 

In  a  few  cases  the  fistula  has  closed  after  the  kidney  has  been 
entirely  destroyed. 

J.  W.  THOMSON  WALKER. 


83o 


TUMOURS  OF  THE  KIDNEY  IN  ADULTS. 

THE  following  points  are  important  in  regard  to  operative 
treatment  of  tumours  of  the  kidney  in  adults : 

(1)  The   results  of  operation  in  the  early  stage  of  malignant 
growths  of  the  kidney  are  encouraging.     Operation  in  the  later 
stage  is  invariably  followed  by  recurrence. 

Diagnosis  must  therefore  be  made  in  the  early  stage. 

(2)  Haematuria  occurs  in  nearly  all  cases  of  renal  growth.     Israel 
found  haematuria  in  92  per  cent,  of  his  cases.     In  70  per  cent,  of 
cases  hsematuria  is  the  first  symptom  of  new  growth  of  the  kidney, 
and  in  the  early  stage  it  is  the  only  symptom. 

(3)  All  cases  of  renal  hsematuria  without  other  signs  or  symptoms 
should  be  explored  for  renal  growth. 

(4)  The  size  of  the  tumour  is  no  contra-indication  to  operation. 

(5)  In  cases  where  the  peri-renal  adipose  tissue  appears  normal 
there  may  be  microscopical  deposits  of  cancer  cells  in  it. 

(6)  The  growth  may  take  origin  in  the  suprarenal  capsule  and 
invade  the  kidney,  or  nodules  of  growth  may  be  present  in  the 
suprarenal  capsule. 

(7)  The  lymphatic  vessels  surrounded  by  adipose   tissue   pass 
from  the  kidney  in  a  mesentery  between  the  layers  of  fascia  to 
glands  lying  along  the  inferior  vena  cava  on  the  right  and  the  aorta 
on  the  left  side.     These  glands  are  found  for  the  most  part  below 
the  level  of  the  renal  vessels.    In  their  course  the  lymphatic  vessels 
do  not  communicate  with  other  plexuses. 

(8)  The  ideal  operation-  should  remove  the  kidney  and  tumour, 
the  adipose  capsule,  the  lymphatic  vessels  and  lymph  glands  and 
the  adipose  tissue  in  which  they  are  embedded,  and  the  suprarenal 
capsule.     Gregoire  insists  that   these  should  be  removed  in   one 
piece. 

Before  embarking  upon  nephrectomy  the  following  points  must 
be  decided : 

(a)  Has  the  growth  spread  beyond  the  kidney  ? 

The  disappearance  of  movement  in  respiration  when  the  kidney 
is  still  small  is  an  important  sign  of  spread  beyond  the  kidney. 
Immobility  in  a  large  tumour  has  not  the  same  significance.  The 
extent  of  the  growth  can  best  be  ascertained  after  exposure  of  the 
kidney.  In  all  large  growths  the  peritoneum  should  be  opened  and 


Tumours  of  the  Kidney  in  Adults.        831 

the  peritoneal  aspect  of  the  tumour  examined.  I  have  twice  had 
to  desist  from  nephrectomy  on  finding  the  peritoneum  adherent 
and  nodular  over  the  highest  part  of  the  kidney  in  tumours  which 
in  other  respects  appeared  to  be  suitable  for  removal.  From  the 
peritoneal  cavity  the  upper  pole  of  the  kidney  can  be  explored  in 
large  growths,  whereas  it  cannot  be  reached  until  a  late  stage  of 
the  operation  if  approached  extra-peritoneally. 

The  lymph  glands  lying  alongside  the  aorta  or  vena  cava  should 
be  examined.  The  most  frequent  seat  of  metastatic  deposit  is  the 
lungs.  A  radiograph  of  the  thorax  should  be  obtained  in  all  cases, 
and  examined  for  secondary  deposits  in  the  mediastinal  glands 
and  lungs.  Such  deposits  may  be  present  and  widespread  with- 
out causing  pulmonary  symptoms  or  with  only  slight  signs  of 
bronchitis.  Next  in  frequency  to  the  lungs,  the  liver  is  the  seat  of 
metastatic  deposit.  This  organ  should  therefore  be  examined  by 
palpation,  percussion  and  the  X-rays. 

(&)  What  is  the  condition  of  the  second  kidney  ? 

The  presence,  health  or  disease  of  a  second  kidney  should  be 
ascertained  and  its  functional  activity  estimated  by  catheterisation 
of  the  ureter,  examination  of  the  urine  thus  obtained,  and  the  use 
of  the  tests  for  the  renal  function. 

Bi-lateral  renal  growths  occur  very  rarely  in  adults.  At  least 
90  per  cent,  are  unilateral.  The  second  kidney  is  frequently  the 
seat  of  chronic  nephritis.  Rarely  it  is  shrunken  and  atrophied  or 
absent.  The  presence  of  disease  such  as  chronic  nephritis  or  stone 
does  not  centra-indicate  operation  if  the  renal  function  is  adequately 
performed. 

Indications  and  Centra-indications  for  Operation. — In  all 
cases  of  malignant  growth  confined  to  one  kidney  nephrectomy 
should  be  performed  if  the  condition  of  the  patient  is  considered 
sufficiently  good  and  the  second  kidney  capable  of  carrying  on 
the  renal  function. 

The  operation  is  contra-indicated  when  :  (1)  There  is  evidence  of 
invasion  of  the  peri-renal  tissues  ;  (2)  enlarged  lymph  glands  in 
the  abdomen  ;  (3)  evidence  of  metastatic  deposit ;  (4)  the  second 
kidney  is  the  seat  of  growth,  of  advanced  nephritis,  or  is  shrunken 
or  absent ;  (5)  the  patient  is  weak  and  cachectic ;  (6)  the  heart  is 
dilated  and  feeble. 

Operation. — Total  nephrectomy  is  the  only  radical  method  of 
treatment.  Partial  nephrectomy  is  unsuited  to  the  treatment  of 
malignant  growth  of  the  kidney.  Nephrectomy  may  be  performed 
by  the  abdominal  (transperitoneal)  or  lumbar  (retroperitoneal) 
route.  In  cases  where  operation  is  performed  before  enlargement 


832        Tumours  of  the  Kidney  in  Adults. 

of  the  kidney  can  be  detected,  the  operation  will  take  the  form  of 
an  exploration  of  the  kidney  for  haematuria,  and  the  discovery  of 
the  growths  leads  to  nephrectomy.  These  constitute  a  considerable 
proportion  of  the  cases,  and  are  those  in  which  the  prognosis 
should  be  most  favourable. 

In  such  cases  the  operation  commences  as  a  retroperitoneal  ex- 
ploration of  the  kidney,  the  adipose  capsule  has  been  opened  and  the 
kidney  has  often  been  incised  before  the  diagnosis  is  made.  The 
incision  in  the  kidney  should  be  closed  with  catgut  sutures,  and 
nephrectomy  carried  out.  The  peri-renal  adipose  tissue  should  then 
be  dissected  from  the  surface  of  the  peritoneum  and  colon  as  far  as 
the  vena  cava  or  the  aorta. 

The  adipose  tissue  is  also  dissected  from  without  inwards  from 
the  muscles  of  the  posterior  abdominal  wall,  leaving  them  bare. 
Near  the  vena  cava  or  aorta  the  spermatic  vessels  will  be  en- 
' countered,  and  should  be  preserved.  The  removal  of  adipose  and 
areolar  tissue  and  with  them  lymphatic  vessels  and  glands  should 
be  carried  out  with  great  care  as  far  as  the  great  vessels.  The 
suprarenal  gland  should  also  be  removed,  and  to  carry  this  out 
good  retraction  is  necessary. 

When  the  new  growth  is  larger  and  a  diagnosis  has  been  made 
before  operation,  abdominal  nephrectomy  will  give  a  better 
approach,  or  the  growth  may  be  exposed  by  the  lumbar  retro- 
peritoneal  method  and  the  incision  extended  and  the  peritoneum 
opened  to  the  outer  side  of  the  colon. 

Gregoire  has  described  an  operation  which  is  more  thorough 
than  these  methods,  and  which  is  to  be  recommended  when  a 
diagnosis  of  new  growth  of  the  kidney  has  been  made  previous  to 
operation.  The  object  of  the  operation  is  to  remove  in  one  piece  the 
kidney,  peri-renal  adipose  tissue,  lymphatics,  and  lymphatic  glands. 

A  firm  pillow  is  placed  under  the  diseased  side,  and  does  not 
extend  further  than  the  vertebral  column,  so  that  the  body  leans  to 
the  healthy  side  and  lies  midway  between  the  dorsal  and  lateral 
positions,  and  is  curved  backwards. 

In  the  anterior  axillary  line  an  incision  is  made  from  the  costal 
margin  to  the  iliac  crest.  From  the  upper  extremity  this  is  carried 
forwards  along  the  costal  margin  for  4  or  5  centimetres,  and  from  the 
lower  end  the  incision  is  prolonged  along  the  iliac  crest  for  a  similar 
distance.  This  is  carried  through  the  muscular  planes,  care  being 
taken  in  cutting  through  the  transversalis  abdominis  not  to  wound 
the  peritoneum. 

With  the  index  fingers,  the  peritoneum,  colon,  and  peri-renal 
tissues  enclosed  within  the  fascia  of  Zuckerkandl  are  displaced 


Tumours  of  the  Kidney  in  Adults.        833 

forwards  and  stripped  off  the  muscles  of  the  posterior  abdominal 
wall,  and  this  is  carried  as  far  as  the  vertebral  column. 

The  reflection  of  the  peritoneum  is  identified,  and  about  1 
centimetre  behind  this  the  fascia  of  Zuckerkandl  is  incised.  The 
peritoneum  and  colon  are  now  stripped  forwards  as  far  as  the  vena 
cava  or  aorta.  Slight  traction  will  detach  the  kidney  at  its  upper 
pole,  but  with  this  the  suprarenal  capsule  must  be  removed  by  blunt 
dissection  with  the  finger. 

A  large  retractor  holds  back  the  peritoneum,  and  the  renal 
vessels  are  well  exposed  and  ligatured.  The  ureter  is  tied  and  cut, 
and  the  kidney  is  now  removed  so  as  to  obtain  better  access.  The 
adipose  tissue  lymphatics  and  glands  are  now  dissected  along  the 
vena  cava  and  aorta,  preserving  the  spermatic  vessels. 

Dangers  of  Nephrectomy  in  Renal  Growths. — The  im- 
mediate danger  is  haemorrhage. 

The  veins  of  the  peri- renal  tissues  are  greatly  enlarged  when  the 
new  growth  has  reached  a  fair  size.  These  veins  are  easily  torn, 
and  may  give  rise  to  free  venous  haemorrhage,  which  is  difficult  to 
control.  The  bleeding  ceases  when  the  kidney  is  removed,  but 
occasionally  may  give  rise  to  continuous  oozing  for  some  days  or 
weeks  after  the  operation.  Formidable  veins  may  also  be  met  with 
at  the  upper  pole,  and  are  difficult  to  reach.  They  are  controlled 
during  the  operation  by  packing,  and  may  have  ceased  to  bleed  at 
the  end  of  the  operation.  In  Gregoire's  operation  the  peri-renal 
veins  are  more  likely  to  escape.  The  inferior  vena  cava  has  been 
torn.  This  should  not  occur  unless  considerable  force  in  tearing 
away  glands,  etc.,  has  been  exercised.  Lateral  suture  of  the  vein 
has  been  performed,  but  the  accident  has  always  proved  fatal. 
The  wound  may  be  soiled  with  carcinomatous  tissue.  In  a  large 
number  of  cases  recurrence  takes  place  in  the  operation  scar,  and 
there  is  no  doubt  that  the  growth  became  implanted  during  removal 
of  the  kidney.  In  one  of  my  cases  in  which  a  nodule  of  growth 
appeared  in  the  scar  I  had  dissected  out  a  mass  of  glands  extending 
from  the  pillars  of  the  diaphragm  to  the  common  iliac  artery. 
During  the  removal  a  large  cyst  contained  in  the  mass  burst  and 
flooded  the  wound  with  cancerous  debris. 

Heart  failure  is  a  serious  danger  since  the  heart  muscle  is 
frequently  enfeebled  by  the  absorption  of  toxins.  Five  out  of  eight 
fatal  cases  (62  per  cent.)  in  Israel's  operations  were  due  to  heart 
failure. 

Pulmonary  embolism  has  been  caused  by  the  detachment  of  a 
clot  in  the  renal  veins  during  the  operation.  (Israel.) 

Results. — The  mortality  of  nephrectomy  for  renal  growths  has 

S.T. — VOL.  n.  53 


834        Tumours  of  the  Kidney  in  Adults. 

fallen    rapidly   during    recent   years,  as   the  following  statistics 

demonstrate : 

1885  Minges.           .         .         .  Mortality,  76  per  cent. 

1888  Tuffier             ...  „  65 '2  „      „ 

1888  Guillet            ...  72    „      „ 

1891  Chevalier        ...  „  58    „      ,, 

1892  Earth     ....  42    „      „ 
1898  Heresco           ...  „  24    „      „ 
1902  Albarran  and  Imbert       .  „  22    ,,      ,, 

Schmieden  collected  329  fully  described  cases  of  nephrectomy  for 
renal  growth.  Of  these  108  died,  or  32*8  per  cent. 

On  analysing  these  results  he  found  that  the  mortality  during 
the  first  ten  years  of  renal  surgery  was  64 '3  per  cent.,  in  the  second 
ten  years  43*0  per  cent.,  and  in  the  third  22'0  per  cent,  in  adults. 

The  high  death-rate  in  the  earlier  operations  was  largely  due  to 
septic  infection,  and  this  also  accounted  for  the  high  mortality  of 
transperitoneal  nephrectomy  as  compared  with  the  retroperitoneal 
operation.  In  the  transperitoneal  operation  previous  to  1890  the 
mortality  was  50  per  cent.,  according  to  the  statistics  of  Gross  and 
Brodeur,  while  the  mortality  of  the  lumbar  retroperitoneal  opera- 
tions was  estimated  by  the  same  authorities  at  37  per  cent,  and 
38  per  cent,  respectively. 

Albarran  and  Imbert' s  statistics  of  operations  performed  after 
1890  showed  a  mortality  of  23  per  cent,  for  lumbar  nephrectomy, 
and  21*10  per  cent,  for  transperitoneal. 

Death  is  due  in  these  cases  to  septic  infection,  heart  failure, 
shock,  asthenia  and  anuria  from  inefficiency  of  the  remaining  kidney. 

Late  Results. — Recurrence  takes  place  in  60  per  cent,  of  cases, 
and  in  over  70  per  cent,  of  these  it  occurs  within  the  first  year. 
After  the  first  year  recurrence  is  less  common,  and  it  is  rare  after 
the  third  or  fourth  year.  Cases  in  which  recurrence  has  taken 
place  after  three  years  are  recorded. 

Garceau  gives  the  following  table  of  collected  cases.  Time 
between  nephrectomy  and  death  from  metastasis : 

1  year  or  under      .         .         .         .         .         .         .  17 

1  to  2  years 8 

2  to  3      „ 4 

3  to  4      „ 1 

4  to  5      „ -.         .  1 

7  to  8      „       .         . 1 

10  to  11    „ 1 

33 


Tumours  of  the  Kidney  in  Adults.        835 

The  recurrent  growth  is  most  frequently  found  in  the  scar.  It 
occurs  also  in  the  lymph  glands,  lungs,  and  liver,  and  in  these 
cases  metastasis  has  almost  certainly  taken  place  before  the 
operation. 

Forgue  found  that  twenty-eight  cases  (7  to  10  per  cent.)  had 
survived  at  the  end  of  the  fourth  year  without  recurrence. 

In  Wagner's  cases,  thirty-four  remained  well  from  two  years  to 
eighteen  years ;  but  only  twenty-one  were  free  from  recurrence 
from  three  years  and  upwards  (sixteen  adults,  five  children). 

J.  W.  THOMSON  WALKER. 


53—2 


836 


TUMOURS  OF  THE  KIDNEY  IN  CHILDREN. 

TUMOURS  OF  THE  KIDNEY  in  children  are  invariabty  malignant,  and 
present  some  peculiarities  which  are  important  in  view  of  operative 
treatment. 

They  are  bilateral  in  about  50  per  cent,  of  cases. 

Hsematuria  occurs  in  a  small  number  of  cases  (24  per  cent.),  and 
is  rarely  present  until  after  an  abdominal  tumour  has  been 
discovered.  Tumour  is  constant  (140  in  142  cases,  Walker),  and 
is  the  initial  symptom  in  about  one-third  of  cases. 

The  operations  are  the  same  as  those  practised  in  the  adult. 

The  mortality  is  higher,  and  recurrence  is  more  rapid  and  certain 
than  in  the  adult.  Walker  places  the  general  mortality  from  opera- 
tions and  recurrence  at  93*22  per  cent.  Albarran  and  Imbert  give 
the  mortality  as  25  to  30  per  cent.,  and  state  that  recurrence 
takes  place  in  between  67  and  81  per  cent,  of  cases. 

Simon  collected  the  following  cases  of  survival  for  a  year  or  more 
after  operation : 

Israel  ........  5    years. 

Doderlein     .         .         .         .         .         .         .  4        „ 

Schmid         .......  3        ,, 

Schend 2|      „ 

Eovsing       ....  .  2J      „ 

Malcolm       .         .         .         .         ...  28  months 

Hue     ........  \\  years. 

Eovsing       ....  li      „ 

Steele 1    year. 

Schonstadt  .......  1         „ 

The  longest  survival  of  which  I  have  definite  information  is  a 
case  on  which  Mr.  J.  D.  Malcolm  operated  in  November,  1892.  This 
was  a  female  child  under  two  years,  and  the  tumour  was  a 
"malignant  adenoma."  The  capsule  and  some  enlarged  glands 
were  removed.  Mr.  Malcolm  informs  me  that  the  patient  is  now 
alive  and  well,  eighteen  years  and  three  months  after  the  operation 
(February,  1911).  Abbe,  of  New  York,  recorded  two  cases  of 
prolonged  survival,  one  for  four-and-a-half  years,  in  which  the 
patient  died  of  new  growth  in  the  second  kidney,  and  in  the  other 
the  patient  was  alive  and  well  in  1902,  over  ten  years  after  the 
operation. 

J.  W.  THOMSON  WALKER. 


837 


UREMIA. 

THE  early  symptoms  are  usually  indigestion,  nausea,  vomiting, 
and  sometimes  diarrhoea.  The  best  diet  for  the  stomach  is 
light  solid  food.  Something  with  a  taste  is  less  likely  to  be 
vomited.  Milk  not  infrequently  disagrees.  A  little  stimulant  is 
often  of  service.  Bitters  and  small  doses  of  rhubarb,  with  magnesia, 
Tr.  Nuc.  Vom.,  -\r\_5 ;  Tr.  Rhei,  in.  5 ;  Magnes.  Garb.,  gr.  10; 
Infus.  Gent.  Co.,  ad  3];  [U.S.P.  Tr.  Nuc.  Vom.,  ml2;  Tr.  Rhei, 
ill  2  :  Magnes.  Garb.,  gr.  10  ;  Infus.  Gent.  Co.,  ad  33  ;]  or  Pulv.  Rhei, 
gr.  1 ;  Bismuth.  Garb.,  Sod.  Bicarb.,  aa  gr.  5 ;  Pulv.  Nuc.  Vom., 
gr.  \  ;  Pulv.  Cinnamomi  Co.,  gr.  \\  [U.S.P.  Pulv.  Rhei,  gr.  1  ; 
Bismuth.  Garb.,  Sod.  Bicarb.,  aa  gr.  5;  Pulv.  Nuc.  Vom.,  gr.  \\ 
Pulv.  Cinnam.,  Pulv.  Sem.  Cardamomi,  Pulv.  Zingib.,  aa  gr.  £] 
should  be  given  in  cachets. 

For  the  diarrho3a  give  Salicylate  of  Bismuth,  gr.  15  ;  Pulv.  Opii 
Co.,  gr.  j.  [U.S.P.  Bismuth.  Salicylat.,  gr.  15  ;  Pulv.  Opii,  gr.  ^; 
«Pulv.  Piper.  Nig.,  gr.  ^;  Pulv.  Zingib.,  gr.  J;  Pulv.  Carui,  gr.  £; 
Pulv.  Tragacanth.,  gr.  ^H.]  Sometimes  blood  appears  in  the  stools. 
This  is  usually  due  to  thrombosis  of  a  small  artery  in  the  intestinal 
wall,  and  ulceration  may  follow.  The  food  must  be  as  digestible 
and  leave  as  little  residue  as  possible.  Bismuth  and  very  small 
doses  of  opium  are  the  best  drugs.  Pulv.  Cret.  Aromat.  C  Opio. 
[U.S.P.  Pulv.  Aromatici,  1  part;  Pulv.  Cretse  Co.,  9  parts;  Pulv. 
Opii,  J  part].  Pulv.  Kino  Co.,  [U.S.P.  Pulv.  Kino,  15  parts  ;  Pulv. 
Opii,  1  part ;  Pulv.  Cinnam.,  4  parts].  Tr.  Catechu,  [U.S.P.  Tinct. 
Garnbir  Co.].  Decoct.  Haematoxyli  may  also  be  tried  in  small  and 
repeated  doses. 

At  the  same  time  these  patients  are  anaemic.  The  anaemia  should 
be  treated  with  light  preparations  of  iron  whenever  the  digestion 
can  stand  it.  Beside  those  of  our  Pharmacopoeia  there  are  several 
organic  forms,  such  as  ferratin,  liq.  ferri  albuminati,  glycerole  of 
glycero-phosphates,  with  or  without  red  bonemarrow,  fersan, 
haemoglobin  extract,  Rommel's  haeniatogen,  and  haemaboloid,  which 
can  be  used  for  a  change. 

The  next  symptoms  will  probably  be  headache  and  giddiness.  The 
latter  is  due  to  arterial  sclerosis.  Tincture  of  nux  vomica  is  some- 
times good  for  it.  Headache  is  sometimes  very  severe,  especially 
when  the  blood  pressure  is  high.  It  is  usually  frontal.  The  best 


838  Uraemia. 

drug  I  know  for  it  is  cannabis  indica,  Tr.  Cann.  Ind.,  -\i\l5  ;  Pot. 
Brom.,  gr.  10;  [U.S.P.  Tr.  Cannab.  Ind.,  m8;  Pot.  Brom.,  gr.  10] 
quartis  horis.  It  is  a  variable  drug,  and  some  specimens  produce 
hallucinations  ;  but  it  nearly  always  relieves  the  fearful  pain  of 
uraemic  headache. 

These  patients  commonly  become  drowsy,  and  in  this  condition 
begin  to  have  a  little  twitching  of  the  face  or  of  the  hand  and  arm ; 
or  without  any  premonitory  symptoms,  a  violent  convulsion  may 
take  place.  These  symptoms  are  a  sign  that  the  total  amount  of 
poison  in  the  blood  is  near  the  lethal  dose.  It  has  to  be  got  rid  of 
somehow.  The  natural  passage  for  any  poison  is  with  the  urine, 
and  the  attempt  should  be  made  to  increase  the  flow.  This 
depends  upon  the  rapidity  of  the  blood  current  in  the  kidney,  and 
this  upon  the  blood  pressure.  In  spite,  therefore,  of  the  excess  of 
pressure  already  present,  it  is  advisable  to  give  digitalis  and  theo- 
bromin,  Tr.  Digit.,  n[W;  Diuretin,  gr.  10;  quartis  horis.  Infusion 
of  digitalis  in  2-drachm  [U.S.P.  1  drachm]  doses  sometimes  acts 
better  than  the  tincture,  as  the  alkaloids  it  extracts  from  the  plant 
are  a  little  different,  for  the  danger  of  uraemia  is  greater,  especially 
in  young  patients,  than  that  of  cerebral  haemorrhage.  In  addition, 
purging  and  sweating  will  extract  some  solids  as  well  as  water  from 
the  blood.  For  the  latter  the  hot  bath,  the  hot  air  bath,  the  hot* 
pack,  or  injections  of  pilocarpine  nitrate  (^  gr.)  are  employed.  The 
hot  air  bath  is  made  by  putting  a  metal  funnel,  wide  end  down-' 
wards,  over  a  spirit  lamp,  and  attaching  to  the  small  upper  end  a 
tube  (metal  or  flexible),  which  is  carried  under  the  bedclothes.  The 
latter  should  be  supported  on  a  cradle.  A  hot  pack  is  best  given 
by  hot  dry  blankets,  with  hot  water  bottles  or  hot  bricks.  But  if 
the  fits  continue  venesection  must  be  done,  and  \  pint  of  blood, 
or  more,  taken  away.  The  removal  of  this  amount  reduces  the 
total  poison  considerably  below  the  lethal  dose.  It  accumulates 
again,  no  doubt,  but  slowly,  and  meanwhile  the  power  of  tolerance, 
which  the  body  possesses,  can  increase  too. 

Convulsions  are  not  the  only  severe  symptoms  of  uraemia.  They 
are  sometimes  replaced  by  dyspnoea.  This  "  uraemic  asthma,"  as 
it  is  called,  is  not  due  to  organic  disease  of  the  lungs,  but  is  nervous 
in  origin.  It  is  best  treated  by  oxygen  inhalation. 

In  other  cases  convulsions  are  replaced  by  a  terrible  restlessness, 
which  is  even  worse.  The  patient  is  usaully  half  unconscious,  will 
take  nothing,  does  not  sleep,  and  is  in  a  state  of  extreme  distress, 
continuously  tossing,  turning,  pulling  the  clothes  up,  down,  off,  or 
trying  to  get  out  of  bed.  Oxygen  has  been  recommended  for  this 
variety  of  uraemia  also.  Veronal  in  10-gr.  doses  gave  good  sleep  in 


Amyloid  Disease  of  the  Kidneys.          839 

two  cases  of  the  kind.  Sedatives,  such  as  the  bromides,  broinetone, 
bromural  and  sulphate  of  hyoscyamine  should  be  given,  but  are 
often  unsuccessful.  Morphine  should  also  be  tried,  though  with 
caution. 

Occasionally  uraemia  produces  a  hemiplegia  or  a  monoplegia  like 
that  of  organic  disease.  No  special  treatment  is  needed,  and  the 
cases  will  hardly  be  distinguished  except  by  their  rapid  recovery  if 
the  patient  lives,  or  by  the  absence  of  any  gross  lesion  if  he  dies. 

W.  P.  HERRINGHAM. 


AMYLOID  DISEASE  OF  THE  KIDNEYS. 

THIS  is  a  sequela  of  chronic  suppuration,  or  tuberculosis,  or 
syphilis,  and  occasionally  of  other  chronic  diseases,  such  as 
rheumatoid  arthritis,  and  even  of  rheumatism.  The  diagnosis  is 
difficult.  It  rests  upon  the  presence  of  albuminuria,  the  absence  of 
other  symptoms  of  true  nephritis,  whether  diffuse  or  interstitial, 
and  the  signs  of  amyloid  enlargement  of  the  liver  and  spleen. 

The  treatment  is  that  of  the  underlying  disease.  In  every  case 
iodide  of  potassium  should  be  tried.  Anaemia,  vomiting  and 
diarrhoea,  must  be  treated  as  in  ordinary  chronic  nephritis  (5.^.), 
except  that  arsenic  may  well  be  added  to  the  iron  for  anaemia, 
which  is  not  advisable  in  true  nephritis.  Fresh  air,  sunshine,  and 
good  food  are  rather  part  of  the  treatment  of  the  original  than  of 
the  renal  disease. 

Dropsy,  if  present,  should  be  treated  as  in  nephritis.  Uraemia  is 
seldom  seen. 

W.  P.  HERRINGHAM. 


840 


AFFECTIONS    OF  THE  URETER. 

WOUNDS  OF  THE  URETER. 

WOUNDS  OF  THE  UEETER  are  rare  apart  from  surgical  operation. 
They  may  result  from  blows  on  the  abdomen,  from  stabs  or  bullet 
wounds,  or  from  injury  caused  by  the  foetal  head  during 
parturition. 

The  operations  in  which  the  greatest  danger  of  wounding  the 
ureter  is  incurred  are  operations  upon  the  uterus  and  Fallopian 
tubes.  In  rare  cases  the  ureter  is  partly  torn.  In  such  a  case  a  ureteral 
catheter  should  be  passed  from  the  bladder  up  the  ureter  and 


FlG.  1. — End-to-end  anastomosis 
of  the  ureter. 


FIG.  2. — End-to-end  anastomosis 
by  invagination. 


the  edges  of  the  wound  sutured  over  this.     The  catheter  should  be 
left  in  position  for  a  week. 

If  there  is  an  irregular  tear  of  the  ureter  it  is  better  to  resect 
a  portion  of  the  tube  and  perform  one  of  the  operations  for 
anastomosis.  Complete  section  of  the  ureter  necessitates  immediate 
suture.  This  should  be  done  with  fine  rounded  needles  and  fine 
catgut.  Many  varieties  of  ureteral  suture  have  been  introduced. 

(1)  End-to-end  anastomosis  after  transverse  (Schopf)  or  oblique 
(Bove"e)  section,  or  by  transverse  section  with  longitudinal  splitting 
of  the  ends  (Tatze).     Interrupted  sutures  are  used  and  penetrate 
the  whole  thickness  of  the  wall  (Fig.  1). 

(2)  End-to-end  anastomosis  by  invagination  (Poggi).      This  is 
simplified  by  making  a  longitudinal  incision  in  the  lower  end  of 
the  ureter  (D'Antone)  (Fig.  2). 

(3)  End-to-side  implantation.      One  end  is  ligatured  and    the 
other  cut  obliquely  and  invaginated  into  a  lateral  incision  in  the 
ligatured  segment,  and  secured  by  interrupted  sutures  (Van  Hook) 
(Fig.  3). 

(4)  Lateral  anastomosis  is  performed  by  ligaturing  both  ends 


Wounds  of  the  Ureter. 


841 


and  uniting  two  longitudinal  openings  in  these  in  a  manner 
similar  to  intestinal  anastomosis  (Manari)  (Fig.  4). 

The  peritoneum  may  be  closed  over  the  union,  but  there  is  a 
danger  of  leakage  into  the  extraperitoneal  tissue.  The  peritoneum 
should  therefore  be  sutured  outside  the  junction,  which  is  thus 
rendered  intraperitoneal  and  the  peritoneal  cavity  is  freely  drained. 
A  graft  of  omentum  may  be  stitched  over  the  line  of  union.  A 
ureteral  catheter  may  be  passed  up  the  ureter  from  the  bladder 
and  retained  in  the  ureter,  but  it  may  cause  irritation  and  is  not 
used  by  some  surgeons  on  this  account.  Taddei  introduced  a 
magnesium  tube  over  whicli  the  ends  of  the  ureter  were  brought 
and  invaginated,  the  object  being  to  render  invagination  easy,  and 
to  preserve  the  lumen.  The  magnesium  is  dissolved  by  the  urine 
in  twenty  days. 

Results. — Alksne  collected  all  the  published  records  since  1886. 
He  found  forty-three  complete  recoveries  in  sixty  cases,  nine 


FK;.  3. — End-to-side  implantation. 


FIG.  4. — Lateral  anastomosis. 


recoveries  after  temporary  fistulae,  and  eight  deaths  (11 '6  per 
cent.).  The  mortality  of  both  the  circular  and  the  invagination 
methods  was  the  same,  namely,  10'3  per  cent. 

He  looks  upon  the  invagination  method  of  Poggi  as  the  best. 
This  method  yielded  12  per  cent,  of  fistulae  in  twenty-eight  cases, 
while  the  circular  method  gave  24  per  cent,  of  fistulae.  When  a 
portion  of  the  ureter  has  been  torn  away,  one  of  several  procedures 
may  be  carried  out : — 

(1)  If  the  remaining  portion  will  reach  the  bladder  it  should  be 
implanted  in  it. 

(2)  It  has  been  suggested  that  the  ureter  should  be  carried  across 
the.middle  line  and  implanted  into  the  other  ureter.     (Bernasconi 
and  Columbine.) 

(3)  The  ureter  may  be  implanted  into  the  intestine. 

(4)  The   end  of  the  ureter  may  be  brought  out   on   the  skin 
surface. 

(5)  Nephrectomy  may  be  performed. 


842 


FISTULA  OF  THE  URETER.. 

FISTULA  OF  THE  UEETER  occurs  under  a  variety  of  conditions.  A 
fistula  is  rarely  caused  by  stabs  or  bullet  wounds  ;  more  frequently 
it  may  result  from  injury  caused  by  the  foetal  head  or  by 
instruments  during  parturition. 

A  fistula  may  follow  an  operation  upon  the  ureter  for  stone. 
Most  frequently  it  follows  gynaecological  operations  such  as  vaginal 
or  abdominal  hysterectomy. 

The  fistulous  track  may  open  on  the  surface  of  the  body  or  into 
the  vagina  or  uterus. 

Post-parturition  fistulae  are  situated  close  to  the  bladder,  and  the 
bladder  itself  may  be  involved  so  that  the  opening  is  a  uretero- 
vesico-vaginal  fistula.  Post-operative  fistulae  lie  at  some  distance 
from  the  bladder,  so  that  there  is  a  short  segment  (5  centimetres, 
Bazy)  of  ureter  below  the  fistula. 

There  is  always  a  stricture  of  the  ureter  below  the  fistula. 
Above  the  stricture  and  fistula  the  ureter  is  dilated  and  the 
kidney  is  also  dilated.  Infection  of  the  fistula,  ureter  and  kidney 
invariably  occurs.  The  fistula  very  rarely  closes  spontaneously. 

The  following  information  should  be  obtained  before  operating 
upon  a  ureteral  fistula  : — 

(1)  Is  the  ureter  partly  or  completely  severed?— On  examina- 
tion  of   the   bladder  with  the    cystoscope  I   have  found  that  the 
ureteric  orifice  shows  no  movement  when  the  ureter  is  completely 
severed,    but    that    rhythmic   contraction    of    the    ureteric    orifice 
takes  place  on  the  diseased   side  if  the  ureter  is  only  partially 
severed. 

(2)  Is  the  fistula  vesical  or  ureteral '? — This  may  not  be  evident 
in  some  post-parturition  cases.     If  on  injecting  fluid  coloured  with 
methylene  blue  the  blue  fluid  escapes  from  the  fistula,   the  fistula 
communicates  with  the  bladder.    If  on  the  other  hand  the  coloured 
fluid    does    not    appear    at    the    fistulous    opening,    the    fistula 
communicates  with  the  ureter. 

Examination  with  the  cystoscope  will  show  a  healthy  bladder  in 
ureteric  fistula. 

(3)  Which  ureter  is  fistulous  ? — When   the  fistula  has  followed 
parturition  or  a  gynaecological  operation,  this  may  be  in  doubt. 

Cystoscopic  examination  will  show  one   ureter  motionless  and 


Fistula  of  the  Ureter.  843 

without  efflux,  and  chromo-cystoscopy  will  further  demonstrate 
the  absence  of  efflux. 

(4)  What  is  the  position  of  the  fistula  ? — This  is  ascertained  by 
passing  a  bougie  opaque  to  the  X-rays  along  the  ureter.  The 
bougie  is  arrested  at  the  stricture  on  the  vesical  side  of  the 
fistula,  and  the  distance  from  the  bladder  is  estimated  by  observing 
the  markings  on  the  catheter  and  also  by  obtaining  a  radiogram 
with  the  catheter  in  position.  » 

Treatment. — (1)  The  introduction  of  a  catheter  en  demenre. 
This  is  impossible  in  a  large  proportion  of  cases  on  account  of 
the  stricture  of  the  ureter.  In  a  few  cases  it  has  been  practised, 
but  the  ultimate  result  has  not  been  successful.  The  stricture 
re-contracts  and  the  fistula  opens  after  the  catheter  has  bden 
removed,  or  the  fistula  may  heal  permanently  and  the  reconstruction 
of  the  stricture  brings  about  atrophy  of  the  kidney. 

(2)  Suture   of   the   ureter.      This  is  not  feasible.     The  patent 
segments  of  the  ureter  are  widely  separated  by  a  mass  of  fibrous 
tissue  and  it  is  impossible  to  approximate  them. 

(3)  Transplantation  of  the  ureter,      (a)  Implantation  into  the 
bladder.      (Uretero-cysto-neostomy.)      This   may    be    done   by    a 
transperitoneal  operation  or  by  the  extraperitoneal  route.     Legueu 
recommends  that  the  abdomen  should  be  opened  and  the  position 
of  the  ureter  ascertained.      The  peritoneum  is  then  closed  and  the 
operation  performed  extraperitoneally.  The  urine  is  invariably  septic 
in  these  cases,  so  that  the  extraperitoneal  route  is  to  be  preferred. 

The  ureter  is  followed  downwards  as  low  as  possible  and  cut 
across  above  the  fistula.  An  opening  is  made  in  the  most 
accessible  part  of  the  bladder  and  the  union  of  the  ureter  and 
bladder  made  at  this  point.  It  is  essential  that  no  traction  should 
be  exerted  on  the  newly-formed  union,  and  the  ureter  and 
bladder  should  be  freed  to  avoid  dragging.  For  this  purpose 
Ricard  sutures  the  wall  of  the  bladder  to  the  pelvic  peritoneum. 
On  the  other  hand  the  ureter  must  not  be  stripped  too  extensively 
from  its  surroundings,  lest  sloughing  from  inadequate  blood 
supply  follow. 

Many  varieties  of  implantation  have  been  used. 

The  edges  of  the  ureter  transversely  or  obliquely  cut  are  stitched 
to  the  edges  of  the  bladder  wound,  and  further  sutures  are  placed 
on  the  outside  and  the  union  buried  by  folds  of  the  bladder  wall 
held  by  Lembert's  sutures. 

The  end  of  the  ureter  may  be  introduced  into  the  bladder  and 
project  into  its  lumen  for  some  distance.  The  end  is  split  and  the 
flaps  turned  back  as  a  cuff  on  the  tube  itself,  and  stitched  there. 


844  Fistula  of  the  Ureter. 

The  bladder  wall  is  invaginated  and  stitched  by  series  of  sutures 
to  the  ureter.  (Bicard.) 

The  end  of  the  ureter  may  be  split  and  passed  through  an 
opening  in  the  bladder  wall.  The  two  flaps  are  stitched  to  the 
surface  of  the  vesical  mucous  membrane  by  sutures  passing 
through  the  thickness  of  the  wall  and  tied  on  the  outer  aspect 
of  the  bladder. 

A  button  has  been  used  to  connect  the  ureter  and  bladder. 
(Baldassari.) 

Results  of  Uretero-cysto-neostomy. — Primary  union  is  occasionally 
obtained,  but  frequently  there  is  leakage  of  urine.  This  does  not 
usually  persist,  and  the  wound  heals.  A  few  cases  have  been 
recorded  in  which  by  catheterisation  of  the  implanted  ureter  a 
successful  result  has  been  proved  after  considerable  periods. 

There  are  other  cases,  however,  in  which  the  kidney  has  been  found 
atrophied  post  mortem  without  having  given  any  signs  during  life. 

(b)  Implantation  into  the  bowel.  On  the  right  side  the  CEecum 
or  ascending  colon  should  be  selected  ;  on  the  left,  the  pelvic 
portion  of  the  colon:  The  abdomen  is  opened  in  the  middle  line, 
the  ureter  isolated,  and  the  most  suitable  part  of  the  bowel 
selected.  The  implantation  is  made  into  the  posterior  wall,  if 
possible  extraperitoneally.  Interrupted  sutures  are  used,  and  the 
outer  coat  of  the  ureter  is  stitched  to  the  serous  covering  of  the 
intestine,  the  mucous  membranes  are  then  united,  and  the  opera- 
tion'continued  like  an  entero-anastomosis.  After  the  union  is 
complete  a  third  row  of  sutures  may  be  added  which  invaginates 
the  union  into  the  lumen  of  the  bowel.  The  implantation  may  be 
made  obliquely,  or  a  flap  of  intestinal  mucous  membrane  may  be 
raised  and  the  ureter  implanted  below  this,  so  that  it  is  protected 
by  a  kind  of  valve.  Boari  uses  a  button  to  form  the  union. 

Results  of  Implantation  into  the  Bowels. — Successful  results  have 
been  published. 

The  mucous  membrane  of  the  colon  does  not  resent  the  action  of 
the  urine  and  the  fluid  is  passed  with  the  faeces.  The  dangers  of 
the  operation  are  shock,  peritonitis,  and  ascending  pyelonephritis 
from  infection.  Pagini  found  a  mortality  from  the  operation  of 
58  per  cent,  when  bilateral  implantation  was  performed,  and 
20  per  cent,  when  one  ureter  only  was  implanted.  A  few  cases 
have  been  recorded  in  which  the  patient  continued  in  good  health, 
but  many  cases  die  with  a  comparatively  limited  period  of  ascending 
pyelonephritis. 

(4)  When  the  fistula  opens  high  up  in  the  [vagina  an  opera- 
tion may  be  performed  which  turns  a  small  portion  of  the  vagina 


Fistula  of  the  Ureter.  845 

into  the  bladder.  The  fistula  is  enlarged  and  an  opening  made 
into  the  bladder  close  to  it.  This  part  of  the  vagina  is  then  closed 
off  so  that  the  fistula  and  bladder  become  continuous. 

(5)  The  vagina  may  be  obliterated,  after  first  establishing  a  large 
vesico-vaginal  fistula. 

(6)  Ligature  of  the  ureter  with  the  object  of  producing  atrophy 
of  the  kidney  was  suggested  by  Guyon. 

(7)  Nephrectomy  has  until  recently  been  resorted  to  by  a  large 
number  of  surgeons.     It  should  not  be  performed  until  a  plastic 
operation  has  been  tried  or  unless  septic  pyelonephritis  is  present. 

T.   W.    THOMSON   WALKER. 


846 


STONE  IN  THE  URETER. 

THE  following  points  are  important  in  relation  to  treatment : 
(1)  A  calculus  may  become  arrested  in  the  ureter  at  any  part  of  its 
course,  but  is  most  frequently  found  at  the  upper  end  of  the  ureter, 
at  the  level  of  the  brim  of  the  pelvis,  or  at  the  vesical  end. 

Jeanbrau  gives  the  following  statistics  : — 

Lumbar  segment  of  the  ureter  .         .       46,  22  per  cent. 

Iliac               „            „           „  15,  15         „ 

Pelvic            „            ,,           „  105,  51         ,, 

Intravesical  ,,            ,,           ,,  36,  17         „ 

(2)  Ureteral  calculi  are  solitary  in   90  per  cent,  of  cases.     In 
10  per  cent,  there  are  more  than  one,  and  there  may  be  as  many 
as  twenty-seven  calculi.     They  are  bilateral  in  only  3'6  per  cent, 
of  cases. 

(3)  Calculi  may  be  free  in  the  ureter,  or  impacted  or  encysted. 

(4)  Freely  movable  calculi  may  travel  up  a  dilated  ureter  when 
the  pelvis  of  the  patient  is  raised. 

(5)  An  impacted  stone  frequently  lies  above  a  stricture  of  the 
ureter. 

(6)  An  encysted  calculus  may  cause  rupture  of  the  ureter  and 
peritonitis. 

(7)  An  impacted  calculus  increases  in  size  and  causes  urinary 
obstruction,  and  eventually  hydronephrosis. 

(8)  Infection  takes  place  by  way  of  the  blood  stream  and  kidney 
in  the  majority  of  unrelieved  cases.    Pyelonephritis  or  pyonephrosis 
results. 

(9)  A  good  radiogram  will  show  a  shadow  in  all  but  pure  uric 
acid  calculi. 

(10)  It  is  frequently  necessary  to  obtain  a  radiogram  with  an 
opaque  bougie  in  the  ureter  in  order  to  localise  a  doubtful  shadow. 

(11)  A  bougie  may  be  arrested  by  the  calculus,  or  it  may  pass 
alongside  it  after  a  slight  hitch. 

(12)  As  short  an  interval  as  possible  should  intervene  between 
the  radiography  and   the  operation,  and  the  bladder  should   be 
examined  with  the  cystoscope  immediately  before  the  operation. 
These  precautions  are  necessary  to  avoid  performing  an  operation 
on  the  ureter  after  the  stone  has  passed  into  the  bladder. 


Stone  in  the  Ureter.  847 

The  following  information  should  be  in  2)ossession  of  the  surgeon 
before  he  operates  :  (1)  The  presence  of  a  calculus  in  the  ureter  and 
its  exact  position.  This  is  ascertained  by  means  of  the  X-rays, 
cystoscopy,  and  the  passage  of  an  opaque  ureteric  bougie. 

(2)  The  calculus  is  impacted  or  encysted.     This  is  shown  by  the 
history,  the  size  and  shape  of  the  calculus,  and  the  absence  of  any 
change  in  position  on  repeated  X-ray  examination. 

(3)  The   presence   or   absence  of   other  calculi  in   the  ureters, 
kidneys,  or  bladder. 

(4)  The  condition  of  the  kidney  on  the  side  corresponding  to 
the  stone  and  that  of  the  opposite  kidney.     This  is  obtained  by 
catheterisation  of  the  ureters  and  by  pyelography. 

The  treatment  of  ureteral  calculi  is  medicinal,  instrumental,  or 
operative. 

Medicinal  Treatment. — The  cases  that  are  suitable  for  medi- 
cinal treatment  are  those  in  which  a  small  stone  has  recently  passed 
into  the  ureter.  An  oval  stone  with  its  long  axis  in  the  line  of  the 
ureter  is  more  likely  to  pass  than  a  round  or  a  long  calculus,  or  one 
set  obliquely  to  the  line  of  the  uterer. 

The  patient  is  subject  to  attacks  of  renal  colic,  and  the  stone, 
when  examined  at  intervals  by  the  X-rays,  is  found  to  change 
in  position.  In  some  cases  the  patient  has  passed  calculi 
previously. 

The  treatment  consists  in  the  administration  of  diuretics. 
Potassium  citrate  and  acetate  are  given  in  doses  of  15  or  20  gr. 
thrice  daily,  and  theocin  sodium  acetate,  3  to  8  gr.,  in  cachet. 
Diuretic  mineral  waters,  such  as  Contrexeville  (Pavilion)  and 
Yittel,  should  be  taken  fasting.  The  best  effect  is  obtained  by 
taking  a  large  draught  of  the  diuretic  water  in  the  early  morning, 
and  a  very  light  breakfast  of  tea  and  a  roll,  a  full  meal  at  midday, 
and  another  large  draught  of  the  water  about  five  in  the  afternoon, 
and  a  meal  at  eight  o'clock.  With  the  diuretic  medicine  anti- 
spasmodics,  such  as  atropine  and  belladonna,  may  be  prescribed 
in  the  hope  of  relieving  any  ureteric  spasm  that  may  be  grasping 
the  stone. 

This  treatment  should  not  be  continued  indefinitely.  A  period 
of  from  four  to  six  months  should  be  placed  upon  it,  and  at  the  end 
of  this  time  operative  interference  should  be  recommended. 

Should  signs  of  dilatation  of  the  kidney  or  infection  appear, 
operation  should  be  performed  at  once. 

Instrumental  Treatment. — The  passage  of  a  bougie  up  the 
ureter  is  sometimes  followed  by  the  expulsion  of  a  stone.  With- 
out recommending  this  as  a  routine  method  of  treatment,  I  believe 


848  Stone  in  the  Ureter. 

it  is  worthy  of  trial  in  stones  which  appear  likely,  from  their  size 
and  shape,  to  pass. 

The  injection  of  sterilised  oil  into  the  ureter  has  been  said  to 
assist  the  expulsion  of  the  calculus. 

Nitze  injected  several  cubic  centimetres  of  eucaine  ('2  per  cent.) 
into  the  ureter  with  the  object  of  relieving  spasm.  He  also  intro- 
duced a  ureteral  catheter  (catheter  occlusir)  near  the  distal  end  of 
which  is  a  fine  membranous  balloon,  which  could  be  distended 
with  fluid.  With  this  he  proposed  to  dilate  the  ureter  below  the 
calculus.  Jahr  has  used  a  modification  of  this  apparatus  with 
success  in  one  case. 

Operative  Treatment.  —  Operation  is  indicated  (1)  when 
anuria  has  supervened;  (2)  when  medicinal  and  instrumental 
treatment  have  failed ;  (3)  when  infection  has  taken  place ; 
(4)  when  there  are  signs  of  dilatation  of  the  kidney. 

The  operative  treatment  of  calculous  anuria  has  already  been 
discussed.  The  operation  is  performed  to  relieve  the  anuria,  and 
the  removal  of  the  stone  may  be  deferred  to  a  later  date. 

In  all  other  cases  the  object  of  the  operation  is  to  remove  the 
calculus. 

(1)  When  the  calculus  is  impacted  at  the  junction  of  the  pelvis 
and  ureter,  the  treatment  has  already  been  discussed  under  "  renal 
calculus." 

(2)  Calculus  in  the  lumbar  portion  of  the  ureter  is  exposed  by 
an  oblique  lumbar  incision,  and  the  duct  found  at  the  lower  end  of 
the  kidney  and  traced  downwards.     The  stone  is  easily  felt,  and  is 
removed  by  an  incision  made  directly  upon  it  in  the  long  axis  of 
the  ureter. 

If  the  urine  is  septic,  a  ureteral  compressor  may  be  placed  above 
the  stone  before  incising  the  ureter  to  prevent  contamination  of  the 
wound.  A  large  rubber  drainage  tube  is  left  in  the  lumbar  wound. 

(3)  Calculus  at  the  brim  of  the  pelvis.     This  is  exposed  by  a 
curved    incision    commencing    above    the    level   of    the    anterior 
superior  iliac  spine,  and  passing  downwards  and  inwards  parallel 
to  Poupart's  ligament,  and  about  2  inches  above  it,  and  carried 
inwards   as   far   as   the   outer  edge   of   the  sheath  of   the  rectus. 
The  peritoneum  is  reflected  along  the  external  iliac  vessels,  and  the 
ureter  is  found  adhering  to  it  at  the  bifurcation  of  the  common 
iliac  artery.     The  patient  should  be  placed  in  the  Trendelenberg 
position,  the  calculus  removed,  and  the  ureter  sutured.     Great  care 
must  be   exercised  in  this   operation  and  in  the  extra-peritoneal 
removal  of   stones  in  the   pelvic  portion  of  the  ureter  that  the 
rubber  drainage  tube  does  not  lie  in  contact  with  the  iliac  vessels. 


Stone  in  the  Ureter.  849 

Several  cases  of  ulceration  through  the  external  iliac  artery  from 
this  cause  have  been  recorded.  -I  place  a  large  tube  in  the  iliac 
fossa  well  away  from  the  vessels  and  raise  the  lower  end  of  the  bed 
on  blocks. 

(4)  Calculus  in  the  pelvic  portion  of  the  ureter :  (a)  Extra- 
peritoneal  removal  by  the  iliac  route.  The  incision  is  similar  to 
that  already  described.  The  ureter  is  traced  over  the  pelvic  brim 
into  the  pelvis.  Jhe  stone  can  usually  be  detected  with  the  finger. 
If  it  is  small  and  movable,  a  small  incision  should  be  made  in  the 
ureter  above  the  iliac  vessels.  A  fine  scoop  (Fig.  1),  which  I  have 
introduced,  with  a  soft  silver  handle,  which  may  be  bent  to  the 
required  angle,  is  passed  along  the  lumen,  and  with  the  finger  out- 
side the  ureter  the  stone  is  extracted.  The  wound  is  then  sutured. 
When  the  stone  is  large  and  fixed,  the  ureter  is  carefully  incised 
over  it  and  sutured  after  its  removal. 

(1>)  Extra-peritoneal  removal  by  the  sacral  route.  This  operation 
was  first  performed  by  Morris  and  has  been  advocated  by  Rigby. 
An  incision  is  made  parallel  to  the  sacral  spines  and  2  inches  from 


J. H.  MONTAGUE.   LONDON 

FK;.  1.— Thomson  Walker's  pliable  ureteral  scoop. 

the  middle  line  from  the  third  sacral  spine  to  1£  inches  beyond  the 
tip  of  the  coccyx.  The  gluteus  maximus  muscle  and  great  sacro- 
sciatic  ligament  are  divided  and  the  ureter  found  alongside  the 
rectum.  The  advantages  claimed  for  this  method  are  the  absence 
of  haemorrhage,  the  patient  is  spared  an  abdominal  incision,  and 
dependent  drainage  is  obtained.  The  disadvantage  is  an  extremely 
narrow  field  of  operation. 

(c)  Trans-peritoneal  route.      The  peritoneum  is  opened  in  the 
middle  line  and  the  patient  placed  in  the  Trendelenberg  position. 
The  ureter  is  exposed  by  incision  of  the  peritoneum  over  it  and  the 
stone  removed.      The  ureter   and  peritoneum  are  thus  carefully 
sutured  and  the  laparotomy  wound  drained.     This  operation  entails 
a  risk  of  infection  of  the  peritoneum. 

(d)  Vaginal  route.     A  stone  which  can  be  felt  from  the  vagina 
may  be  removed  by  an  incision  in  the  vaginal  wall. 

(<.')  Calculus  in  the  intra-mural  portion  of  the  ureter.  These 
calculi  are  best  removed  from  within  the  bladder  after  cystotomy. 

After  all  operations  upon  the  ureter  for  stone  the  lumen  of  the 
duct  should  be  examined  by  passing  a  bougie  downwards  into  the 
bladder. 

S.T.— VOL.  ii.  54 


850  Stone  in  the  Ureter. 

If  a  stricture  is  present  it  should  be  incised  in  the  long  axis  of  the 
ureter.  If  the  lumen  is  much  contracted  it  may  be  necessary  to 
perform  a  plastic  operation  for  relief  of  the  stenosis.  This  may  be 
a  longitudinal  incision  with  transverse  suture  of  the  wound,  or  a 
lateral,  or  end-to-end,  or  end-to-side  anastomosis.  After  removing 
the  stone,  the  ureter  should  be  sutured  with  fine  catgut,  the  stitches 
penetrating  only  the  outer  and  muscular  coats.  I  have  not  found 
any  harm  result  when  a  catgut  suture  penetrates  the  whole  thick- 
ness of  the  wall,  but  if  silk  is  used  a  concretion  forms  upon  the 
suture.  Silk  sutures  should  on  this  account  be  avoided.  Suture  of 
the  ureter  is  not  absolutely  necessary  in  order  to  obtain  healing  of 
the  ureteral  wound,  for  some  surgeons  have  obtained  good  results 
without  it.  The  ureter  heals  more  rapidly,  however,  if  its  wall  is 
sutured,  and  in  several  cases  I  have  obtained  healing  by  first 
intention  without  the  escape  of  any  urine.  In  some  operations  on 
stones  in  the  pelvic  segment  of  the  ureter  it  is  difficult  or  impossible 
to  suture  the  ureter  accurately,  and  the  wound  must  be  left  open. 
In  suturing  the  ureter  it  is  an  advantage  to  place  a  ureteric  catheter 
in  the  duct,  so  that  the  lumen  is  not  narrowed  by  the  sutures.  The 
catheter  is  withdrawn  before  the  last  suture  is  tied.  All  manipu- 
lations of  the  ureter  should  be  carried  out  in  the  most  delicate 
manner.  Stripping  of  long  segments  from  the  peritoneum,  pinching 
the  duct  with  dissecting  and  pressure  forceps,  tearing  and  dragging 
on  the  tube  during  the  removal  of  the  calculus  and  the  subsequent 
passage  of  a  bougie  must  be  avoided,  since  damage  to  the  blood 
supply  or  walls  of  the  duct  will  lead  to  sloughing  and  contraction 
of  the  wall  and  to  stricture  and  fistula. 

Results. — Apart  from  cases  of  calculous  anuria  and  when  other 
operations,  such  as  nephrolithotomy,  have  not  been  combined  with 
ureterolithotomy,  the  operative  mortality  is  under  2  per  cent,  in 
extra-peritoneal  ureterolithotomy.  Jeanbrau  collected  sixty  cases 
with  one  death — a  mortality  of  1'66  per  cent. 

When  other  operations  are  combined  with  ureterolithotomy,  the 
mortality  rises  to  13*11  per  cent. 

Trans-peritoneal  ureterolithotomy  has  a  mortality  of  5'5  per  cent. 

Late  Results. — Urinary  fistula  following  ureterolithotomy  results 
from  stenosis  of  the  duct  or  damage  to  the  wall  of  the  ureter  at 
the  operation.  The  number  of  cases  in  which  it  occurs  is  small. 
A  temporary  fistula  has  been  recorded  in  about  5  per  cent,  of  cases, 
but  in  only  3  per  cent,  does  it  become  permanent.  With  the 
knowledge  that  stricture  may  complicate  stone  in  the  ureter,  and 
the  possibility  of  dealing  with  the  stenosis  surgically,  the  frequency 
with  which  fistula  occurs  will  still  further  diminish.  Stenosis  may 


Stone  in  the  Ureter.  851 

also  occur  from  rough  handling  of  the  ureter,  and  all  manipulations 
must  be  delicately  performed. 

The  symptoms  from  which  the  patient  suffered  are  relieved  by 
the  operation.  Patients  upon  whom  I  have  operated  by  extra- 
peritoneal  ureterolithotomy  are  well  seven  years,  five  years,  and 
three  years  after  the  operation,  and  others  more  recently  operated 
upon  enjoy  perfect  health. 

In  the  early  stage  of  dilatation  of  the  kidney  the  organ  may 
completely  or  almost  completely  recover,  so  that  no  difference  can 
be  detected  in  the  functional  power  of  the  two  kidneys.  When 
dilatation  of  the  kidney  has  been  well  established,  even  although 
the  enlargement  of  the  organ  is  not  so  advanced  as  to  be  detected 
by  palpation,  repair  is  not  complete,  and  the  dilated  pelvis  does  not 
shrink  to  its  normal  proportions. 

I  examined  a  case  in  which  I  had  removed  a  calculus  from  the 
ureter  at  the  brim  of  the  pelvis  a  year  previously,  and  found  on 
injecting  Collargol  and  radiographing  the  patient,  that  a  large, 
dense  shadow  was  obtained,  having  the  form  of  a  hydronephrosis, 
with  a  capacity  of  a  little  over  2  oz. 

Eecurrence  of  stone  in  the  same  ureter  is  rare.  In  a  case  in 
which  I  removed  a  calculus  weighing  7  gr.  from  the  ureter  at  the 
brim  of  the  pelvis  I  stitched  the  ureter  with  four  strands  of  fine  silk. 
The  patient  subsequently  passed  two  stones  at  intervals  of  six 
months.  In  the  first  stone  was  embedded  one  silk  ligature,  and  in 
the  second  the  remaining  three.  The  patient  has  since  remained 
well  for  six  years. 

J.  W.  THOMSON  WALKER. 


54  — 


852 


DISEASES  AND  AFFECTIONS   OF  THE 
BLADDER. 

CALCULUS    OF  THE    BLADDER. 

VESICAL  CALCULI  are  divisible  into  primary  and  secondary 
varieties.  The  latter  are  secondary  to  inflammation  of  the  urin- 
ary tract.  The  real  causation  of  the  former  is  as  yet  imperfectly 
understood  ;  predisposing  factors,  however,  may  be  both  general 
and  local.  The  general  predisposing  factor  is  the  presence  of 
some  diathesis,  such  as  the  uric-acid  diathesis,  oxaluria,  phos- 
phaturia,  or  cystinuria.  Local  factors  are  obstruction  to  the 
outflow  of  urine  (stricture  and  enlarged  prostate),  and  stagnation 
of  urine,  such  as  occurs  with  diseases  of  the  nervous  system  or  the 
presence  of  a  sacculus. 

Of  the  utmost  importance  for  diagnostic  purposes  is  cysto- 
scopy.  It  is  performed  with  local  anaesthesia  applied  to  the 
urethra,  and  causes  less  discomfort  to  the  patient  than  rectal 
examination  or  examination  with  the  sound.  Its  one  disadvantage 
is  that,  being  a  skilled  method  of  diagnosis,  it  cannot  be  carried 
out  by  all.  Its  advantages  are  that  it  enables  us  to  differentiate 
stone  from  other  conditions  producing  the  same  symptoms.  If 
stone  is  present  it  informs  us  of  its  size,  shape,  composition,  and 
whether  one  or  more  are  present.  It  informs  us  also  of  its  position, 
whether  free,  situated  in  a  sacculus,  or  projecting  from  a  ureter. 
It  informs  us,  lastly,  whether  intra-vesical  projection  of  the 
prostate  or  sacculation  of  the  bladder  is  present.  All  these 
points  influence  us  in  deciding  the  correct  treatment  for  each 
individual  case. 

Failing  cystoscopy,  the  sound  may  give  us  positive  informa- 
tion. This  examination  is  conducted  with  the  patient  in  a 
horizontal  position  ;  the  pelvis  should  be  raised  upon  a  cushion 
or  sand-bag.  A  moderate  distension  of  the  bladder  should  be 
used  in  order  to  obliterate  all  folds.  The  sound  is  introduced, 
and  the  most  dependent  part  of  the  bladder  examined  first. 
This  is  done  by -elevating  the  handle  so  that  the  instrument  comes 
to  lie  almost  vertically.  If  a  stone  is  not  felt  in  this  situation 
the  beak  is  rotated  and  the  rest  of  the  bladder  carefully  explored. 
There  are  various  sources  of  error,  however :  a  stone  may  be 
missed  because  it  is  small,  covered  with  mucus  or  blood  clot,  or 


Calculus  of  the  Bladder.  853 

hidden  behind  an  enlarged  prostate  or  in  a  sacculus.  An  ulcer 
or  growth  with  a  phosphatic  deposit  upon  it  may  be  mistaken  for 
a  stone.  In  a  young  patient  the  sound  must  not  be  used  until 
urinary  tuberculosis  has  first  been  excluded. 

X-ray  examination  may  also  help  diagnosis.  Oxalate  stones 
cast  a  dense  shadow,  and  phosphatic  ones  a  slight  one.  A  pure 
uric-acid  stone  gives  no  shadow  at  all.  The  whole  of  the  urinary 
tract  should  be  skiagraphed,  as  it  is  important  to  know  whether 
further  stones  exist  in  the  kidneys  or  ureters. 

It  is  scarcely  necessary  to  say  that  there  is  no  palliative 
treatment.  Spontaneous  fracture  of  stone  sometimes  occurs, 
and  has  been  known  to  follow  a  diuresis  induced  by  the  copious 
drinking  of  mineral  waters.  The  fracture  appears  to  be  due  to 
the  swelling  of  the  colloid  framework  of  the  stone,  produced  by 
urine  of  lowered  specific  gravity.  Spa  treatment  may  alleviate 
symptoms  by  relieving  concomitant  cystitis. 

Preventive  treatment  of  stone  is  directed  to  those  conditions 
which  we  know  favour  stone  formation.  Thus  urinary  obstruc- 
tion is  removed  and  cystitis  treated.  With  regard  to  the  gouty 
or  uric-acid  diathesis  we  are  unable,  in  the  present  state  of  know- 
ledge, to  influence  the  endogenous  production  of  uric  acid,  but 
we  can  eliminate  from  the  diet  those  foods  which  are  the  source 
of  the  exogenous  uric  acid.  These  are  the  nuclein-containing 
foods,  viz.,  the  highly  cellular  organs,  such  as  liver,  kidney  and 
pancreas.  With  these  patients  attention  should  be  paid  to 
general  hygiene,  and  regular  exercise  taken.  Those  drugs  are 
prescribed  which  will  render  the  urine  alkaline  and  keep  the  uric 
acid  in  solution.  Such  drugs  are  potassium  citrate,  lithium 
carbonate,  lithium  citrate,  urodonal,  etc.  In  the  same  way 
diuresis  and  flushing  of  the  urinary  tract  are  encouraged  by  the 
use  of  the  alkaline  mineral  waters.  Phosphaturia  is  corrected 
by  prescribing  acid  sodium  phosphate  or  the  dilute  mineral  acids. 
These  drugs  increase  the  acidity  of  the  urine  and  so  keep  the 
phosphates  in  solution.  Patients  suffering  from  oxaluria  should 
diminish  as  far  as  possible  the  intake  of  both  the  oxalates  and  the 
calcium  salts.  Foods  rich  in  oxalates  are  :  Rhubarb,  spinach, 
strawberries,  tea  and  cocoa.  Foods  rich  in  calcium  are  :  Milk 
and  eggs,  cabbage,  asparagus,  radishes,  etc.  The  oxalates  are 
kept  in  solution  in  normal  urine  by  magnesium  and  sodium 
phosphate.  These  salts,  or  waters  containing  them  (such  as 
Hunyadi),  should  be  prescribed  therefore.  The  diluent  waters 
should  also  be  used  freely,  preferably  those  with  but  small  calcium 
content  (Vichy  and  Contrexeville). 


854  Calculus  of  the  Bladder. 

OPERATIONS   FOR    VESICAL   CALCULUS. 

(1)  Litholapaxy. 

(2)  Supra-pubic  lithotomy. 

(3)  Median  perineal  lithotomy. 

Litholapaxy  is  the  operation  of  choice.  Its  advantages  are 
that  there  is  no  wound,  and  the  convalescent  period,  therefore,  is 
only  a  matter  of  one  or  two  days.  In  skilled  hands  it  has  a  lower 
mortality  than  the  other  operations,  but  where  opportunity  to 
acquire  this  special  skill  has  not  been  forthcoming,  supra-pubio 
operation  is  the  safest  proceeding.  In  St.  Peter's  Hospital  during 
1909  and  1910  there  were  performed  ninety-six  litholapaxies  with 
two  deaths,  i.e.,  mortality  of  2'08  per  cent.  ;  and  eleven  supra- 
pubic  lithotomies  with  one  death,  i.e.,  mortality  of  9'09  per  cent. 

Recurrence  is  not  more  common  after  a  properly  performed 
litholapaxy  than  after  cutting  operations  ;  it  is  due,  not  to 
retention  of  fragments,  but  to  the  persistence  of  the  conditions 
which  gave  rise  to  the  original  stone.  When  disease  of  the  lungs, 
heart  or  kidneys  is  present  and  .general  anaesthesia  is  deemed 
inadvisable,  litholapaxy  can  be  efficiently  and  painlessly  per- 
formed with  local  anaesthesia. 

The  contra-indications  to  litholapaxy  are  : 

(1)  Inexperience  in  this  operation  on  the  part  of  the  surgeon. 

(2)  The  presence  of  acquired  sacculation  of  the  bladder.     This 
condition  is  recognised  by  the  cystoscope,   and  litholapaxy  is 
never  justifiable  unless  a  cystoscopic  examination  has  been  made. 
It  occurs  in  old  back-pressure  bladders  ;  the  sacculi  are  hernial 
protrusions   of   the   mucous   membrane   through   the    muscular 
bundles,  and  their  walls  are  exceedingly  thin  (mucous  membrane 
with  a  thin  external  fibrous  layer).      The  danger  of  litholapaxy 
is  that  small  fragments  may  remain  behind  in  a  sacculus,  and 
cause  ulceration  and  perforation  of  its  thin  wall.     Pelvic  cellulitis 
or  general  peritonitis  will  then  ensue. 

(3)  A  urethra  too  small  to  admit  the  instrument.     Stricture  is 
best  treated  by  internal  urethrotomy,  followed  by  litholapaxy  at 
the  end  of    a  week.     If   bad  cystitis  is  present  in  addition  to 
stricture,  median  perineal  lithotomy  and  subsequent  drainage  of 
the  bladder  is  preferable  to  litholapaxy.     It  is  only  available, 
however,  in  the  case  of  small  stones.     Speaking  generally,  if 
preliminary  treatment  is  adopted  in  cases  of  cystitis,  litholapaxy 
can  be  performed.     In  children  litholapaxy  is  inadvisable  under 
the  age  of  three.     In  expert  hands  stones  can  be  crushed  in 
children  even   younger   than   this.     It   must    be  remembered, 


Calculus  of  the  Bladder.  855 

however,  that  the  bladders  are  small  and  thin-walled,   and  we 
regard  supra-pubic  lithotomy  as  the  safer  proceeding. 

(4)  Large  stones. — Stones  above  1|  to  2  oz.  should  be  removed 
by  the  supra-pubic  method. 

(5)  Hard  stones,  though  more  difficult,  are  no  bar  in  skilled 
hands  to  litholapaxy. 

(6)  Encysted  stones  should  be  dealt  with  by  supra-pubic  cysto- 
tomy.     Some  can  then  be  crushed  in  situ,  others  can  be  delivered 
after  small  "  nicks  "  have  been  made  in  the  mouth  of  the  sacculus 
in  several  places.    If  this  manoeuvre  fails,  the  stone  must  be  split 
by  means  of  a  chisel  and  mallet  while  the  assistant  steadies  it  by 
means  of  a  finger  in  the  rectum. 

(7)  When  sufficient  enlargement  of  the  prostate  is  present  to 
render  litholapaxy  difficult,  supra-pubic  operation  should  be  per- 
formed ;   the  prostate  can  be  removed  at  the  same  time  or  later. 
Litholapaxy  in  these  cases  is  unwise,  as  retention  of  urine,  some- 
times permanent,  is  a  not  uncommon  sequel. 

The  Operation  of  Litfwlapaxy.  —  The  patient  is  placed 
horizontally  upon  his  back  with  the  legs  separated.  A  catheter 
is  passed  and  the  bladder  washed  with  some  mild  antiseptic 
solution  ;  3  to  6  oz.  are  then  left  in  the  bladder  and  the  catheter 
withdrawn.  Small  stones  can  be  evacuated  without  crushing. 
If  too  large  for  simple  evacuation  the  lithotrite  is  introduced,  and 
the  handle  elevated  so  that  the  instrument  lies  at  an  angle  of 
45  degs.  with  the  horizontal.  The  beak  of  the  instrument  is  now 
pressed  gently  against  the  floor  of  the  bladder,  so  that  it  comes  to 
be  situated  at  the  most  dependent  part  of  that  organ.  The  beak 
is  opened,  and  the  stone,  which  in  obedience  to  the  law  of  gravity 
is  also  situated  at  the  most  dependent  part  of  the  bladder,  drops 
upon  the  female  blade.  The  male  blade  is  now  closed  upon  the 
stone  and  locked.  The  stone  is  then  crushed.  This  manoeuvre 
is  repeated  until  the  larger  fragments  have  been  dealt  with. 
During  the  whole  operation  the  female  blade  is  not  moved,  but  is 
kept  in  contact  with  the  floor  of  the  bladder.  Before  withdraw- 
ing the  lithotrite  the  beak  is  rotated  and  the  sides  of  the  bladder 
base  gently  explored  for  large  fragments  by  opening  and  closing 
the  blades.  The  soft  bladder  wall  is  easily  distinguished  from 
the  more  resistent  stone.  If  doubt  arises,  the  blades  are  rotated 
to  the  centre  of  the  bladder  before  the  instrument  is  locked,  and 
if  there  is  any  resistance,  such  as  is  felt  when  the  bladder  wall  is 
grasped,  the  blades  are  again  separated.  If  no  more  fragments 
are  felt  the  evacuating  tube  is  now  introduced,  the  pump  attached, 
and  the  fragments  evacuated.  When  most  of  the  dtbris  has  been 


856  Calculus  of  the  Bladder. 

withdrawn  the  beak  of  the  evacuating  tube  is  rotated  downwards, 
the  bulb  of  the  pump  squeezed,  and  the  beak  of  the  tube  rapidly 
rotated  upwards  again.  By  this  manoeuvre  any  debris  lying  on 
the  base  of  the  bladder  is  set  into  motion  and  evacuated  while  in 
suspension.  Should  a  fragment  too  large  for  evacuation  be 
caught  in  the  eye  of  the  tube,  it  is  recognised  by  a  characteristic 
click  ;  it  is  dislodged  by  means  of  a  stylet.  The  lithotrite  must  be 
introduced  again,  however,  and  the  fragment  crushed.  A  click 
is  also  heard  if  the  bladder  wall  is  sucked  into  the  eye  of  the  tube, 
but  it  gives  rise  to  a  different  sensation  both  to  the  ear  and  to  the 
fingers  grasping  the  instrument.  This  difference  cannot  be 
described,  but  is  readily  recognised  after  very  little  practice. 

After-treatment. — Should  any  difficulty  in  micturition,  or  bad 
cystitis,  exist  before  operation,  a  soft  catheter  is  tied  in  for 
twenty-four  hours.  The  patient  is  allowed  up  as  soon  as  the 
urine  is  free  from  blood.  Before  his  discharge  cystoscopy  is 
again  performed,  and  if  any  small  fragments  are  present  they 
are  evacuated. 

Supra- pubic  Lithotomy. — The  advantages  of  this  over  the 
perineal  operation  are  that  the  mortality  is  less,  that  the  surgeon 
can  see  what  he  is  doing,  that  larger  stones  can  be  removed  and 
primary  union  obtained  in  clean  cases.  In  addition  there  is  no 
risk  of  incontinence  or  damage  to  the  genital  apparatus,  as  some- 
times occurs  with  perineal  lithotomy.  The  indications  for  the 
operation  have  been  discussed  already  in  dealing  with  litholapaxy. 
No  detailed  description  of  this  operation  is  necessary.  The 
bladder  is  opened  supra-pubically  and  the  stones  removed  with 
scoop  or  forceps. 

Median  Perineal  Lithotomy. — Practically  the  only  indication 
for  this  operation  is  the  presence  of  a  small  stone  associated  with 
severe  cystitis,  or  with  severe  cystitis  and  stricture.  Its  advan- 
tage over  the  supra-pubic  operation  is  that  the  convalescent 
period  is  shorter.  Larger  stones  are  sometimes  crushed  by 
introducing  the  lithotrite  through  the  perineal  wound.  This 
we  consider  inferior  to  supra-pubic  lithotomy. 

The  operation  of  median  perineal  lithotomy  is  performed  as 
follows  :  A  grooved  staff  is  passed  into  the  bladder  ;  the  patient 
is  then  placed  in  the  lithotomy  position.  The  staff  is  cut  down 
upon  and  the  urethra  opened  immediately  behind  the  bulb. 
The  edges  of  the  urethra  are  grasped  with  catch  forceps,  and  a 
gorget  is  passed  along  the  grooved  staff  into  the  bladder.  The 
staff  is  now  withdrawn.  Next  the  finger  is  passed  into  the 
urethra  and  the  gorget  withdrawn.  The  finger  is  now  pushed 


Calculus  of  the  Bladder.  857 

onwards  into  the  bladder,  dilating  as  it  goes  the  posterior  urethra 
and  the  meatus.  Stone  forceps  can  now  be  passed  ;  with  these 
the  stone  is  seized  and  withdrawn.  Drainage  of  the  bladder  is 
secured  by  introduction  of  a  soft  rubber  tube,  which  is  stitched 
to  the  skin. 

In  the  female  two  additional  methods  of  dealing  with  vesical 
stone  should  be  mentioned.  Firstly,  small  stones  (up  to  |  inch 
in  diameter)  may  be  removed  by  dilating  the  urethra ;  this 
method  is  liable  to  be  followed  by  incontinence.  Secondly, 
vaginal  lithotomy  is  recommended  by  some  surgeons  ;  we 
consider  it  inferior  to  both  litholapaxy  and  supra-pubic  lithotomy. 
It  carries  in  addition  the  danger  of  vesico-vaginal  fistula. 

SYDNEY  G.  MACDONALD. 


858 


CYSTITIS. 

THIS  is  due  to  a  combination  of  causes,  which  may  be  divided 
into  :  (1)  The  exciting  cause.  (2)  The  predisposing  causes. 

The  exciting  cause  is  the  presence  of  bacteria.  The  mere 
presence  of  bacteria  in  the  bladder  is  not  sufficient  in  itself  to 
produce  inflammation  of  that  organ.  Injection  of  organisms  into 
a  healthy  bladder  does  not  produce  cystitis,  except  in  the  case  of 
organisms  (such  as  those  of  the  proteus  group)  which  have  the 
power  of  decomposing  urea. 

The  predisposing  causes  are,  firstly,  injury  to  the  bladder,  such 
as  that  produced  by  calculus,  new  growth,  foreign  bodies,  or 
parasites  such  as  the  bilharzia  ;  and,  secondly,  stagnation  of 
urine.  The  latter  may  be  produced  by  obstruction,  such  as  the 
presence  of  an  enlarged  prostate  or  stricture,  or  by  inability  to 
empty  the  bladder,  as  in  disease  of  the  nervous  system,  or  the 
presence  of  a  sacculus. 

Acute  Cystitis. — All  grades  of  inflammation  are  met  with, 
from  a  simple  catarrh  to  a  more  deeply  seated  infection  involving 
the  submucous  and  even  the  muscular  coats.  Ulceration  is  not 
uncommon.  Rarely  a  gangrenous  form  of  cystitis  is  met  with, 
in  which  sloughs  and  actual  casts  of  the  mucous  membrane  are 
passed.  This  sometimes  occurs  in  diabetics. 

The  patient  must  rest  in  bed.  The  diet  at  first  should  con- 
sist mainly  of  milk,  the  ordinary  diet  being  resumed  gradually 
as  improvement  occurs.  All  irritating  substances,  such  as 
seasoned  foods,  spices,  tea,  coffee,  and  alcohol,  are  rigidly 
withheld  as  long  as  any  cystitis  remains.  Copious  alkaline 
waters  (Contrexeville,  Evian,  Vichy)  are  taken  ;  these  help  to 
flush  out  the  bladder  and,  by  diluting  the  urine,  render  it  less 
irritating.  The  bowels  are  kept  freely  open.  Pain  and  strangury 
are  best  relieved  by  hot  fomentations  or  hot  baths.  Hot  rectal 
infusions  often  give  relief.  Failing  these  measures  morphia  and 
belladonna  are  given  in  suppositories  or  hypodermically.  With 
regard  to  drugs,  the  most  satisfactory  are  the  alkalies,  combined 
with  hyoscyamus  and  buchu.  Urotropine  is  more  useful  in  the 
subacute  and  chronic  cases.  The  balsams  are  avoided  in  the 


Cystitis.  859 

acute  stage,  as  they  are  ill  tolerated  both  by  stomach  and  kidneys . 
When  the  acuter  symptoms  have  subsided  local  treatment  (lavage) 
may  be  considered.  The  most  comforting  lotions  in  this  stage 
are  the  mildly  astringent  ones,  as  potassium  permanganate 
(1  in  6,000),  protargol  (|  per  cent.),  or  silver  nitrate  (1  in  10,000). 
Before  instrumentation,  however,  bacteriological  examination 
should  be  made  and  the  tubercle  bacillus  excluded.  Cystoscopic 
examination  is  important  in  all  cases  of  spontaneous  cystitis  (in 
most  of  these  the  primary  disease  is  in  the  kidney),  and  in  cases 
in  which  pyuria  persists.  By  this  means,  for  example,  we  can 
distinguish  pyelitis  from  cystitis,  or  recognise  that  the  condition 
is  a  tuberculous  one.  All  cases  of  cystitis  associated  with  fever 
and  severe  constitutional  symptoms  must  be  regarded  as  cases  of 
renal  infection.  When  pyelitis  is  present  stone  must  be  excluded 
by  X-ray  examination. 

Chronic  Cystitis. — This  may  result  from  an  acute  cystitis 
or  it  may  be  chronic  from  the  start.  All  the  symptoms  met  with 
in  acute  cystitis  may  be  present ;  they  differ  only  in  degree.  On 
the  other  hand,  there  may  be  no  symptom  beyond  pyuria. 

Treatment  is  directed  to  the  cause  (e.g.,  stricture,  enlarged  pro- 
state, stone,  or  pyelitis).  Rest  in  bed  is  unnecessary,  mild  exercise 
is  allowed,  fresh  air  and  general  tonic  treatment  are  important. 
A  normal  diet  is  allowed,  but  all  irritating  substances  are  avoided 
as  in  acute  cystitis.  The  diuretic  mineral  waters  should  be 
freely  taken.  Of  drugs,  the  urinary  antiseptics  are  prescribed : 
the  best  are  urotropine  and  helmitol ;  these  are  of  most  help  when 
the  urine  is  alkaline.  When  they  are  not  well  tolerated  they 
should  be  substituted  by  ammonium  benzoate  or  boric  acid. 
When  the  cystitis  is  an  acid  one  more  relief  is  obtained  from 
alkalies.  In  every  case  of  chronic  cystitis,  cystoscopy  is  of  the 
utmost  importance  in  regard  to  future  treatment.  Apart  from 
establishing  the  source  of  the  pus,  it  may  reveal  the  presence  of 
unsuspected  growth,  ulceration,  stone,  sacculus,  vesico-intestinal 
fistula,  etc. 

In  chronic  cystitis  lavage  is  essential.  Solutions  of  silver 
nitrate  (1  in  10,000)  or  hydrogen  peroxide  (1  to  2  oz.  of  20  volumes 
solution  to  the  pint)  are  amongst  the  most  useful.  Better  results 
are  obtained  with  weak  than  with  strong  solutions.  Ulceration 
when  present  can  often  be  advantageously  treated  by  direct 
applications  through  an  endoscopic  tube.  Under  certain  con- 
ditions the  advisability  of  surgical  interference  has  to  be  con- 
sidered. In  the  gangrenous  form  cystotomy  is  essential  ;  it  is 
also  advisable  in  resistent  cases  where  pain  and  frequency  are 


86o  Cystitis. 

marked  features.  It  is  by  cystotomy  alone  that  absolute  rest  to 
the  bladder  can  be  obtained.  Drainage  is  inadvisable  in  cases  of 
colon  infection ;  though  temporary  relief  is  obtained,  relapse 
always  occurs.  Supra-pubic  cystotomy  is  the  operation  of 
choice.  Though  affording  less  satisfactory  drainage  than  the 
perineal  operation,  it  is  more  comfortable  for  the  patient.  In 
the  latter  operation  the  drainage  tube  lies  upon  the  inflamed 
trigone,  and  every  movement  of  the  patient  is  associated  with 
pain. 

Vaccine  Therapy  in  Cystitis. — This  can  be  summed  up  in  a 
few  words  as  follows  :  In  acute  cases  it  is  useless.  In  sub- 
acute  cases  it  is  valuable,  provided  the  autogenous  vaccine  be 
used.  In  chronic  cases  (and  this  applies  mainly  to  colon  infec- 
tions) it  is  a  valuable  prophylactic  agent  (as  already  stated  under 
BaciUuria),  and  patients  can  be  kept  free  from  symptoms 
although  organisms  may  abound  in  the  urine. 

SYDNEY    G.    MACDONALD. 


86 1 


TUBERCULOUS   CYSTITIS. 

THIS  may  be  primary  or  secondary. 

The  vast  majority  of  cases  of  vesical  tuberculosis  are  secondary 
to  similar  diseases  of  the  kidney,  a  smaller  number  to  tuberculosis 
of  the  genital  organs.  When  secondary  to  renal  tuberculosis  the 
vesical  infection  occurs  by  direct  spread  of  the  tuberculous 
process  down  the  ureter  (i.e.,  by  continuity  of  tissues),  and  the 
vesical  lesion  is  limited  in  the  early  stage  to  the  tissues  imme- 
diately surrounding  the  corresponding  ureteric  orifice.  When 
secondary  to  disease  of  the  testis  the  earliest  lesion  in  the  bladder 
is  found  to  the  inner  side  of  the  ureteric  orifice  of  the  same  side, 
infection  having  occurred  at  the  point  where  the  vas  deferens 
and  ureter  cross.  When  secondary  to  tuberculosis  of  the  prostate 
the  vesical  lesion  begins  in  the  trigonal  region,  but  this  is  a  rare 
condition. 

Given  a  young  patient  with  frequency  of  micturition  and 
pyuria,  one  has  to  determine  : 

(1)  Whether  cystitis  is  actually  present. 

(2)  If  so,  whether  it  is  tuberculous  in  nature. 

(3)  The  primary  source  of  infection. 

(1)  Is   Cystitis  Present?      The   same   train  of   symptoms  is 
found  in  the  early  stages  of  renal  tuberculosis,  without  any  vesical 
lesion.     Painful  micturition  does  not  necessarily  mean  disease 
of  the  bladder.     It  may  be  due  entirely  to  prostatic  disease  or 
to  disease  of  the  lower  end  of  the  ureter.     This  question  can  be 
decided,  firstly,  by  ascertaining  whether  distension  of  the  bladder 
evokes  pain,  and,  secondly,  by  cystoscopy. 

(2)  Is  the  Cystitis  Tuberculous  ?      The  history  of  the  case 
will  enable  one  to  exclude  a  cystitis  of  urethral  origin.     Bacterio- 
logical examination  will  show  the  presence  or  absence  of  tubercle 
bacilli.    If  the  latter  examination  is  negative,  but  strong  suspicion 
exists  that  the  disease  is  tuberculous,  the  biological  test  must  be 
made  (viz.,  inoculation  of  a  guinea-pig). 

(3)  The  Primary  Source  of  Infection.     Routine  examination 
of  the  genital  organs  will  enable  one  to  say  whether  they  are 
definitely  tuberculous.     Palpation  of  the  kidneys  will  give  only 
negative  information  in  the  majority  of  cases.     The  most  impor- 
tant examination  is  the  cystoscopic  one,  since  on  this  examination 
treatment  depends.     It  informs  us  of  the  extent  of  disease  in  the 


862  Tuberculous  Cystitis. 

• 

bladder,  whether  it  is  primary,  or  whether  renal  tuberculosis  is 
also  present,  and,  if  so,  whether  one  kidney  or  both  kidneys  are 
involved. 

The  treatment  of  vesical  tuberculosis  resolves  itself  into  the 
treatment  of  the  primary  organ  infected,  and  will  be  discussed 
when  tuberculosis  of  these  organs  is  being  considered. 

In  the  majority  of  cases  the  proper  treatment  of  tuberculosis 
of  the  bladder  is  nephrectomy.  When  this  has  been  performed  in 
suitable  cases  it  is  surprising  how  rapidly  the  vesical  symptoms 
disappear.  Apart  from  this,  however,  there  are  certain  conditions 
to  be  considered  : 

(1)  The  extension  of  the  tuberculous  process  to  the  bladder 
is   often   signalised   by   the   onset   of   acute   vesical   symptoms. 
Cystoscopy  in  this  stage  is  exceedingly  painful  and  difficult,  and, 
beyond   showing   the   presence   of   an   intense   and   generalised 
cystitis,  gives  little  information.     This  stage  must  be  treated  by 
absolute  rest  in  bed.    Food  must  be  of  the  lightest  nature,  all 
irritating  substances,  such  as  alcohol,  spices,  coffee,  etc.,  must  be 
avoided.      Of  drugs,  sandalwood,    taken  in  capsules,  gives  the 
most  relief.     Suppositories  of  belladonna  and  morphia  may  be 
necessary.     No  local  treatment  is  permissible  owing  to  the  in- 
creased danger  of  producing  a  secondary  infection.     Under  this 
strict  regime  these  acute  symptoms  subside  in  a  few  weeks,  and 
enable  the  all-important  cystoscopy  to  be  made. 

(2)  We  have  yet  to  consider  the  treatment  of  primary  vesical 
tuberculosis  and  secondary  tuberculosis  after  nephrectomy  (or 
orchidectomy,   etc.)  has  been  carried  out.     This  resolves  itself 
into  general  tonic  treatment — rest,  forced  feeding,  fresh  air  in 
the  country  or  at  the  seaside  (when  this  is  possible),  combined 
with  tuberculin  injections.     There  is  no  type  of  tuberculosis  which 
yields  such  excellent  results  with  tuberculin  as  vesical  tuberculosis 
in  this  stage.     Koch's    new  tuberculin    (T.B.)  is  injected .  sub- 
cutaneously  every  tenth  day  (this  ensures  the  injection  during 
the  positive  phase).     It  is  not  necessary  to  know   the    opsonic 
index  ;  dosage  is  controlled  entirely  by  the  clinical  manifestations. 
An  initial  dose  of  5^5^  milligramme  may  be  given  ;  if  there  is 
increase  in  the  pain  and  frequency  of  micturition,  the  size  of  the 
next  dose  must  be  reduced.     If  no  reaction  occurs,  the  next  dose 
given  is  30*00  milligramme,  and  so  on.     The  correct  dose  is  the 
maximum  dose  which  produces  no  increase  in  the  symptoms  ;  this 
dose  increases,  however,  from  time  to  time  so  long  as  improve- 
ment is  maintained.    The  maximum  dosage  may  reach,  but  rarely 
exceeds,  5^0  milligramme. 


Tuberculous  Cystitis.  863 

Bladder  lavage  is  best  avoided ;  it  is  only  justifiable  when  a 
secondary  pyogenic  infection  has  already  occurred.  In  the  latter 
case  the  appropriate  vaccine  is  combined  with  the  tuberculin. 
Other  forms  of  local  treatment  are  usually  unnecessary,  though 
strongly  advocated  by  various  Continental  surgeons.  Rovsing 
recommends  injection  into  the  bladder  of  50  cubic  centimetres 
of  5  per  cent,  carbolic.  This  is  left  in  for  three  minutes  and 
then  washed  out.  The  process  is  repeated  at  weekly  intervals. 
Luys  is  a  strong  advocate  of  silver  nitrate  ;  the  individual  lesions 
are  touched  directly  with  solid  silver  nitrate  by  means  of  a 
direct-vision  cystoscope.  Instillations  of  various  substances,  such 
as  sublimate  or  iodoform  emulsion,  have  also  been  recommended, 
lonisation  has  also  been  tried.  These  various  forms  of  local 
treatment  possess  this  one  common  disadvantage,  that  they 
produce  pain  and  irritation,  and  necessitate  that  the  patient 
should  remain  in  bed. 

Cystotomy  with  a  view  to  curettage,  etc.,  is  to  be  condemned. 
It  is  unnecessary  and  futile,  and  is  followed  by  tuberculous 
infection  of  the  wound.  There  is  one  class  of  case  in  which 
cystotomy  may  be  considered,  however,  viz.,  when  a  solitary 
ulcer  persists  in  spite  of  treatment,  or  gives  rise  to  serious  haemor- 
rhage or  pain.  In  such  cases  recovery  may  be  hastened  by  clean 
excision  of  the  ulcer,  followed  by  suture  and  closure  of  the  bladder. 

When  extensive  genital  and  urinary  tuberculosis  are  combined, 
extensive  operations  (such  as  excision  of  prostate  and  vesicles 
combined  with  nephrectomy)  cannot  be  advised.  In  addition  to 
the  high  immediate  mortality  the  danger  of  dissemination  and 
general  miliary  tuberculosis  is  great. 

REFERENCES. 

Fenwick,  "  Clinical  Cystoscopy."  Twenty-fourth  German  Congress  of 
Surgery. 

SYDNEY    G.    MACDONALD. 


864 


DIVERTICULA   AND    SACCULI    OF    THE    BLADDER. 

DIVERTICTJLA  or  sacculi  of  the  bladder  may  be  congenital  or 
acquired.  In  the  acquired  form,  which  is  due  to  urinary  obstruc- 
tion, the  sacculi  consist  of  hernial  protrusions  of  the  mucous 
membrane  through  the  muscle  bundles.  They  are  multiple  and 
rarely  attain  a  large  size.  They  occur  more  commonly  in  males 
after  middle  life  (rarely  in  females),  and  are  invariably  associated 
with  marked  trabeculation  of  the  bladder  and  other  back  pressure 
signs. 

The  congenital  sacculi  are  more  commonly  single,  and  may 
attain  a  large  size  (they  may  be  as  large  as  the  bladder  itself). 
They  are  situated  at  the  apex  of  the  bladder,  or  to  the  outer  side 
and  in  front  of  the  ureteric  orifices.  They  may  give  rise  to 
symptoms  at  any  age ;  there  is  no  urinary  obstruction  present, 
and  no  trabeculation  of  the  bladder. 

Any  of  the  symptoms  may  call  for  relief .  Catheterisation  and 
lavage  are  only  palliative  measures,  and,  owing  to  the  difficulty 
in  washing  the  sacculus  itself,  fail  to  cure  the  cystitis. 

Drainage,  supra-pubic  or  perineal,  is  also  only  a  temporary  or 
palliative  measure  ;  it  may  be  called  for  when  severe  cystitis  is 
present,  either  as  a  preliminary  step  to  excision,  to  remove  a 
stone,  or  to  give  relief  in  cases  that  are  too  bad  for  more  radical 
treatment.  In  either  case,  in  addition  to  the  cystostomy  tube, 
a  tube  should  be  passed  right  into  the  sacculus,  so  that  efficient 
lavage  can  be  carried  out  subsequently. 

Other  palliative  operations  that  have  been  performed  are  : 
Simple  enlargement  of  the  opening  of  the  sacculus  ;  division  and 
suture  of  the  septum  between  it  and  the  bladder  ;  or  the  estab- 
lishment of  a  new  anastomotic  opening  between  the  sacculus  and 
the  bladder,  with  the  object  of  securing  better  drainage  of  the 
sacculus.  The  two  latter  operations  may  be  the  only  methods 
available  in  cases  when  a  large  sacculus  is  situated  low  down  in 
the  pelvis,  or  is  too  adherent  to  important  structures  to  permit 
complete  excision.  The  objection  to  these  operations  is  that 
inability  to  empty  the  bladder  still  remains,  since  the  walls  of  the 
sacculus  are  non-contractile,  either  because  they  are  fibrotic  or 
because  they  are  adherent  to  surrounding  structures. 


Diverticula  and  Sacculi  of  the  Bladder.     865 

The  operation  of  choice  is  excision  of  the  sacculus.  It  is  avail- 
able in  cases  where  the  sacculus  is  situated  at  the  apex,  or  at  the 
lateral  aspect  of  the  bladder.  The  operation  is  performed  as 
follows  :  The  bladder  is  washed  and  distended,  and  then  exposed 
supra-pubically.  If  the  sacculus  is  situated  at  the  side,  the 
rectus  muscle  on  that  side  is  divided.  The  limits  of  the  sacculus 
are  then  examined  and  the  peritoneum  stripped  upwards.  The 
bladder  is  next  opened  and  the  position  of  the  ureters  ascer- 
tained, if  this  was  impossible  from  the  cystoscopy.  The  opera- 
tion is  facilitated  by  using  the  Trendelenberg  position.  The 
sacculus  is  defined,  freed  and  excised.  In  separating  it  from 
the  bladder  the  whole  of  the  fibrous  opening  between  it  and  the 
bladder  must  be  excised.  The  wound  thus  left  in  the  bladder  is 
sutured  with  through-and-through  catgut  sutures.  A  large 
drainage  tube  is  stitched  into  the  bladder,  the  extra-peritoneal 
space  from  which  the  sacculus  was  removed  and  the  supra-pubic 
space  are  also  drained. 

When  the  sacculus  is  adherent  to  the  rectum,  large  vessels, 
pelvis,  etc.,  it  should  be  shelled  out,  leaving  the  fibrous  capsule 
behind  (Young).  This  obviates  the  danger  of  damage  to  these 
structures  and  lessens  haemorrhage.  If  the  opening  of  the  ureter 
is  situated  in  the  sacculus,  the  ureter  is  carefully  dissected  down 
to  the  point  at  which  it  disappears  into  the  sacculus  ;  the  portion 
of  sacculus  bearing  the  ureteric  orifice  is  then  separated  as  a  flap 
from  the  rest  of  the  sacculus.  This  flap  is  subsequently  turned 
in  to  the  bladder  and  sutured.  This  method,  which  was  used  by 
Young,  is  preferable  to  transplantation  of  the  ureter,  as  it  obviates 
the  danger  of  stricture  and  lessens  that  of  ascending  renal 
infection. 

SYDNEY  G.  MACDONALD, 

REFERENCE. 
"  Annals  of  Surgery,"  1906. 


S.T. — VOL.  ii.  55 


866 


ECTOPIA 

THIS  is  a  condition  in  which  the  mucous  membrane  of  the 
bladder  and  urethra,  from  the  urachus  above  to  the  meatus  below, 
is  spread  out  on  the  surface  of  the  hypogastrium.  At  the  margins 
the  mucous  membrane  becomes  continuous  with  the  skin  of  the 
belly  wall.  It  is  often  stated,  in  descriptions  of  this  condition, 
that  the  anterior  wall  of  the  bladder  is  absent.  This  is  not  so. 
The  whole  of  the  bladder  is  present. 

Ectopia  vesicse  is  more  common  in  males  than  females,  in  the 
ratio  of  3  to  1.  In  female  specimens  the  only  difference  from  the 
above  description  is  that  the  clitoris  is  completely  cleft. 

Operations  for  relief  of  ectopia  vesicae  are  divisible  into  two 
classes.  In  the  first  class  the  object  is  to  effect  a  plastic  closure 
of  the  bladder,  in  the  second  group  the  urinary  stream  is  diverted 
into  the  intestine. 

(1)  Plastic  Closure  of  the  Bladder. — This  has  been  effected 
both  by  skin  and  intestinal  flaps.     The  great  objections  to  this 
type  of  operation  are  that,  as  there  is  no  sphincter,  incontinence 
of  urine  continues.     In  addition,  fistulse  generally  result,  as  also 
calculus  formation  from  the  presence  of  hairs.     The  latter  feature 
may  be  obviated  by  using  sliding  flaps,  so  that  the  hairy  skin 
surface    remains    external.      Trendelenberg,    by    dividing    the 
sacro-iliac   joints   and  bringing  the   pubic   bones   together,  was 
enabled  to  freshen  the  bladder  edges  and  unite  these  directly. 

(2)  Diversion  of  the  Urinary  Stream. — The   original   opera- 
tion consisted  in  the  transplantation   of  the  ureters  into   the 
rectum.     The  result,  however,  was  death  from  ascending  renal 
infection.     Maydl,  therefore,  transplanted  the    trigone  into  the 
sigmoid  colon.     By  leaving  the  valvular  orifices  of  the  ureters 
intact  the  risk  of  ascending  renal  infection  is  diminished.     He, 
moreover,  considered  risk  of  infection  to  be  less  if  he  utilised  the 
comparatively  empty  sigmoid  instead  of  the  rectum.     This  is 
probably  a  fallacy,  however,  as  the  faeces  do  not  remain  in  the 
rectum,  they  merely  pass  through  it  during  defsecation.     The 
operation  was  performed  as  follows  :    The  trigone  was  carefully 
freed  and  the  wound  cleansed.     The  abdomen  was  then  opened 
in  the  mid-line  and  a  loop  of  sigmoid  drawn  up.     A  longitudinal 
incision  was  made  in  the  latter,  the  trigone  was  then  rotated  so 


Ectopia  Vesicae.  867 

that  the  ureteric  orifices  lay  one  above  the  other,  instead  of  side 
by  side,  and  sutured  to  the  margins  of  the  incision  in  the  colon. 
Two  rows  of  sutures  were  used,  the  first  uniting  all  the  coats,  and 
being  then  covered  by  a  row  of  Lembert  sutures.  The  wound 
was  then  completely  closed. 

This  operation  has  been  modified  in  various  ways.  For  instance, 
the  bowel  has  been  divided  at  the  junction  of  the  sigmoid  and 
rectum,  the  trigone  implanted  into  the  upper  end  of  the  rectum, 
and  the  sigmoid  anastomosed  to  the  rectum  lower  down.  This 
adds  to  the  severity  of  the  operation  ;  however,  the  advantage 
claimed  is  that  the  liability  of  ascending  renal  infection  is 
diminished. 

Moynihan  has  successfully  transplanted  the  whole  of  the 
bladder  into  the  rectum,  thus  increasing  the  capacity  of  the  latter 
and  allowing  a  longer  retention  of  urine  (three  to  four  hours). 
His  operation  has  the  additional  advantage  in  the  male  that  it  is 
an  extra-peritoneal  operation.  In  the  female,  however,  the  opera- 
tion is  intra-peritoneal,  and  the  uterus  and  appendages  must  first 
be  removed.  Moynihan' s  operation  was  performed  as  follows  : 

The  ureters  were  catheterised,  an  incision  was  then  made 
all  round  the  margin  of  bladder  mucous  membrane  and  skin,  and 
the  bladder  carefully  dissected  up.  The  whole  bladder  was  thus 
isolated  with  a  pedicle  consisting  of  the  two  ureters.  The  peri- 
toneal covering  of  the  rectum  (which  organ  was  lying  at  the 
bottom  of  the  wound)  was  then  stripped  upwards  from .  its 
anterior  surface  for  4  or  5  inches.  An  incision  3|  inches  in  length 
was  made  in  the  outer  surface  of  the  rectum,  the  bladder  was 
turned  upside  down,  so  that  its  former  lower  border  now  became  the 
upper  border  and  its  former  anterior  surface  now  became  posterior. 
It  was  then  sutured  to  the  opening  in  the  rectum  by  a  continuous 
suture,  including  all  coats  with  the  exception  of  the  mucous 
membrane.  The  toilet  of  the  wound  was  then  performed  and  the 
skin  edges  brought  together  as  far  as  possible. 

In  addition  to  these  operations  ectopia  vesicse  has  been  treated 
by  making  an  anastomosis  between  the  bladder  and  rectum  and 
then  closing  the  parietal  wound.  The  only  objection  to  this 
operation  is  that  the  closure  of  the  bladder  fails. 

The  best  age  for  operation  is  about  four  or  five.  By  this  time 
the  parts  are  sufficiently  large  for  manipulation  and  the  risk  of 
shock  less  than  in  younger  children.  Before  operation  the  con- 
dition of  the  kidneys  must  be  ascertained  by  ureteral  catheterisa- 
tion. 

SYDNEY  G.  MACDONALD. 

55—2 


868 


INJURIES    OF    THE    BLADDER, 

RUPTURE    OF    THE    BLADDER. 

THIS  is  a  rare  injury  owing  to  the  deep  situation  of  this  organ 
in  the  pelvis.  Most  commonly  the  bladder  is  full  at  the  time  of 
injury.  Rupture  is  produced  by  direct  injury  to  the  hypo- 
gastrium,  such  as  by  a  kick  from  a  horse,  or  a  blow,  or  by  com- 
pression of  the  lower  part  of  the  abdomen  as  in  buffer  accidents, 
or  by  the  passage  of  a  vehicle  wheel  over  the  body.  Under  the 
latter  conditions  rupture  of  the  bladder  may  complicate  fracture 
of  the  pelvis.  Rupture  of  the  bladder  may  also  occur  during 
parturition,  and  cases  of  pathological  rupture,  due  to  carcino- 
matous  or  tuberculous  ulceration,  etc.,  have  been  described. 

Traumatic  rupture  may  be  completely  intra-peritoneal  or  com- 
pletely extra-peritoneal,  or  the  rent  may  involve  both  intra-  and 
extra-peritoneal  portions  of  the  bladder.  The  commonest  type 
is  the  intra-peritoneal  one.  When  occurring  with  fracture  of  the 
pelvis,  the  rupture  is  nearly  always  extra-peritoneal.  Prognosis 
is  always  serious ;  the  best  results  following  operation  show  a 
mortality  of  nearly  30  per  cent.  An  important  point  to  take  into 
consideration  here  is  whether  the  urine  is  septic  or  aseptic. 

Treatment. — In  cases  which  are  seen  early  and  in  which  there 
is  a  strong  suspicion  that  rupture  has  occurred,  the  only  safe 
treatment  is  exploration.  A  vertical  supra-pubic  incision  is  made 
and  the  anterior  wall  of  the  bladder  explored  extra-peritoneally. 
If  extra-peritoneal  rupture  is  present,  blood  and  urine  are  found 
in  the  pre-vesical  tissues.  If  the  urine  is  aseptic,  the  edges  of  the 
bladder  rent  are  trimmed  and  the  latter  closed  by  a  single  row  of 
through-and-through  catgut  sutures.  Pre-vesical  drainage  is 
employed.  If  the  urine  is  septic  or  the  rent  cannot  be  sutured, 
drainage  of  the  bladder  by  means  of  a  large  tube  is  adopted  ;  the 
pre-vesical  space  is  also  drained. 

If  the  rupture  is  an  intra-peritoneal  one,  the  incision  is  extended 
and  the  peritoneal  cavity  opened.  The  latter  is  cleaned  with  dry 
abdominal  swabs,  and  the  rent  sutured  by  a  row  of  interrupted 
through-and-through  catgut  sutures  (including  serous  coat  and 
mucosa)  ;  this  is  buried  by  a  second  row  of  sutures,  taking  up 
peritoneum  only.  The  abdominal  cavity  is  closed  without  drain- 
age. This  operation  is  facilitated  by  adopting  the  Trendelenberg 


Injuries  of  the  Bladder.  869 

position.  When  the  urine  is  septic  the  pelvis  should  be  drained 
by  means  of  a  tube  applied  either  through  the  abdominal  wound 
or  through  the  rectum.  In  the  female  the  pouch  of  Douglas 
can  be  drained  through  the  vagina. 

If  the  rupture  involves  both  intra-  and  extra-peritoneal  portions 
of  the  bladder,  the  intra-peritoneal  portion  is  first  sutured,  then  the 
extra-peritoneal  portion. 

Some  doubt  may  exist  as  to  whether  the  case  is  one  of  rupture 
of  the  bladder  or  rupture  of  the  deep  urethra.  The  latter  injury 
is  always  associated  with  fracture  of  the  pelvis,  and  is  best  treated 
by  supra-pubic  operation.  Rupture  of  the  membranous  or 
bulbous  portion  of  the  urethra  is  always  accompanied  by  perineal 
signs. 

After-treatment. — When  the  bladder  has  been  closed,  a  soft 
catheter  must  be  tied  in  for  three  or  four  days.  The  catheter  is 
changed  daily,  and  the  bladder  washed  morning  and  evening  with 
some  antiseptic  lotion,  such  as  oxycyanide  or  perchloride  of 
mercury  (1  in  6,000).  Urotropine,  or  some  other  urinary  anti- 
septic, is  also  prescribed.  After  the  catheter  has  been  left  out 
regular  catheterisation  is  carried  out  until  the  eighth  or  tenth  day, 
when  the  patient  is  allowed  to  pass  water  naturally. 

WOUNDS    OF    THE    BLADDER. 

These  may  occur  from  gunshot  wounds,  or  from  the  penetration 
of  some  sharp  body,  e.g.,  a  fall  upon  a  spike.  In  these  cases  the 
wound  must  be  explored  and  the  injury  to  the  bladder  dealt  with 
as  already  described  under  Rupture  of  the  Bladder. 

SYDNEY  G.   MACDONALD. 


8yo 


TUMOURS    OF    THE    BLADDER. 

GROWTHS  of  the  bladder  are  found  more  often  in  males  than 
females.  They  are  more  commonly  malignant  than  benign. 
They  are  uncommon  below  the  age  of  thirty,  and  rare  in  children. 

In  adults  up  to  the  age  of  forty  the  benign  papilloma  is  the 
commonest  growth,  after  forty  malignant  growths  are  the 
commonest. 

It  cannot  be  emphasised  too  strongly  that  haematuria  is  an 
urgent  indication  for  cystoscopy.  Should  the  haemorrhage  be 
too  profuse  to  allow  of  this,  it  may  be  controlled — pending 
cystoscopy — by  absolute  rest  in  bed.  The  patient  should  drink 
copiously  the  mineral  waters,  such  as  Contrexeville,  and  ergot 
( 1  drachm  doses  of  the  liquid  extract)  combined  with  urotropine 
should  be  prescribed.  Lavage  with  dilute  solutions  of  silver 
nitrate  (1  in  10,000)  is  the  best  method  of  producing  local 
haemostasis.  Should  clot  retention  occur,  the  clots  should  be 
evacuated  by  means  of  the  litholapaxy  evacuator. 

A  Single  Papilloma  should  be  removed  by  supra-pubic  cysto- 
tomy.  This  is  the  only  safe  method  of  treatment,  because  we 
may  be  unable  to  tell  with  the  cystoscope  whether  it  is  benign  or 
malignant,  and  also  because  if  not  excised  death  from  haemorrhage 
will  ultimately  result.  The  pedicle  of  the  papilloma  is  grasped 
with  clamp  forceps,  and  an  incision  made  around  this,  including 
a  wide  area  of  mucous  membrane  and  submucous  tissue.  A 
ligature  of  catgut  is  then  placed  round  the  pedicle,  the  growth  is 
removed,  and  the  mucous  membrane  brought  together  with  one 
or  two  catgut  sutures.  If  absolute  haemostasis  has  been  obtained, 
the  bladder  may  be  safely  closed,  drainage  being  secured  by  a 
catheter,  which  is  retained  for  five  days.  Otherwise  supra-pubic 
drainage  is  employed.  In  either  event  the  bladder  must  be 
washed  twice  daily  until  the  urine  is  clear.  Owing  to  the  local 
infectivity  of  many  of  these  growths  the  utmost  care  must  be 
taken  during  operation  to  avoid  breaking  the  tumour,  and  also 
to  avoid  contact  between  it  and  the  vesical  walls.  Thomson 
Walker  advocates  lavage  of  the  bladder  with  a  strong  solution  of 
formalin  (1  in  500)  immediately  after  completion  of  the  opera- 
tion. 

On  account  also  of  this  local  infectivity  piecemeal  operations 


Tumours  of  the  Bladder.  871 

by    means    of    the    operating    cystoscope    must    be    strongly 
condemned. 

The  patient  should  be  urged  to  return  for  cystoscopy  every  few 
months  at  first,  so  that  any  local  recurrence  may  be  dealt  with 
at  once. 

The  treatment  of  multiple  papillomata  is  a  very  difficult 
question,  and  one  upon  which  the  last  word  has  not  yet  been 
said.  The  tumours  may  be  removed  individually,  but  in  addition 
to  these  tumours  one  commonly  finds  large  areas  of  the  mucous 
membrane  in  a  condition  of  villosis.  All  these  areas  of  mucous 
membrane  must  be  carefully  dissected  away.  This  is  a  long  and 
tedious  task,  and  under  the  best  conditions  is  but  a  palliative 
measure.  It  is  an  open  question  whether  it  would  not  be  better 
in  the  early  stages  to  transplant  the  trigone  into  the  rectum  and 
excise  the  rest  of  the  bladder  in  toto.  Rovsing1  holds  strongly 
the  opinion  that  cure  can  be  looked  for  only  by  performing  a 
preliminary  bilateral  ureterostomy  and  then  excising  the  bladder 
unopened. 

In  considering  whether  radical  cure  should  be  attempted 
in  a  case  of  Carcinoma  the  cystoscope  is  of  prime  importance. 
Thus  the  extent  of  involvement  of  the  mucous  membrane 
and  the  situation  of  the  growth  are  ascertained.  Growths 
occupying  the  upper  zone  of  the  bladder  give  the  best  prog- 
nosis ;  they  are  more  easily  accessible  and  a  wider  area  of 
bladder  can  be  removed.  Those  occupying  the  middle  zone  are 
less  satisfactory,  and  in  those  springing  from  the  base  prognosis 
is  worst — in  them  dissemination  is  rapid  and  operation  advisable 
only  in  the  earliest  stages.  Induration  of  the  bladder  base  or 
palpable  glands  felt  per  rectum  are  centra-indications  to  surgical 
interference.  With  the  cystoscope  it  is  impossible  to  tell  how 
much  infiltration  of  the  deeper  layers  of  the  bladder  has  already 
occurred  ;  this  instrument  may  show  only  a  small  involvement 
of  the  mucous  membrane  in  growths  which  have  infiltrated  the. 
muscular  walls  or  invaded  the  peri-vesical  tissues  too  extensively 
to  allow  operation.  In  all  doubtful  cases  a  supra-pubic  incision 
should  be  made  and  the  external  aspect  of  the  bladder  palpated. 
If  the  growth  proves  too  extensive  for  excision  the  incision  is 
closed  without  opening  the  bladder.  When  the  growth  is  situated 
at  the  apex  of  the  bladder  the  peritoneal  cavity  should  be  opened 
and  the  bladder  examined  from  the  peritoneal  aspect.  Extensive 
involvement  of  the  peritoneum  means  also  extensive  lymphatic 
involvement,  and  though  partial  resection  of  the  bladder  may 
give  relief,  it  will  not  prevent  dissemination  of  the  growth.  If 


872  Tumours  of  the  Bladder. 

intestine  or  omentum  is  adherent  to  the  bladder  heroic  opera- 
tions are  useless. 

The  types  of  operation  employed  are  as  follows  :  If  the  growth 
is  situated  at  the  apex  the  bladder  is  opened  and  the  limits  of 
the  growth  determined.  The  patient  is  then  placed  in  the 
Trendelenberg  position  and  the  peritoneal  cavity  opened.  The 
peritoneal  area  which  corresponds  to  the  portion  of  bladder  to  be 
resected  is  marked  out  by  a  circular  incision.  If  any  puckering 
of  the  peritoneum  is  present  a  margin  of  at  least  1  inch  is  allowed. 
The  peritoneal  cavity  is  then  closed  and  the  growth,  with  at  least 
1  inch  margin  of  the  whole  thickness  of  healthy  bladder  wall,  is 
excised.  The  raw  surfaces  of  the  bladder  wall  are  then  brought 
together  by  means  of  a  single  row  of  catgut  sutures  including  all 
the  coats.  The  supra-pubic  space  is  drained  and  the  wound  other- 
wise closed.  The  bladder  is  drained  by  means  of  a  catheter. 
If  cystitis  is  present  the  bladder  should  be  drained  by  means  of 
a  supra-pubic  tube.  Another  method,  applicable  more  for  growths 
of  the  middle  zone  and  some  of  those  of  the  basal  zone,  is  to  split 
the  bladder  from  the  original  incision  right  down  to  the  growth. 
The  peritoneum,  when  necessary,  is  first  separated,  partly  by 
stripping,  partly  by  dissection.  An  oval  portion  of  the  whole 
thickness  of  the  bladder  wall  is  then  excised,  consisting  of  the 
growth  surrounded  by  a  wide  margin  of  healthy  tissue.  At  each 
snip  of  the  scissors  spurting  vessels  are  clamped  and  through- 
and-through  traction  sutures  of  catgut  placed  in  each  side  alter- 
nately, but  not  tied.  When  the  portion  of  bladder  has  been 
resected  each  suture  is  threaded  through  the  opposite  side  and 
tied,  thus  bringing  the  cut  surfaces  of  bladder  together. 

Growths  of  the  basal  zone  can  also  be  removed  by  this  method, 
the  peritoneum  having  been  stripped  back.  Smaller  growths  in 
the  region  of  the  base  should  be  excised  as  follows  :  A  fixation 
stitch  is  passed  through  the  mucous  membrane  1|  inches  below 
.the  lowest  limit  of  the  growth ;  the  latter  is  then  surrounded  by 
an  oval  incision  cutting  through  all  layers  of  the  bladder  wall. 
With  each  cut  stitches  are  placed  through  one  side  of  the  gap  left 
in  the  bladder.  After  removal  of  the  tumour  these  stitches  are 
threaded  through  the  opposite  cut  surface  and  tied ;  the  gap  in 
the  bladder  wall  is  thus  closed. 

If  the  growth  is  situated  in  the  region  of  the  ureteric  orifice, 
the  ureter  must  be  transplanted.  It  is  best  done  at  the  time  of 
excision  of  the  growth.  The  ureter  is  first  catheterised,  the  area 
of  bladder  wall  carrying  the  ureteric  orifice  and  the  growth  are 
then  excised  as  above,  the  ureter  is  picked  up  in  the  retro-vesical 


Tumours  of  the  Bladder.  873 

tissue  at  its  point  of  entry  into  the  bladder  and  fastened  by  one 
or  two  catgut  stitches  into  the  upper  part  of  the  wound.  Drainage 
of  the  retro-vesical  cellular  tissue  is  obtained  by  means  of  a  small 
tube  which  is  secured  by  a  catgut  stitch  just  below  the  trans- 
planted ureter.  Thus  one  end  of  this  tube  lies  in  the  retro-vesical 
tissues,  the  other  passes  through  the  bladder  and  out  through  the 
supra-pubic  wound. 

Palliative  Operations. — When  the  growth  is  too  extensive 
for  partial  cystectomy,  total  cystectomy  is,  in  the  majority  of 
cases,  contra-indicated  also.  The  general  condition  of  the  patient 
at  this  stage  is  too  feeble  and  the  immediate  mortality  high.  In 
addition  to  this  it  is  an  open  question  whether  the  patient  is  any 
better  off  than  he  would  be  by  simple  drainage  of  the  bladder. 

Cystostomy  as  a  means  of  relief  (by  affording  permanent 
drainage  of  the  bladder)  is  indicated  in  inoperable  cases  when 
serious  hemorrhage  or  clot  retention  occur  and  when  the  internal 
meatus  becomes  blocked  with  growth  and  micturition  accordingly 
difficult  and  painful.  It  is  also  indicated  when  vesical  spasm  is 
a  marked  feature  of  the  case  ;  the  spasm  and  pain  caused  thereby 
are  thus  checked.  In  cases  in  which  the  bladder  is  full  of  soft  car- 
cinomatous  growth  some  months'  respite  from  pain  and  obstruc- 
tion can  be  obtained  by  curettage  of  the  bladder.  The  bladder  is 
packed  with  gauze  for  forty-eight  hours  to  check  haemorrhage. 
The  gauze  itself  acts  as  a  sufficient  drain,  after  curettage,  for  the 
urine.  The  danger  of  this  form  of  treatment,  however,  is  that 
the  growth  may  fungate  through  the  wound  and  prevent  its 
closure.  When  the  symptoms  in  this  type  of  case  demand  surgical 
relief,  it  is  perhaps  better  to  perform  a  bilateral  nephrostomy  or 
ureterostomy.  In  the  latter  operation  the  ureters  are  brought 
out  upon  the  loins  and  the  urine  collected  in  some  suitable 
apparatus,  such  as  that  of  Rovsing. 

SYDNEY  G.  MACDONALD. 

REFERENCE. 
1  Transactions,  Second  Congress  of  "  Association  International  de  Urologie." 


874 


DISEASES  AND  AFFECTIONS  OF  THE  PENIS. 
BALANITIS   AND  POSTHITIS. 

INFLAMMATION  of  the  glans  and  prepuce  is  nearly  always 
associated  with  a  long  prepuce,  dirt,  or  venereal  disease.  In  some 
cases  the  fixed  and  adherent  prepuce  renders  the  inspection  of  the 
glans  impossible,  and  one  is  unable  to  ascertain  with  certainty  the 
condition  beneath  until  this  fold  of  skin  can  be  withdrawn.  In 
all  such  cases  the  possibility  of  syphilis  being  present  must  be  taken 
into  consideration. 

In  mild  cases  a  large  fomentation  (boracic)  should  be  applied  ; 
the  patient  should  be  instructed  to  syringe  some  weak  antiseptic 
(1  in  200  carbolic)  beneath  the  swollen  prepuce.  In  a  short  time 
the  inflammation  subsides ;  the  prepuce  can  be  retracted,  the 
diagnosis  confirmed,  and  local  remedies  can  be  applied. 

In  the  more  severe  types  this  is  not  sufficient,  and  in  order  to 
gain  access  to  the  hidden  region  the  swollen  foreskin  must  be 
divided  in  the  middle  line,  as  in  the  operation  for  circumcision,  so 
that  the  inflamed  glans  is  thoroughly  exposed,  or  even  the  complete 
operation  of  circumcision  may  be  performed.  This  latter  procedure 
as  a  routine  is  not  to  be  advised ;  mere  division  of  the  prepuce, 
allowing  it  to  contract,  is  sufficient  for  the  moment.  The  operation 
of  circumcision  should  be  completed  when  the  active  inflammation 
has  subsided. 

Sometimes  an  active  phagedeiiic  ulceration  complicates  matters, 
and  requires  special  treatment. 

IVOR  BACK. 


CAVERNOSITIS. 

FIBROUS  SCLEROSIS  of  the  cavernous  bodies  and  corpus  spongio- 
surn  does  not  yield  to  treatment.  Iodide  of  potassium  in  10-gr. 
doses  should  be  tried. 

IVOR  BACK. 


§75 


CONGENITAL   MALFORMATIONS   OF  THE  PENIS. 

THE  plastic  operations  required  for  the  repair  of  these  defects  lie 
essentially  in  the  domain  of  the  specialist,  and  ought  only  to  be 
undertaken  by  a  surgeon  who  has  frequent  opportunities  of 
perfecting  his  technique ;  so  that  only  the  simplest  outlines  of 
treatment  will  be  given  here. 

Hypospadias. — Here  operation  is  demanded  for  two  reasons  : 
(1)  Fertile  coitus  is  impossible  owing  to  the  opening  of  the  urethra 
in  some  abnormal  position ;  and  (2)  the  malformed  penis  is 
usually  bent  in  such  a  way  that  the  urine  is  sprayed  out  and  the 
scrotum  is  constantly  wet,  and  therefore  liable  to  eczema.  Two 
main  varieties  are  met  with :  (1)  That  in  which  the  urethra  opens 
at  the  base  of  the  glans  penis ;  and  (2)  that  in  which  it  opens  at  the 
junction  of  the  scrotum  and  the  penis.  The  former  is  the  simpler, 
and  is  usually  not  associated  with  incurvation  of  the  penis.  In  this 
case,  if  there  is  a  redundant  preputial  hood,  the  best  treatment  is 
to  make  an  incision  into  it,  push  the  glans  penis  through,  and 
repair  the  urethra  by  means  of  the  preputial  skin  which  now  lies 
on  the  under-surface  of  the  penis.  If  the  prepuce  is  not  redundant, 
attempts  may  be  made  to  repair  the  urethra  by  cutting  up  lateral 
flaps  of  skin  and  bringing  them  together  in  "the  middle  line  over  a 
catheter.  In  the  second  class  of  case,  where  the  urethra  opens  at 
the  back,  the  penis  is  usually  markedly  curved  downwards.  Before 
any  satisfactory  operation  can  be  undertaken  the  penis  must  be 
straightened.  This  is  best  done  by  making  a  series  of  transverse 
nicks  with  a  tenotome  in  one  or  more  places  until  the  organ  can  be 
made  to  lie  flat  upon  the  abdominal  wall.  In  order  to  prevent 
re-contraction  it  is  best  to  cover  in  these  incisions  by  minute 
Tiersch's  skin-grafts.  This  will  prevent  granulation. 

Most  of  the  operations  which  have  been  described  for  the  restora- 
tion of  a  complete  hypospadias  are  theoretically  excellent,  but  fail 
in  practice.  The  best  method  is  the  one  advocated  by  Mr.  Bucknall. 
It  consists  essentially  of  using  a  portion  of  scrotal  skin  in  the 
line  of  the  median  raphe  to  complete  the  urethra.  The  steps  of  the 
operation  are  exceedingly  complicated,  and  the  reader  is  referred  to 
the  original  article  for  the  details  of  its  technique.1 

Epispadias. — This  is  a  condition  in  which  the  urethra  is 
deficient  on  the  dorsal  surface  of  the  penis,  and  is  usually  associated 


876  Injuries  of  the  Penis. 

with  a  more  or  less  complete  ectopia  vesicae.  The  object  of  the 
operation  is  to  restore  a  channel  for  the  passage  of  urine  along  the 
penis.  This  has  heen  done  by  making  lateral  incisions,  depressing 
the  floor  of  the  urethra  into  the  centre  of  the  penis,  and  bringing 
the  edges  of  the  lateral  incisions  together  over  a  catheter.  But 
if  there  is  any  degree  of  ectopia  vesicae  present  it  must  be 
remembered  that  the  normal  sphincter  of  the  bladder  is  absent, 
and  that,  even  if  the  operation  is  successful,  the  patient  will 
afterwards  have  to  wear  a  portable  urinal. 


IVOR  BACK, 


KEFERENCE. 
1  Lancet,  1907,  II.,  p.  887. 


INJURIES  OF  THE  PENIS. 

Bruises  and  Lacerations  of  the  penis  are  treated  on  ordinary 
surgical  lines ;  local  cleanliness  and  the  application  of  a  cooling 
lotion  or  surgical  dressing  are  all  that  is  required. 

An  accident  which  may  give  rise  to  copious  and  even  alarming 
haemorrhage  is  rupture  of  the  fraenal  artery  during  coitus.  The 
artery  should  be  ligated,  but  as  this  is  sometimes  difficult  to  effect, 
it  may  be  underrun  by  a  curved  needle  carrying  a  ligature,  the 
haemorrhage  being  efficiently  checked  by  this  means. 

IVOR  BACK. 


877 


MALIGNANT  DISEASE   OF  THE  PENIS. 

SARCOMA  is  exceedingly  rare.  Carcinoma  is  met  with  in  two 
forms :  (1)  A  squamous-celled  variety,  which  arises  from  the 
epithelium  of  the  glans  penis  ;  and  (2)  a  columnar-celled  form, 
which  derives  its  origin  from  the  epithelium  lining  the  glands 
of  Tyson.  There  is  little  doubt  that  chronic  irritation  predis- 
poses to  the  condition,  and  the  most  important  factor  in  pro- 
ducing this  is  the  retention  of  the  sniegma  behind  a  long 
prepuce.  This  is  one  of  the  reasons,  and  not  the  least  cogent 
one,  for  performing  the  operation  of  circumcision  for  phimosis 
in  children,  for  it  is  said  that  epithelioma  of  the  penis  is  almost, 
if  not  quite,  unknown  amongst  circumcised  persons.  The  lym- 
phatic glands  are  involved  early.  The  inguinal  glands  drain 
the  skin  of  the  penis  and  are  enlarged  when  the  prepuce  is 
attacked ;  but  when  the  body  of  the  penis  is  enlarged,  secondary 
deposits  are  found  in  the  lumbar  glands.  If  the  disease  is  recog- 
nised early,  amputation  of  the  penis  through  the  body  is  indicated. 
In  this  case  there  is  some  hope  that  removal  of  the  diseased 
portion,  if  associated  with  eradication  of  the  inguinal  glands,  will 
cure  the  disease.  The  operation  in  itself  is  not  difficult.  A 
straight  bougie  is  introduced  into  the  urethra  and  the  penis  held 
up  vertically.  A  flap,  whose  length  is  equal  to  the  circumference 
of  the  penis,  is  then  marked  out  and  reflected  from  the  skin  of  the 
under-surface.  It  is  better  to  fashion  the  flap  from  this  surface 
than  from  the  dorsal  one,  so  that  the  urine  does  not  tend  to  dribble 
over  the  surface  of  the  wound  during  the  process  of  healing.  The 
flap,  which  consists  only  of  skin  and  subcutaneous  tissue,  is  raised 
from  the  penis,  and  a  straight  incision  made  round  the  dorsum  at 
the  base  of  the  flap.  The  corpora  cavernosa  are  now  cut  through 
at  the  level  of  the  base  of  the  flap.  The  corpus  spongiosum, 
however,  is  divided  at  a  point  about  ^  inch  distal  to  this.  The 
bougie  is  then  withdrawn.  A  small  opening  is  now  made  in 
the  skin  flap,  and  the  protruding  |  inch  of  corpus  spongiosum 
is  drawn  through  this.  The  flap  is  fixed  over  the  end  of  the 
penis  with  fine  silk  sutures,  and  the  orifice  of  the  urethra  sutured 
to  the  margins  of  the  aperture  in  the  skin  flap,  after  slitting 
it  up  vertically  for  about  £  inch  on  each  side.  This  prevents 
contraction  during  healing.  In  all  cases  the  inguinal  glands 


878          Malignant  Disease  of  the  Penis. 

on  either  side  should  be  removed,  whether  there  is  any  macro- 
scopic evidence  of  disease  or  not.  If  the  disease  when  first  seen 
has  involved  the  corpora  cavernosa  and  the  lymphatic  glands, 
radical  extirpation  of  the  penis  is  necessary.  The  operation  is 
performed  as  follows  :  The  patient  is  placed  in  the  lithotomy 
position  and  a  bougie  introduced  into  the  urethra.  An  incision 
is  made  along  the  whole  length  of  the  middle  line  of  the 
scrotum.  This  is  carried  back  until  the  urethra  is  exposed.  The 
corpus  spongiosum  is  divided  about  2  inches  in  front  of  the 
triangular  ligament,  and  the  proximal  portion  of  it  isolated.  The 
incision  in  the  scrotum  is  then  carried  round  the  dorsum  of  the 
penis,  and  the  whole  organ  is  removed,  the  crura  being  detached 
from  the  rami  of  the  pubes  with  a  periosteum  elevator.  The 
urethra  is  fixed  in  the  posterior  angle  of  the  wound,  and  the  two 
cut  edges  of  the  scrotum  are  united.  As  in  the  former  case,  the 
inguinal  glands  should  always  be  removed.  It  is  no  use  attempting 
to  remove  enlarged  lumbar  glands  by  laparotomy,  since,  if  these 
are  so  large  as  to  be  palpable  through  the  abdominal  wall,  the 
prognosis  is  hopeless.  If  when  the  case  is  first  seen  the  disease  is 
in  a  hopelessly  advanced  state  and  there  is  no  chance  of  a  radical 
operation  being  successful,  the  end  of  the  penis  may  be  amputated 
as  a  palliative  measure.  This  will  at  any  rate  rid  the  patient  of 
the  fungating  mass,  which  is  a  source  of  great  discomfort  to  him. 

IVOR  BACK. 


§79 


PAPILLOMATA  OF   THE   PENIS. 

PAPILLOMATA  are  fairly  common,  usually  in  connection  with 
gonorrhoea.  They  may  disappear  spontaneously.  In  recent  cases 
lactic  acid  is  almost  a  specific.  In  advanced  cases  circumcision  will 
be  required.  The  warts  should  be  destroyed  by  the  actual  cautery. 
Cleanliness  is  essential. 

IVOR  BACK. 


PARAPHIMOSIS. 

THIS  condition  may  be  treated  in  the  following  way  :  The  penis 
is  seized  behind  the  corona  glandis  between  the  interlocked  index 
and  middle  fingers  of  both  hands  and  an  attempt  made  to  reduce 
the  glans  by  firm  pressure  with  both  thumbs.  The  attempt  is  more 
likely  to  be  successful  if  an  anaesthetic  is  given.  If  the  condition 
has  been  present  for  twenty-four  hours  or  more  before  advice  has 
been  sought,  there  is  always  much  swelling  and  cedema  of  the 
retracted  prepuce,  and  it  is  nearly  always  necessary  to  divide  the 
constricting  band  along  the  dorsuin  under  anaesthesia  before 
reduction  can  be  effected. 

IVOR  BACK. 


88o 


PHIMOSIS. 

IF  the  prepuce  is  abnormally  long,  and  can  only  be  retracted  with 
difficulty  owing  to  its  tightness  or  actual  adhesion  between  the 
prepuce  and  the  glans,  active  treatment  is  required  in  order  to 
prevent  many  of  the  troublesome  complications  associated  with 
this  condition.  In  the  slighter  forms  of  phimosis  in  children  it  is 
sufficient  to  press  the  prepuce  back  gently,  and  to  instruct  the 
nurse  to  perform  the  same  action  daily,  until  the  fold  of  the  skin  is 
sufficiently  stretched  to  allow  free  exposure  of  the  glans  penis. 
In  the  more  advanced  cases  circumcision  should  be  performed, 
and  the  surgeon  should  be  very  ready  to  perform  this  excellent  and 
advisable  operation. 

Circumcision. — There  are  many  different  ways  of  performing 
this  operation.  The  best  method  is  as  follows :  The  skin  of  the 
penis  having  been  carefully  cleansed,  the  prepuce  is  seized  with 
Spencer  Wells'  or  catch  forceps  on  either  side  of  the  middle  line  of 
the  dorsum.  A  probe  or  a  director  is  introduced  beneath  the  fore- 
skin, between  it  and  the  glans,  to  separate  any  adhesions  that 
may  be  there ;  and  then  the  prepuce  is  divided  in  the  middle 
line  between  the  forceps  with  scissors,  down  to  the  junction  of  the 
mucous  membrane  with  the  corona. 

In  this  way  two  flaps  of  prepuce  will  be  formed,  consisting  of 
double  layers  of  the  cutaneous  mucosa.  These  are  now  carefully 
trimmed  away  with  scissors,  following  the  line  of  the  corona  to 
the  fraenum  below ;  about  %  inch  of  the  mucous  layer  should  be  left 
to  form,  as  it  were,  a  little  frill  round  the  coronal  margin.  If 
too  much  of  this  layer  is  left,  it  is  apt  to  swell  up  afterwards 
and  cause  some  trouble.  Care  must  also  be  taken  to  see  that 
too  much  of  the  cutaneous  layer  is  not  removed,  as  it  is  quite 
easy  to  "  flay  "  the  penis  of  a  small  child.  Bleeding  is  checked  by 
pressure  forceps  and  fine  catgut  ligatures,  and  the  cut  edges  of 
the  mucous  and  cutaneous  surfaces  are  accurately  approximated 
with  fine  catgut  stitches.  If  catgut  is  used,  it  softens  in  a  few  days, 
and  does  not  require  deliberate  removal. 

In  this  method  the  fraenal  artery  is  not  divided.  When  the  fore- 
skin is  very  long,  the  above  method  is  rarely  sufficient,  as  it 
leaves  a  long  pendulous  mass  of  tissue  beneath  the  frsenum,  which 
swells  up  and  becomes  cedematous.  In  such  cases  it  is  better  to 
free  the  cutaneous  completely  from  the  mucous  layer,  suturing  the 


Phimosis.  88 1 

latter  across  the  region  of  the  fraenum,  and  securing  the  fraenal 
artery.  A  small  triangular  flap  is  fashioned  from  the  central 
portion  of  the  cutaneous  layer,  and  this  is  adjusted  to  the 
triangular  raw  surface  left  at  the  frsenal  region.  This  modification 
gives  a  much  better  result. 

After-treatment  consists  in  applying  regularly  cooling  antiseptic 
dressings.  In  very  young  children  a  pad  of  gauze  soaked  in 
boracic  acid  is  placed  over  the  penis  (not  round  it)  and  frequently 
changed.  In  adults  the  following  plan  is  useful :  After  the  operation 
is  concluded  a  small  huckaback  towel  is  taken,  and  a  hole  is 
cut  in  its  centre,  through  which  the  penis  is  drawn.  A  piece  of 
oiled  silk  or  waterproof  is  placed  over  this,  with  a  similar  aperture 
in  its  centre.  The  organ  is  now  loosely  wrapped  in  a  strip  of  gauze 
or  lint  soaked  in  lotio  plumbi  c  opio.  This  acts  as  an  antiseptic 
sedative  styptic  dressing.  It  should  be  changed  every  three  or  four 
hours.  The  patient  can  be  instructed  to  clean  his  hands,  soak  the 
lint,  and  apply  it  himself.  This  dressing  never  becomes  adherent. 
For  the  first  few  nights  a  draught  of  30  gr.  of  bromide  of 
potassium  and  10  gr.  of  chloral  hydrate  should  be  given.  If 
priapism  causes  trouble,  the  bowels  should  be  thoroughly  opened, 
and  the  bedclothes  reduced  to  a  minimum.  In  this  way  the  comfort 
of  the  patient  is  ensured.  He  should  remain  in  bed  for  four  or 
five  days,  after  which  he  may  get  up,  but  the  penis  should  be  kept 
up  in  contact  with  the  abdominal  wall  by  means  of  a  triangular 
badge  or  a  pair  of  "  bathing  drawers"  until  healing  is  complete. 

IVOR   BACK. 


S.T.— VOL.  II.  0<! 


882 


DISEASES   AND   AFFECTIONS    OF   THE 
URETHRA. 

INJURIES  OF  THE  URETHRA. 

THE  chief  injuries  to  which  the  urethra  is  liable  are  abrasion  or 
perforation  from  the  misuse  of  catheters  or  other  instruments,  and 
rupture  as  the  result  of  blows  or  falls  upon  the  perineum. 
Occasionally  in  acute  gonorrhoea  there  may  be  very  severe 
haemorrhage  from  the  canal,  which  will  require  active  measures  to 
secure  its  cessation  (see  Gonorrhoea). 

The  treatment  of  the  minor  injuries  is  simple.  Haemorrhage,  if 
profuse,  should  be  checked  by  the  injection  of  a  few  drachms  of 
adrenalin  solution  (1  in  10,000),  and  a  cooling  lotion  (lotio  plumbi 
subacetatis  c  opio)  should  be  applied  to  the  organ  if  there  is  pain 
and  swelling.  False  passages,  if  present,  should  be  allowed  to  heal, 
and  if  there  is  no  urgency  from  retention  of  urine  or  other  con- 
dition, no  instruments  should  be  passed  for  several  days.  Wounds 
of  the  urethra  heal  rapidly,  on  the  whole.  In  the  more  severe 
cases  special  attention  has  to  be  paid  to  the  condition  of  the 
perineum  with  a  view  to  ascertaining  whether  the  urine  is  escaping 
into  the  cellular  tissue  outside  the  urethra. 

Blows  or  Falls  on  the  Perineum  may  produce  several  forms 
of  injury. 

(1)  There   is    bruising    and    laceration    of    the    urethra,    and 
haemorrhage  into  the  cavernous  tissue  ;  the  fibrous  sheath,  however, 
remains  intact. 

(2)  With  the  above  there  is  considerable  extravasation  of  blood 
into  the  perineal  tissues. 

(3)  The  urethra  is  lacerated  and  ruptured,  so  that  urine  as  it 
passes  along  the  canal  is  extravasated,  the  fibrous  sheath  of  the 
corpus  spongiosum  being  torn. 

The  routine  treatment  of  all  such  cases  is  as  follows.  If  there  is 
evidence  of  urethralinjury  obtainable  from  the  history,  or  from  the 
presence  of  blood  at  the  meatus,  or  from  the  patient's  inability  to 
micturate,  the  case  should  from  the  first  be  regarded  as  one  of 
possible  urethral  rupture.  The  patient  must  on  no  account 
attempt  to  pass  water  until  the  extent  of  the  injury  has  been 
ascertained. 


Injuries  of  the  Urethra.  883 

A  catheter  should  be  passed,  preferably  a  gum-elastic  or  a  rubber 
instrument  which  has  been  thoroughly  sterilised.  If  this  passes 
without  difficulty  it  is  safe  to  assume  that  there  is  slight  laceration 
only,  and  the  patient  may  be  allowed  to  micturate  as  he  desires, 
but  the  perineum  should  be  watched  in  case  there  has  been  any 
leakage  of  urine  through  a  minute  opening  in  the  canal. 

If  the  catheter  passes  with  difficulty,  catching  frequently  at  a, 
point  of  obvious  rupture,  the  passage  of  the  instrument  causing 
free  bleeding,  the  instrument  should  be  tied  in  for  forty-eight 
hours,  a  careful  watch  being  kept  on  the  perineum  as  before. 

If  a  soft  instrument  cannot  be  passed,  a  metal  instrument  may 
be  used,  but  it  will  frequently  fail,  and  is  very  unpleasant  to 
the  patient  if  it  has  to  be  retained  ;  in  most  cases  where  its  use  is 
necessary  there  will  be  sufficient  evidence  of  urethral  injury  present 
to  render  a  perineal  section  advisable. 

If  a  perineal  haematoma  is  present,  its  size  must  determine  the 
need  for  surgical  interference.  Small  collections  of  blood  may  well 
be  left  alone,  but  the  larger  extravasation  should  be  dealt  with  by 
incision  and  drainage,  since  if  left  alone  they  may  become  iniected, 
and  further,  by  exerting  pressure  on  the  urethra  they  interfere 
with  micturition. 

In  cases  where  no  doubt  exists  as  to  extensive  urethral  rupture, 
or  in  those  where  no  instrument  can  be  passed,  or  where  after  a 
time  signs  of  urinary  extravasation  make  their  appearance,  a 
perineal  section  should  be  performed.  The  operation  may  be  simple 
or  difficult,  according  to  the  extent  of  the  injury  and  its  duration. 
In  cases  where  much  extravasation  of  urine  is  present,  free  drainage 
of  the  perineum,  with  catheter  drainage  of  the  bladder,  will  be 
indicated;  in  more  recent  cases  an  attempt  may  be  made  to  suture 
the  wounded  urethra,  a  catheter  being  left  in  situ,  and  the  perineal 
opening  drained.  It  is  imperative  to  attempt  this  in  cases  of  com- 
plete transverse  rupture  of  the  canal  owing  to  the  trouble  which 
ensues  from  the  development  of  a  traumatic  stricture,  one  of  the 
most  difficult  varieties  of  urinary  obstruction. 

The  procedure  is  as  follows :  The  patient  is  placed  in  the 
lithotomy  position,  and  a  Wheelhouse  staff,  or,  if  this  is  not  at 
hand,  a  large  gum-elastic  catheter,  is  passed  down  to  the  site  of  the 
rupture.  The  perineum,  having  been  carefully  cleansed  and  shaved, 
is  incised  freely  for  two  or  three  inches,  strictly  in  the  middle  line. 
This  incision  is  deepened  until  the  end  of  the  staff  or  catheter  is 
exposed  at  the  distal  torn  end  of  the  urethra.  Clots  are  now  washed 
away  with  an  irrigator,  and  a  search  is  made  for  the  proximal  end 
of  the  ruptured  canal.  Sometimes  extreme  difficulty  will  be 

56—2 


884  Injuries  of  the  Urethra. 

encountered  at  this  stage,  the  torn  end  may  have  retracted  so 
deeply  into  the  bruised  perineal  tissues  that  its  identification  is  by 
no  means  easy.  Pressure  on  the  bladder  above  the  pubes  may 
assist  the  operator  in  causing  urine  to  flow  through  the  torn 
proximal  end,  but  in  cases  of  extreme  difficulty  it  may  be  advisable 
to  open  the  bladder  above  the  pubes  and  pass  a  catheter  from  the 
bladder  through  the  internal  urinary  meatus,  out  through  the  torn 
proximal  end  of  the  canal,  a  procedure  termed  retrograde 
catheterisation.  This  step  is  certainly  a  serious  one,  but  it  is  justified 
by  the  superior  results  that  are  obtained  if  the  torn  ends  of  the  tube 
can  be  approximated. 

The  rent  of  the. two  ends  being  identified,  they  are  carefully 
sutured  together  with  fine  catgut;  silk  must  not  be  used.  The 
bruised  and  lacerated  edges  should  be  accurately  trimmed,  and  the 
corpus  spongiosum  in  which  the  urethra  lies  may  be  mobilised  by 
dissection  from  the  corpora  cavernosa,  so  that  there  is  no  tension 
on  the  line  of  suture.  Accurate  suture  may  be  a  matter  of  great 
difficulty  if  the  rupture  lies  deep,  but  upon  it  depends  the  patient's 
subsequent  comfort  to  such  an  extent  that  every  effort  must  be  made 
to  secure  a  firm  junction.  A  rubber  catheter  should  be  tied  into 
the  bladder,  and  the  perineal  wound  should  be  freely  drained. 

There  is  usually  some  leakage  of  urine  along  the  suture  line : 
this  is  provided  for  by  the  perineal  drainage,  but  the  extensive 
stricture  which  often  develops  in  such  cases  is  prevented.  Regular 
instrumentation,  at  the  time  and  for  some  period  subsequently,  are 
required  to  bring  the  case  to  a  successful  issue. 

Foreign  Bodies  in  the  Urethra. — Foreign  bodies  in  this  canal 
are  of  two  main  kinds,  those  that  descend  from  above,  i.e.,  from  the 
bladder,  and  those  that  are  introduced  from  without,  pencils, 
stones,  cinders,  pins,  etc.  The  first  variety  comprises  urethral 
calculi,  which,  in  the  majority  of  cases,  are  expelled  by  the  bladder 
along  the  urethra,  becoming  impacted  in  some  part  of  the  tube, 
either  near  the  triangular  ligament  or  the  fossa  navicularis.  More 
rarely  calculi  may  form  in  the  urethra  itself,  and  in  such  cases  they 
are  often  of  considerable  size  and  only  removable  by  incision  of  the 
urethal  wall.  If  a  calculus  is  impacted  deeply  in  the  urethra,  an 
attempt  may  be  made  to  extract  it  with  the  special  urethral  forceps 
devised  by  Thompson,  but  the  nianoauvre  will  generally  fail ;  in  such 
a  case  the  stone  must  be  gently  pushed  back  into  the  bladder  and 
crushed. 

It  is  well  to  lear  in  mind  tJtdt  in  cases  of  impacted  calculus  a  second 
or  tliinl  »(<»!<•  may  Represent  in  the  bladder. 

If  the  calculus  lies  near  the  anterior  part  of  the  canal,   it  can 


Injuries  of  the  Urethra.  885 

usually  be  extracted  with  forceps,  especially  if  the  meatus  is  incised 
so  as  to  give  the  necessary  freedom  of  access.  If  any  great  diffi- 
culty is  experienced,  the  attempt  should  be  abandoned,  and  the 
operation  of  external  urethrotomy  should  be  performed.  This 
treatment  is  also  suitable  to  large  stationary  urethral  calculi,  and 
for  the  removal  of  foreign  bodies  of  extraneous  origin  which  are  not 
amenable  to  manipulation.  In  no  case  should  any  attempt  be 
made  to  force  such  a  body  back  into  the  bladder. 

Operation. — The  patient  is  placed  in  the  lithotomy  position,  and 
an  incision  is  made  down  to  the  urethra  in  the  middle  line — the 
exact  position  of  the  foreign  body  has  been  previously  ascertained 
accurately  by  means  of  a  sound.  The  urethra  is  incised,  and  the 
stone  or  foreign  body  is  extracted  with  as  little  bruising  of  the 
edges  of  the  incision  as  possible.  If  no  urinary  infection  is  present, 
the  edges  of  the  incision  should  be  closed  with  fine  catgut  sutures, 
a  catheter  being  tied  in  for  a  few  days  to  accelerate  healing.  In 
cases  with  much  bruising,  ulceration,  or  infection,  this  step  should 
be  omitted,  the  wound  being  allowed  to  close  gradually,  and  the 
canal  being  kept  patent  with  bougies. 

Large-headed  pins  introduced  head  first  into  the  canal  may  be 
extracted  by  the  method  of  Poulet:  "  The  head  of  the  pin  is  fixed 
by  the  thumb  and  finger  of  the  left  hand  to  prevent  it  slipping  :  the 
penis  is  next  bent  at  the  part  of  the  urethra  against  which  the 
point  of  the  pin  is  lying  ;  as  a  consequence  the  point  can  be  pro- 
truded through  the  wall  of  the  canal :  the  point  is  grasped  and  the 
pin  withdrawn  until  the  head  is  in  contact  with  the  floor  of  the 
urethra.  The  shaft  of  the  pin  is  now  drawn  down  to  the  root  of 
the  penis,  and  then  by  pushing  upwards  the  head  of  the  pin 
emerges  from  the  meatus  and  is  withdrawn.  If  the  object  is  a  hair- 
pin, both  portions  are  made  to  protrude,  one  is  then  cut  off  with 
pliers,  and  the  same  manoeuvre  is  undertaken." 

IVOR  BACK. 


886 


STRICTURE. 

STRICTURE  of  the  urethra  consists  in  a  replacement  of  the  uurmal 
muscular  and  elastic  walls  by  fibrous  tissue.  Organic  strictures 
are,  in  the  great  majority  of  cases,  due  to  gonorrhcea.  A  small 
number,  however,  result  from  injury.  The  object  of  treatment  is 
to  restore  the  lumen  of  the  canal,  and,  what  is  extremely  important, 
to  do  this  without  introducing  a  septic  element,  and  thus  infecting 
the  urethra  or  bladder. 

The  treatment  of  Uncomplicated  Strictures  is  usually  carried 
out  by  means  of  dilatation.  Dilatation  is  performed  by  passing 
instruments  of  gradually  increasing  size  at  intervals  of  a  week. 
It  is  a  mistake  to  pass  instruments  more  frequently  than  this. 
Instrumentation  always  bruises  the  stricture  somewhat,  so  that 
there  is  a  slight  reaction  and  swelling  in  the  urethra  for  a  few 
days.  The  following  instruments  are  necessary :  (1)  Filiform 
bougies,  preferably  made  of  whalebone  ;  (2)  gum-elastic  bougies 
with  olivary  heads  and  pronounced  necks;  the  shaft  should  be 
fairly  rigid :  the  best  pattern  is  the  French  one  made  by  Dela- 
rnotte ;  (3)  curved  steel  bougies.  It  is  important  to  know  how 
these  instruments  may  be  properly  sterilised.  Steel  bougies,  of 
course,  can  be  readily  sterilised  by  boiling.  But  this  method 
is  not  applicable  to  gum-elastic  bougies.  At  the  same  time 
it  is  a  mistake  to  suppose  that  gum-elastic  bougies  cannot  be  boiled 
at  all.  The  best  varieties  made  to-day  will  stand  boiling  for  some 
time,  though  even  now  they  are  gradually  destroyed  by  the  process. 
A  convenient  method  of  sterilising  gum- elastic  bougies  is  to  place 
them  in  a  long  glass  tube,  which  is  closed  by  a  hollow  rubber 
stopper.  Tho  base  of  the  stopper  is  made  of  metal  which  is  per- 
forated, and  the  hollow  receptacle  is  filled  with  paraforrn  granules 
which  emit  a  continuous  formalin  vapour.  After  a  bougie  has  been 
placed  for  thirty-six  hours  in  such  a  medium  it  is  completely 
sterile.  When  only  an  occasional  bougie  is  required  it  is  best, 
after  use,  to  wash  the  instrument  thoroughly  and  then  boil  it  for 
about  a  minute,  afterwards  placing  it  in  the  glass  cylinder  for 
future  use. 

Supposing  that  from  the  patient's  history  a  tentative  diagnosis 
of  stricture  has  been  made,  it  remains  to  examine  the  urethra  and 
confirm  the  diagnosis.  For  this  purpose  the  urethroscope  gives 


Stricture.  887 

invaluable  information.  The  largest  tube  which  can  be  introduced 
readily  should  be  passed  as  far  back  -as  the  bulb,  if  possible.  By  its 
means  the  constriction  is  easily  seen,  its  calibre  roughly  estimated, 
and  the  condition  of  the  rest  of  the  urethra  made  out.  It  is  most 
useful  in  locating  the  orifice  of  a  very  small  stricture,  and  in  the 
diagnosis  of  multiple  strictures.  A  word  of  warning  must  be  intro- 
duced here  about  a  danger  of  instrumentation,  and  that  is  the 
occurrence  of  what  is  known  as  urethral  shock.  Certain  patients 
who  have  never  had  an  instrument  passed  before  are  profoundly 
shocked  by  the  manoeuvre.  In  passing  an  instrument  for  the  first 
time  it  is  therefore  wise  to  put  the  patient  to  bed,  preferably  in  a 
nursing  home,  where  for  twenty-four  hours  he  can  be  kept  under 
observation.  The  risk  of  shock  is  diminished  by  the  previous 
injection  into  the  urethra  of  a  2  per  cent,  solution  of  eucaine 
lactate  with  an  ordinary  stylographic  pen-filler.  This  is  especially 
indicated  if  the  patient  is  nervous.  He  should  lie  on  his  back  with 
the  pelvis  slightly  raised  and  the  knees  flexed.  The  surgeon  stands 
on  his  right.  The  glans  and  prepuce  must  be  thoroughly  cleaned 
before  instrumentation,  and  if  there  is  any  urethral  discharge  the 
canal  must  be  flushed  out  with  an  antiseptic  solution.  Ordinarily, 
micturition  is  sufficient  to  cleanse  the  urethra.  The  instrument 
selected  for  the  first  attempt  should  be  a  medium-sized  gum  elastic 
bougie,  about  a  No.  12  French.  The  instrument,  well  sterilised 
and  lubricated,  is  passed  down  the  urethra,  which  is  kept  on  the 
stretch  without  torsion  by  the  fingers  of  the  left  hand  placed  behind 
the  glans.  By  trying  successive  sizes  an  instrument  will  eventually 
be  found  which  will  just  pass  the  stricture.  This  is  sufficient  for 
the  first  occasion.  A  week  later  this  instrument  may  be  passed 
again,  and  larger  sizes  then  introduced  until  one  is  found  which 
is  just  gripped  by  the  stricture.  It  is  most  important  that  no  force 
should  ever  be  used.  If  this  is  done  the  stricture  will  be  torn 
rather  than  dilated,  and  the  healing  of  the  tear  will  cause  it  to  con- 
tract down  instead  of  to  dilate.  The  time  occupied  in  dilating  the 
stricture  by  such  means  varies  within  wide  limits.  In  a  recent 
soft  local  stricture  it  may  be  complete  in  two  or  three  weeks.  But 
in  an  old  extensive  fibrous  stricture  one  may  have  to  be  content 
with  very  slow  progress.  Dilatation  should  be  continued  with 
bougies  until  a  No.  20  French  can  be  introduced  with  ease. 
After  this  steel  instruments  should  be  passed,  starting  with  a 
No.  9  to  11  English.  The  technique  of  passing  this  instrument  is 
somewhat  different  from  that  of  the  gum-elastic  bougie.  The  penis 
should  be  held  in  the  line  of  the  right  Poupart's  ligament.  When 
about  4  inches  of  the  bougie  has  passed,  the  handle  is  swung  to  the 


888  Stricture. 

mid-line,  being  still  pushed  gently  onwards ;  and,  finally,  when  the 
point  is  judged  to  be  under  the  symphysis,  the  handle  is  depressed 
until  the  point  enters  the  bladder  almost  by  the  weight  of  the 
bougie  alone.  The  commonest  mistakes  that  are  made  are  depres- 
sion of  the  handle  before  the  point  has  got  well  under  the  sym- 
physis, failure  to  keep  the  urethra  on  the  stretch,  and  torsion  of 
the  urethra.  If  any  difficulty  is  met  with  at  the  bulb  it  may  often 
be  overcome  by  manipulating  the  point  of  the  bougie  past  this 
place  with  the  finger  of  the  other  hand  in  the  perineum.  As  the 
size  of  the  steel  bougie  which  can  be  passed  increases,  the  period 
between  each  dilatation  may  be  lengthened,  so  that  when  a  No.  14  to 
16  had  been  passed  it  is  only  necessary  to  dilate  the  stricture  once  in 
every  six  months.  Dilatation  twice  a  year  with  a  bougie  of  this 
size  should  continue  throughout  the  patient's  life,  and  he  should  be 
warned  that  if  he  stops  treatment  the  stricture  is  likely  to  close 
down  again.  In  certain  cases  the  stricture,  when  the  patient  is 
first  seen,  is  so  small  as  to  be  permeable  by  no  ordinary  bougie. 
Recourse  must  then  be  had  to  the  filiform  whalebone  bougie,  which 
may  be  bent  into  a  bayonet  shape.  This  will  often  succeed  where 
a  straight  bougie  has  failed,  because  the  orifice  of  the  stricture  is 
rarely  in  the  middle  line  of  the  urethra.  In  these  cases  it  is  well 
to  put  the  patient  to  bed  for  two  or  three  days,  and  tie  in  the 
filiform  bougie.  It  will  be  found  at  the  end  of  this  time  that  the 
stricture  has  dilated  to  such  a  size  that  a  small  French  bougie  is 
easily  introduced,  and  interrupted  dilatation  can  be  proceeded  with, 
as  already  described. 

Two  common  difficulties  are  caused  by  multiple  strictures,  and 
by  false  passages.  Multiple  strictures  may  be  very  troublesome. 
The  orifices  of  the  various  strictures  are  frequently  not  in  the  same 
line,  and  so  the  point  of  the  bougie  is  diverted  from  the  axis  of  the 
urethra.  And  again,  the  more  superficial  stricture  may  grasp  the 
bougie  so  tightly  that  it  has  not  the  necessary  mobility  to  enter  into 
the  deeper  strictures.  The  obvious  way  to  avoid  this  is  to  dilate 
the  superficial  strictures  first  and  the  deeper  later.  But  multiple 
strictures  often  do  better  if  treated  at  the  outset  by  a  cutting 
operation.  A  false  passage  may  be  known  to  exist  by  a  constant 
obstruction  at  a  definite  point  to  an  instrument  finer  than  the 
calibre  of  the  stricture.  When  there  is  a  definite  false  passage,  it 
is  best  to  use  a  whip  bougie.  The  point  of  this  can  be  manipulated 
past  the  false  passage  without  difficulty,  and  the  stricture  may  be 
dilated  by  pushing  it  in  as  far  as  it  will  go  readily.  This  gives  the 
false  passage  time  to  heal,  while  the  orifice  of  the  stricture  is  kept 
regularly  open,  and  subsequently  there  should  be  no  difficulty  in 


Stricture.  889 

continuing  the  dilatation  with  the  steel  bougies,  as  described  above. 
AVhile  instruments  are  being  passed  it  is  well  to  give  an  occasional 
purge  and  a  urinary  antiseptic  ;  urotropiue  is  undoubtedly  the  best. 
Besides  the  grave  catastrophe  of  infection  and  the  occurrence  of 
urethral  shock,  other  and  more  immediate  accidents  may  occur  from 
the  passage  of  instruments:  (1)  A  slight  amount  of  haemorrhage 
is  not  uncommon.  It  can  usually  be  arrested  by  placing  the  patient 
in  the  recumbent  position  for  half-an-hour  or  more.  More  severe 
liu'inorrhage  may  be  checked  by  the  application  of  adrenalin. 
Occasionally,  if  a  steel  bougie  has  been  forcibly  passed  into  the 
bladder  through  a  false  passage  in  the  deep  urethra,  intra-vesical 
haemorrhage  with  clot  may  occur  and  lead  to  clot  retention.  In 
this  case  it  may  be  necessary  to  pass  a  catheter  with  a  large  eye, 
or  even  to  remove  the  clots  from  the  bladder  with  Bigelow's 
evacuator ;  (2)  Catheter  fever.  This  is  not  a  good  name,  since  it 
implies  a  septic  element,  whereas,  as  a  matter  of  fact,  what  is 
known  as  catheter  fever  may  follow  on  the  passage  of  an  absolutely 
aseptic  instrument.  It  is  characterised  by  a  suddeii  rise  of  tem- 
perature within  twelve  hours  of  the  passage  of  the  instrument,  and 
one  or  more  rigors.  In  graver  cases  there  may  be  suppression  of 
urine  without  pyrexia,  which  may  lead  to  delirium,  and  even  death. 
The  treatment,  when  the  condition  arises,  should  consist  in  rest, 
low  diet,  urinary  antiseptics,  the  administration  of  quinine  or 
salicylates,  and  the  temporary  cessation  of  local  treatment. 

Certain  classes  of  stricture  may  prove  resistant  to  intermittent 
dilatation.  Such  are  those  of  very  long  standing,  with  almost 
cartilaginous  walls,  multiple  strictures,  resilient  strictures,  which 
habitually  relapse,  and  strictures  in  those  who  are  intolerant  of 
instrumentation.  These  cases  are  best  treated  by  internal 
wetkrotomy,  particularly  the  cartilaginous  variety,  in  which  it  is 
found  that  interrupted  dilatation  is  successful  to  a  point,  say,  the 
passage  of  a  No.  1'2  French,  but  week  after  week  it  is  impossible  to 
dilate  the  stricture  further  than  this. 

Many  instruments  have  been  devised  for  internal  urethrotomy ; 
of  these  the  Maisonneuve  is  one  of  the  best.  It  consists  of  a 
line  flexible  guide,  a  grooved  director,  and  a  triangular  knife  on 
a  long  handle,  which  fits  into  the  groove  of  the  director.  The 
Maisonneuve  cuts  the  stricture  from  before  backwards.  The  guide 
is  passed  and  tied  in  beforehand,  or,  if  this  cannot  be  done,  it  is 
passed  under  the  anaesthetic.  The  director  is  then  screwed  on  to 
the  end  of  the  guide,  and  passed  through  the  stricture  into  the 
bladder.  The  knife  is  inserted  into  the  groove,  and  firmly  pressed 
through  the  stricture.  In  all  ordinary  cases  the  director  is  grooved 


890  Stricture.  . 

along  its  concavity,  so  that  the  stricture  is  cut  on  its  dorsal  surface. 
It  is  best  to  pass  the  knife  twice  through  the  stricture,  so  as  to  be 
certain  that  all  fibrous  tissue  is  divided.  After  the  withdrawal  of 
the  urethrotorne  a  full-sized  steel  bougie  is  passed,  to  make  sure  of 
complete  division,  and,  finally,  a  full-sized  catheter  is  tied  in.  The 
catheter  is  tied  in  to  prevent  the  urine,  which  may  be  septic,  from 
coming  into  contact  with  the  wound  for  a  day  or  two.  It  is  removed 
in  forty-eight  hours,  and  after  three  days  the  patient  is  allowed  to 
get  up.  It  will  often  be  found  that  after  removal  of  the  catheter 
there  is  a  slight  rise  of  temperature.  This  is  due  to  the  fact  that 
the  urine  is  now  allowed  to  get  in  contact  with  the  surface  of  the 
wound,  but  the  pyrexia  is  usually  temporary,  and  of  no  importance. 
Afterwards,  large  steel  bougies  must  be  passed  at  intervals,  exactly 
in  the  same  manner  as  in  ordinary  interrupted  dilatation. 

Acute  Retention  of  Urine  is  a  complication  of  stricture.  It  is 
caused  by  the  gradual  narrowing  of  the  stricture  to  such  a  point 
that  urine  will  no  longer  pass.  The  acute  onset  is  generally  pre- 
cipitated by  an  excess  of  alcohol.  When  the  condition  has  advanced 
to  an  extreme  degree  there  is  often  some  dribbling  of  urine.  This 
is  known  as  retention  incontinence.  It  is  important  to  know  this, 
because  the  presence  of  retention  is  sometimes  overlooked  on 
account  of  this  symptom. 

The  treatment  must  be  conducted  in  a  routine  manner.  The 
patient  must  be  put  to  bed,  and  an  attempt  made  to  pass  a  catheter  ; 
but  only  a  soft  rubber  one  at  first,  preferably  a  No.  6  or  No.  7. 
Sometimes  the  retention  is  largely  due  to  spasm,  and  steady 
pressure,  even  with  a  soft  catheter,  may  gradually  overcome  it.  If 
this  is  not  successful  a  gum-elastic  catheter  of  successively  smaller 
sizes  may  be  tried,  but  on  no  account  must  force  be  used.  If 
gentle  manipulation  with  a  gum-elastic  catheter  fails,  no  further 
attempt  to  pass  an  instrument  should  be  made  at  the  moment. 
An  enema  should  be  given,  and  15  gr.  of  pulv.  ipecac,  co. 
[U.S.P.  pulvis  ipecacuanhas  et  opii.]  administered  by  the  mouth. 
The  patient  should  then  be  immersed  in  a  bath  as  hot  as  he 
can  bear.  These  measures  often  relax  the  spasm,  and  he  may 
be  able  to  pass  some  urine  in  the  bath ;  and  afterwards  it  may 
be  found  possible  to  pass  an  instrument  where  it  could  not 
be  done  before.  If,  in  spite  of  this  treatment,  no  urine  is  still 
passed  and  no  instrument  can  be  introduced,  the  bladder  should 
be  aspirated  supra-pubically.  This  must  be  done  with  careful 
antiseptic  precautions.  The  pubes  must  be  shaved  and  made 
aseptic,  and  the  trocar  and  cannula  must  be  boiled.  The  trocar 
is  inserted  in  the  middle  line,  about  1  inch  above  the  pubes, 


Stricture.  891 

with  a  slight  inclination  downwards  and  backwards.  The  cannula 
should  be  a  small  one,  so  that  the  'urine  can  be  withdrawn  from 
the  bladder  gradually  ;  to  let  it  out  suddenly  is  to  run  the 
risk  of  causing  a  certain  degree  of  shock.  When  the  bladder  is 
empty,  the  cannula  is  removed  and  the  small  wound  covered  with 
gauze  and  collodion.  After  supra-pubic  aspiration  it  is  sometimes 
found  that  the  patient  can  pass  his  urine  per  vias  naturales,  or  a 
small  catheter  can  be  introduced.  If  this  can  be  done,  it  should 
be  tied  in  for  twenty-four  hours.  This  will  cause  the  stricture  to 
dilate,  so  that  when  the  instrument  is  removed,  one,  two,  or  three 
sizes  larger  can  be  introduced  on  the  next  day  without  much 
difficulty,  and  the  stricture  can  then  be  dilated  interruptedly  in  the 
manner  already  described.  But  if,  after  trying  all  palliative 
measures,  including  aspiration,  no  instrument  can  be  passed, ' 
an  external  urctlirotoiny  must  be  performed.  Of  the  various 
methods  which  have  been  advocated,  Wheelhouse's  is  the  only  one 
which  is  available  in  the  case  of  acute  retention.  The  patient  is 
placed  in  the  lithotomy  position,  Wheelhouse's  staff,  which  has  a 
hooked  end,  is  passed  down  the  urethra  as  far  as  the  stricture,  and 
an  incision  about  1£  or  2  inches  long  is  made  in  the  middle 
line  of  the  perineum,  between  the  anus  and  the  posterior  border 
of  the  scrotum.  The  incision  is  gradually  deepened,  and  the 
hooked  end  of  the  staff  carefully  felt  for.  The  main  responsi- 
bility falls  upon  the  assistant,  for  it  is  his  duty  to  see  that  the 
patient  lies  flat  upon  his  back,  and  to  hold  the  staff  exactly  in  the 
middle  line.  If  this  precaution  is  not  observed,  it  may  be  extremely 
difficult  to  find  the  urethra,  in  spite  of  the  presence  of  the  staff  in 
it.  When  the  urethra  is  found,  an  incision  is  made  through  its 
lower  wall  distal  to  the  stricture,  and  the  end  of  the  staff  pushed 
through.  The  hook  is  then  made  to  catch  in  the  angle  of  the 
incision  in  the  urethra,  which  is  held  on  the  stretch.  The  stricture 
is  incised  from  before  backwards  along  its  lower  border.  A  Pridgen 
Teale  probe-pointed  gorget  is  passed  along  the  proximal  portion  of 
the  urethra  into  the  bladder  and  the  urine  is  evacuated.  A  large 
gum-elastic  catheter  is  passed  into  the  bladder  per  urethram,  the 
point  being  directed  into  the  proximal  urethra  through  the  wound. 
The  wound  need  not  be  sewn  up.  The  catheter  is  fixed  in  by 
means  of  tape,  tied  round  it  with  a  clove  hitch,  and  strapped  to  the 
penis.  The  catheter  should  be  allowed  to  remain  in  situ  as  long  as 
possible,  being  merely  turned  round  once  daily.  After  a  few  days 
a  discharge  will  be  seen  oozing  from  between  the  catheter  and  the 
lips  of  the  meatus.  This  is  an  indication  that  it  must  be  changed. 
On  the  first  occasion  it  is  well  to  give  an  anaesthetic,  but  afterwards, 


892  Stricture. 

when  a  new  urethra  is  more  or  less  formed,  it  may  be  changed 
without  this.  The  wound  in  the  perineum  should  heal  in  ahout  ten 
days,  and  the  patient  may  be  allowed  to  get  up  in  a  fortnight.  But 
afterwards  he  must  attend  for  the  periodical  passage  of  a  steel 
bougie,  since  the  new  urethra  formed  by  the  operation  shows  a  great 
tendency  to  contract ;  and  he  must  be  warned  that  if  he  does  not 
persevere  in  the  after-treatment  he  may  suffer  from  another  attack 
of  acute  retention. 

IVOR  BACK. 


§93 


EXTRAVASATION  OF  URINE. 

As  a  result  of  softening  behind  a  stricture,  or  as  the  result  of 
rupture,  the  urine  may  be  exlravasated  into  the  cellular  tissues  very 
widely.  The  extent  of  this  extravasation  is  limited  by  certain 
anatomical  boundaries.  If  the  leak  in  the  canal  lies,  as  is  usually 
the  case,  distal  to  the  superficial  layer  of  the  triangular  ligament 
in  the  penile  portion  of  the  canal,  the  urine  passes  up  beneath 
the  membranous  fascia  of  Colles  and  Scarpa,  distending  the 
superficial  tissues  of  the  penis,  scrotum,  and  perineum.  It  does 
not  pass  down  into  the  thighs,  but  tracks  up  along  the  abdominal 
wall  to  the  axilla. 

The  longer  the  duration  of  the  extravasation  before  the  patient 
comes  under  treatment,  the  worse  is  the  prognosis ;  and  this  is  also 
markedly  affected  by  the  cause  of  the  extravasation.  In  cases  of 
stricture  the  urine  is  more  likely  to  be  offensive  and  infected,  and 
so  acts  as  a  deadly  poison  on  the  tissues,  producing  early  a  form 
of  gangrenous  cellulitis ;  while  the  sufferer  from  a  stricture  of 
long  standing  is  usually  in  an  unhealthy  state,  and  his  kidneys 
may  be  extensively  diseased.  On  the  other  hand,  in  extravasa- 
tion from  rupture,  the  general  condition  of  the  patient  is  entirely 
different. 

Treatment  consists  in  making  free  incisions  into  the  swollen 
cedematous  areas.  Two  mistakes  are  often  made.  The  incisions 
are  too  small,  and  are  not  made  sufficiency  deep.  In  the  abdominal 
wall  they  must  go  down  to  the  aponeurosis  of  the  external  oblique. 
One  special  large  and  deep  incision  must  be  made  into  the  perineum 
down  to  the  urethra,  and  if  the  urine  is  not  foul  there  is  no  need  to 
introduce  a  catheter  or  tube;  but  this  must,  of  course,  be  done  if 
severe  cystitis  is  present. 

In  a  few  cases  of  rupture  from  injury  it  may  be  wise  to  attempt 
to  repair  the  canal  in  the  manner  already  described. 

Further  treatment  consists  in  supporting  the  patient's  strength 
with  stimulants.  Since  in  cases  of  long-standing  stricture  the 
general  condition  of  the  patient  is  bad,  he  is  very  liable  to  die  from 
septic  absorption. 

The  wounds  must  be  fomented,  or,  if  it  is  possible,  the  patient 
should  sit  in  a  solution  of  warm  boracic  acid  for  a  couple  of  hours 
during  the  day. 


894  Fistulae  of  the  Urethra. 

In  some  cases  of  injury  the  urethra  may  give  way  behind  the 
triangular  ligament,  the  escaping  urine  thus  being  extravasated  into 
the  cellular  tissue  of  the  pelvis  and  abdomen.  Such  cases  closely 
simulate  extra-peritoneal  rupture  of  the  bladder,  and  the  general 
lines  of  treatment  are  to  make  free  incisions  wherever  the  fluid 
tends  to  accumulate,  to  pass  a  catheter  into  the  bladder,  aided,  if 
need  be,  by  a  supra-pubic  incision,  and  to  provide  in  this  way 
drainage  of  the  viscus  for  some  time.  In  many  cases  a  section 
of  the  perineum  will  be  required  as  well. 

IVOR  BACK. 


FISTULA  OF  THE  URETHRA. 

FISTULJE  occur  as  the  result  of  the  gradual  giving  way  of  the 
urethra  behind  a  stricture.  The  commonest  situation  is  the 
perineum,  because  the  commonest  situation  of  a  stricture  is 
the  bulb.  But  they  also  occur  in  the  anterior  urethra,  where  they 
are  known  as  penile. 

In  the  treatment  of  fistula  the  first  thing  to  do  is  to  cure  the 
stricture  by  dilatation,  if  possible.  In  some  cases  the  fistula  will 
then  close  of  its  own  accord.  But,  unfortunately,  this  does  not 
usually  happen.  In  the  case  of  perineal  fistulre  it  is  generally 
necessary  to  do  an  external  urethrotomy  in  the  manner  already 
described,  and  to  cut' out  the  fistulous  tract  at  the  time  of  the 
operation. 

The  repair  of  a  penile  fistula  is  undertaken  as  follows.  The  edges 
of  the  skin  are  freed  all  round  the  fistula,  and  the  excess  of  granu- 
lation tissue  cut  away.  The  edges  of  the  orifice  of  the  urethra 
should  then  be  brought  together  with  fine  catgut  sutures,  so  that 
the  line  of  sutures  is  at  right  angles  to  the  axis  of  the  urethra. 
The  edges  of  the  skin  are  united  over  this  with  horsehair  or  fine 
silkworm  gut.  It  is  advisable  to  keep  a  catheter  in  the  urethra  for 
a  day  or  two. 

IVOR  BACK. 


§95 


PERI-URETHRAL   ABSCESS. 

AN  abscess  in  the  cellular  tissues  of  the  perineum  may  be  the 
direct  result  of  laceration  or  disease  of  the  urethra,  and  will  require, 
in  many  cases,  an  external  urethrotomy  for  its  proper  treatment ; 
but  there  are  other  conditions  which  may  produce  the  same 
formation  without  any  appreciable  breach  of  continuity  in  the 
urethra  which  necessitates  its  section. 

The  common  causes  are  as  follows  : 

(1)  Gonorrhoea,  producing  suppuration  in  the  glands  of  Cowper, 
or  local  follicular  abscesses,  which  may  track  along  the  perineum, 
and  are  important  in  that  they  may  be  a  cause  of  retention  of 
urine. 

They  are  treated  by  free  incision,  without  any  interference  with 
the  urethra,  beyond  that  which  may  be  required  for  the  treatment 
of  the  gonorrhoea. 

(2)  Prostatic  abscess,  either  from  acute  gonorrhoeal  infections  or 
infections  subsequent  to  the  formation  of  calculi,  may  point  down 
in  the  perineum   and   form   a   peri-urethral   abscess.      It  is  also 
treated  by  perineal  incision ;  and  it  is  not  necessary  to  encroach  on 
the  urethra,  the  walls  of  which  occasionally  remain  intact  across  a 
prostatic  abscess  cavity. 

(3)  Infection  of  a  perineal  haematoma.     This  has  been  considered 
already.     Free  incision  alone  is  necessary. 

(4)  Peri-urethral    abscess   from    stricture   or   laceration   of   the 
urethra. 

Peri-urethral  abscess  from  stricture  may  be  of  very  slow  develop- 
ment, and  is  easily  overlooked.  There  may  be  no  marked  urinary 
obstruction,  but  the  abscess  arises  from  a  process  of  infection  and 
softening  behind  a  stricture  of  long  standing.  The  urine  may  be 
perfectly  clear  and  free  from  pus  and  albumen. 

At  first  a  peri-urethral  abscess  occurs  as  a  hard,  indurated  nodule 
in  the  line  of  the  urethra.  There  is  no  redness,  fluctuation  cannot 
be  obtained,  and  tenderness  may  not  be  marked.  It  spreads,  and 
gradually  the  whole  perineal  region,  together  with  the  scrotum, 
becomes  osdematous,  and  finally  as  the  pus  approaches  the  surface 
the  skin  becomes  reddened.  If  neglected  the  process  may  spread  as 
an  extravasation  along  the  planes  of  cellular  tissue,  reaching  even 
as  high  as  the  axilla. 


896  Peri-Urethral  Abscess. 

A  free  incision  should  be  made  into  the  abscess,  the  contents  of 
which  are  exceedingly  foul,  a  finger  should  be  introduced  to  break 
down  the  partitions  of  the  various  loculi,  and  free  drainage  should 
be  provided.  Fomentations  and  boracic  baths  are  necessary 
to  diminish  the  fcetor.  There  is  no  need  to  interfere  with  the 
urethra  at  this  juncture,  unless  the  urine  is  very  foul.  Many  of 
these  cases  heal  readily  and  well,  and  the  stricture  can  be  dealt 
with  by  subsequent  dilatation.  If  the  urethra  is  opened  into  this 
septic  cavity,  acute  infection  may  spread  to  the  bladder. 

If,  on  the  other  hand,  the  bladder  is  already  infected,  and  the 
urine  foul  and  ammoniacal,  external  urethrotomy  should  be  per- 
formed, and  the  stricture  should  be  incised.  A  metal  perineal 
tube  should  be  introduced  into  the  bladder  along  the  urethra  from 
the  wound  ;  the  organ  should  be  drained  until  it  recovers  ;  urethral 
drainage  by  means  of  a  catheter  passed  along  the  whole  canal 
from  the  meatus  is  inadequate  in  a  bad  case.  As  soon  as  the 
wound  has  begun  to  granulate  healthily,  and  the  cystitis  has  cleared 
up,  the  perineal  tube  should  be  left  out,  and  instruments  should 
be  passed  daily  along  the  urethra,  to  preserve  its  calibre  and  to 
accelerate  healing  of  the  perineal  wound.  A  gum-elastic  instrument 
may  be  tied  in  for  twenty-four  to  forty- eight  hours,  to  facilitate  the 
process  of  healing  in  the  later  stages.  So  long  as  any  stricture  is 
left  in  such  a  case  the  perineal  wound  will  fail  to  close.. 

Peri-urethral  abscess  from  laceration  usually  develops  more  rapidly, 
but  it  requires  the  same  treatment.  At  an  early  stage  it  may  be 
feasible  to  identify  and  suture  the  torn  ends  of  the  urethra,  but 
such  a  proceeding  is  rarety  successful  in  the  presence  of  suppuration. 
Drainage  of  the  bladder  will  not  be  required,  and  is  even  likely  to  be 
injurious;  but  instruments  should  be  passed  daily  per  urctltrnni  as 
soon  as  the  abscess  cavity  has  become  healthy. 

IVOR  BACK. 


89y 


CHRONIC  URETHRITIS  (GLEET). 

BEFORE  commencing  the  treatment  of  any  case  of  gleet  it  is 
essential  to  discover  whether  the  discharge  is  coming  from  the 
anterior  or  posterior  part  of  the  urethra  or  from  both.  To  ascertain 
this,  the  anterior  urethra  must  be  freely  irrigated  with  cold  boiled 
water  :  cold  fluid  is  used  in  preference  to  warm,  since  the  latter  may 
cause  relaxation  of  the  compressor  and  permit  the  fluid  to  enter 
and  cleanse  the  posterior  urethra.  The  washings  from  the  anterior 
urethra  should  be  carefully  inspected  for  shreds  or  epithelial  debris. 
The  patient  is  then  told  to  pass  his  water  :  clear  urine  indicates 
that  the  anterior  urethra  alone  is  affected ;  cloudy  urine  which  does 
not  clear  with  acetic  acid  shows  that  the  posterior  urethra  is 
affected ;  the  presence  of  prostatic  threads  indicates  a  prostatic 
infection.  This  method  is  to  be  preferred  to  the  old  "  two-glass  " 
method,  which  is  fallacious. 

When  chronic  anterior  urethritis  is  present,  the  penis  should 
be  examined  for  a  constriction  of  the  external  meatus,  since 
this  is  a  fairly  common  cause  of  persistent  discharge,  the  purulent 
secretion  being  dammed  up  behind  the  meatus  and  causing 
chronic  inflammation  or  ulceration  of  the  fossa  navicularis.  If  a 
contracted  meatus  is  found,  it  should  be  dilated  by  the  passage  of 
graduated  straight  bougies  until  a  No.  14  English  passes  easily. 
For  the  same  reasons  a  gleet  associated  with  a  stricture  demands 
immediate  treatment  of  the  stricture,  preferably  by  the  method  of 
intermittent  dilatation. 

Next,  the  urethra  itself  must  be  examined  :  this  is  best  done  by 
some  form  of  urethroscope,  preferably  of  a  pattern  allowing  of  the 
inflation  of  the  urethra  with  air,  since  by  this  means  the  folds  of 
the  mucous  membrane  are  obliterated.  In  using  the  urethroscope 
the  tube  used  should  be  the  largest  which  can  be  passed  without  diffi- 
culty, and  it  should  be  passed  at  once  as  far  into  the  urethra  as 
possible ;  any  fluid  present,  e.g.,  lubricant  or  urine,  is  then 
carefully  removed  by  means  of  cotton-wool  swabs  securely 
mounted  on  long  holders.  After  adjusting  the  lamp  to  the 
tube  the  urethra  is  gently  inflated  with  air  and  examined  from 
behind  forwards  by  slowly  withdrawing  the  tube.  The  special 
points  to  be  looked  for  are  the  presence  of  infected  follicles,  patches 
of  ulceration  or  evidence  of  submucous  infiltration.  If  no  urethro- 
scope is  available  the  passage  of  an  acorn-headed  bougie  will  often 

S.T. — VOL.  u.  57 


898  Chronic  Urethritis  (Gleet). 

give  valuable  information,  the  patient  complaining  of  pain  when 
the  head  of  the  bougie  passes  any  ulcerated  area.  If  definite 
granular  patches  are  seen  they  may  be  treated  locally  by  the 
application  through  the  urethroscope  tube  of  20  per  cent,  silver 
nitrate  solution  on  a  wool  swab.  Frequently  the  granular  patches 
are  multiple  ;  if  this  is  so,  or  if  no  urethroscope  is  available,  the 
anterior  urethra  should  be  dilated  by  the  passage  of  straight  steel 
bougies  or  by  a  Kollrnann's  anterior  urethra  dilator,  which  consists 
of  a  straight  sound,  the  shaft  of  which  can  be  made  to  expand  by 
turning  a  handle  at  the  end.  After  dilatation  the  urethra  should 
be  irrigated  with  one  of  the  following  solutions :  5  per  cent, 
argyrol,  3  per  cent,  protargol,  or  silver  nitrate  10  gr.  to  1  pint  of 
distilled  water.  Irrigation  may  be  carried  out  with  a  back-flow 
catheter  attached  to  a  4-oz.  syringe,  or,  better  still,  with  a  glass 
urethral  nozzle  (Wyndham  Powell's  or  Janet's)  connected  to  a  glass 
tank  containing  the  solution.  This  treatment  should  be  carried 
out  once  or  twice  a  week  according  to  the  severity  of  the  case. 

If,  however,  the  discharge  does  not  entirely  disappear,  the  applica- 
tion of  stronger  silver  solutions  (such  as  protargol,  10  to  15  per  cent. ; 
argyrol,  up  to  20  per  cent. ;  or  silver  nitrate,  5  to  8  gr.  to  1  oz.)  by 
means  of  the  back-flow  catheter  and  syringe  should  be  tried.  This 
must  only  be  done  by  the  surgeon,  never  by  the  patient  himself. 
If  the  strong  solutions  are  used,  the  patient  must  be  warned  that 
lor  a  day  or  two  after  the  injection  the  discharge  will  be  more 
profuse. 

In  the  interval  between  the  injections  the  patient  should  be 
instructed  to  use  a  weak  injection  of  £  per  cent,  argyrol ;  but  these 
injections  must  be  suspended  for  a  day  or  so  after  the  use  of  the 
stronger  injections  described  above,  and  it  must  be  remembered 
that  the  constant  use  of  irritating  injections  may  in  itself  be  a 
cause  of  persistent  discharge  from  irritation. 

The  time  necessary  for  a  cure  depends  to  a  large  degree  on  the 
duration  of  the  original  discharge  ;  but  treatment  on  these  lines  will 
usually  succeed,  if  patiently  persisted  in. 

The  treatment  of  a  gleet  due  to  an  affection  of  the  posterior 
urethra  depends  largely  on  whether  the  prostate  is  also  infected 
or  not.  When  there  is  no  evidence  of  any  prostatic  infection, 
simple  irrigation  is  the  best  form  of  treatment  to  adopt.  For 
irrigation  the  following  apparatus  is  required :  A  glass  urethral 
nozzle  (Maiocchi's,  the  best :  Wyndham  Powell's  or  Janet's),  a  tank 
to  hold  the  solution  (this  should  be  suspended  about  8  feet  from 
the  ground),  and  6  feet  of  rubber  tubing  with  a  tap  or  clip  to  con- 
nect the  tank  to  the  nozzle.  The  patient  must  first  pass  his  water, 


Chronic  Urethritis  (Gleet).  899 

the  glans  penis  be  cleansed  by  running  some  of  the  solution  over 
it,  and  the  anterior  urethra  then  thoroughly  irrigated.  The  nozzle 
of  the  irrigator  is  then  firmly  inserted  into  the  rneatus,  the  outflow 
orifice  being  closed,  if  the  Maiocchi  nozzle  is  used,  and  the  solution 
is  thus  allowed  to  flow  into  the  bladder.  Usually  there  is  no  diffi- 
culty in  passing  the  compressor,  but  if  there  is  much  spasm  a  few 
drops  of  2  per  cent,  novocaine  may  first  be  injected.  Three  irriga- 
tions of  about  §  pint  should  be  used  at  each  sitting,  the  patient 
emptying  his  bladder  after  each  irrigation.  The  following  solutions 
may  be  used :  Permanganate  of  potash,  1  in  5,000,  increasing  to 
1  in  2,000 ;  argyrol,  1  per  cent. ;  or  silver  nitrate,  2  gr.  to  1  pint. 
If  these  injections  do  not  succeed,  the  instillation  into  the 
posterior  urethra  of  silver  nitrate  (5  gr.  to  1  oz.)  by  means  of 
a  Guyon's  syringe  is  often  useful. 

When  there  is  definite  evidence  of  a  prostatic  infection  it  is 
necessary  to  remove  the  infected  secretion  of  the  prostate  as  far  as 
possible,  so  as  to  allow  the  irrigating  fluid  to  reach  the  infected 
area.  This  may  be  effected  in  the  following  ways  :  (1)  By  the 
passage  of  a  large  steel  sound ;  this  method  is  usually  valueless, 
since  no  sound  which  will  pass  the  external  meatus  is  large  enough 
to  dilate  the  prostatic  urethra :  (2)  by  the  use  of  Kollmann's 
posterior  urethral  dilator,  an  instrument  similar  to  the  anterior 
dilator,  except  that  it  is  curved  like  a  sound  and  has  the  dilating 
portion  at  the  curved  end  only :  (3)  by  massage  of  the  prostate 
per  rectum. 

The  latter  two  methods  are  of  the  most  value  if  used  in  combina- 
tion. Whichever  method  is  chosen,  the  dilatation  and  massage  is 
preceded  and  followed  by  irrigation  with  one  of  the  fluids  mentioned 
above.  A  small  quantity  of  the  solution  is  left  in  the  bladder  after 
the  first  irrigation  ;  this  is  passed  after  the  dilatation  or  massage, 
and  prevents  the  infected  secretions  being  carried  into  the  bladder. 
This  treatment  should  be  carried  out  once  or  twice  a  week,  the 
patient  taking  urotropine  or  some  other  urinary  antiseptic  in  the 
interval.  Deep  instillation  of  silver  nitrate  (5  gr.  to  1  oz.)  is 
also  useful,  the  Guyon  syringe  being  used  for  this  purpose. 

It  must  be  remembered  that  these  cases  are  extremely  chronic, 
and  that  long  and  persistent  treatment  is  necessary.  In  some  cases 
vaccines  are  useful,  a  stock  gonococcus  vaccine  being  used  if 
gonococci  are  present,  but,  as  is  often  the  case,  cannot  be  cultivated. 
Vaccines  prepared  from  any  other  organisms  found  in  the  discharge 
may  also  prove  valuable. 

C.  H.  S.  FRANKAU. 

57—2 


QOO 


DISEASES  AND  AFFECTIONS   OF  THE 
SCROTUM. 

Wounds  of  the  Scrotum  must  be  treated  on  ordinary  anti- 
septic lines,  and  sewn  up.  If,  however,  the  wound  becomes  septic, 
cellulitis  may  ensue,  and  owing  to  the  lax  condition  of  this  part  it 
is  apt  to  be  of  a  violent  nature.  The  whole  scrotum  may  become 
red  and  oedematous,  and  abscess  formation  may  occur.  In  such 
a  case  free  incisions  into  the  osdematous  area  are  demanded, 
followed  by  the  application  of  a  fomentation.  Weak  biniodide 
lotion  is  more  efficacious  than  boracic.  Most  often  the  inflamma- 
tion subsides,  but  occasionally,  especially  in  infants,  the  whole 
scrotum  may  slough  off. 

Haematoma  of  the  Scrotum  may  result  from  blows,  but  is 
more  commonly  post-operative.  It  is,  therefore,  exceedingly 
important  in  operations  in  this  region  to  see  that  every  bleeding 
point  has  been  ligatured  before  the  wound  is  sewn  up.  It  is  best 
treated  by  supporting  the  scrotum  in  the  manner  already  described, 
and  applying  lotio  plumbi  cum  opio.  It  may  take  some  weeks 
before  the  effusion  is  completely  absorbed,  and  until  this  happens 
the  patient  should  wear  a  suspender. 

Epithelioma  of  the  Scrotum  may  appear  in  the  form  of 
warty  growths  or  of  an  excavated  ulcer.  In  either  case  the  treat- 
ment is  the  same.  The  whole  of  the  affected  area  should  be  excised, 
the  line  of  the  incision  being  at  least  1  inch  from  the  edge  of  the 
growth.  Owing  to  the  nature  of  the  scrotal  skin  there  is  usually 
no  difficulty  in  getting  the  edges  together,  however  big  the  growth 
has  been.  The  inguinal  glands  on  both  sides  should  be  extirpated 
at  the  same  time. 

IVOR  BACK. 


901 


DISEASES    AND    AFFECTIONS    OF    THE 
TESTICLE. 

HERNIA   TESTIS. 

A  HERNIA  of  the  testis  may  result  from  a  penetrating  wound 
which  has  become  septic,  or  from  tuberculous  or  gummatous 
abscesses  which  have  involved  the  skin  of  the  scrotum  and 
made  their  way  to  the  surface.  In  order  that  an  operation 
may  be  successful  it  is  essential  that  any  septic  infection  must 
be  got  rid  of  first.  The  testis  should  therefore  be  dressed  with 
a  compress  of  biniodide  of  mercury  (1  in  4,000)  for  a  week  or 
more,  and  when  the  wound  is  comparatively  clean  an  operation 
may  be  undertaken.  An  elliptical  incision  should  be  made  in  the 
scrotum,  surrounding  the  hernia,  and  the  edges  freed.  The  whole 
of  the  diseased  area  should  then  be  cut  out,  and  the  edges  of  the 
tunica  albuginea  united  with  catgut  sutures.  The  wound  in  the 
scrotum  is  sewn  up  with  fine  silkworm  gut.  Before  undertaking 
such  an  operation  it  must,  of  course,  be  made  certain  that  the 
fungating  mass  which  protrudes  from  the  testis  is  not  an  outlying 
portion  of  malignant  disease  of  the  organ. 

IVOR   BACK. 


902 


IMPERFECT   DESCENT   OF   THE   TESTIS. 

THE  testis  may  be  retained  in  some  part  of  its  normal  descent 
(retained  testis)  or  it  may  be  in  a  completely  abnormal  position 
(ectopia  testis).  Arrests  in  the  normal  course  of  development  may 
be  subdivided  according  to  the  position  in  which  the  testis  lies. 
Thus  it  may  be  retained  in  the  abdominal  cavity,  in  which  it  may 
be  fixed,  or  float  freely  :  or  it  may  descend  as  far  as  the  internal 
abdominal  ring,  and  remain  there  without  entering  the  inguinal 
canal :  or,  again,  it  may  be  retained  actually  in  the  inguinal 
canal :  and,  lastly,  it  may  rest  in  a  position  under  the  skin,  at  the 
junction  of  the  scrotum  and  the  abdominal  wall. 

For  these  conditions  no  palliative  measures  are  of  any  avail. 
Reliance  on  the  application  of  a  special  truss,  designed  more  or  less 
in  the  shape  of  a  horseshoe,  so  that  the  testis  can  be  brought  down 
into  the  scrotum  and  retained  there  without  pressure  on  the  con- 
stituents of  the  cord,  is  not  to  be  advocated.  It  is  only  in  rare 
cases  that  a  retained  testis  can  be  thus  manipulated  into  the  scrotum, 
and  even  if  it  can,  the  apparatus  does  not  effect  a  cure,  for  as  soon 
as  the  truss  is  removed  the  testis  is  again  drawn  up.  In  fact,  it  is 
less  harmful  to  leave  things  as  they  are  than  to  employ  this  form 
of  truss,  the  use  of  which  has  been  known  to  cause  atrophy  of  the 
testis  from  pressure.  It  has  therefore  been  superseded  by  operative 
methods. 

The  operative  procedures  available  are :  (1)  Orchidopexy,  or 
fixing  the  testis  in  the  scrotum  ;  (2)  re-position  of  the  testis  in  the 
abdomen  ;  and  (3)  castration. 

If  the  testis  is  completely  retained  within  the  abdomen,  the  con- 
dition may  cause  no  pain  nor  inconvenience,  and  in  this  case  it  is 
wise  to  leave  things  as  they  are.  The  only  danger  in  doing  so  is 
that  if  an  acute  orchitis  supervenes  upon  an  attack  of  gonorrhoea, 
peritonitis  may  result ;  and  though  this  is  extremely  rare,  the 
patient  should  be  warned  of  the  danger  of  exposing  himself  to 
infection.  The  argument  that  the  retained  testis  is  more  liable  to 
malignant  disease  than  one  in  the  normal  situation,  and  should 
therefore  be  removed  at  all  costs,  is  not  convincing.  The  statistics 
of  malignant  disease  of  the  testicle  rest  upon  such  a  small  number 
of  cases  that  there  is  not  enough  evidence  to  justify  the  removal  of 
any  retained  testis  upon  this  suspicion. 


Imperfect  Descent  of  the  Testis.          903 

In  96  per  cent,  of  cases  of  retention  of  the  testis  there  is  co- 
existent a  congenital  hernia,  which  demands  a  radical  cure.  When 
the  parts  are  exposed  for  this,  a  decision  can  be  come  to  as  to  the 
most  suitable  method  of  dealing  with  the  testis. 

Orchidopexy  is  only  possible  if  the  testis  has  already  come  down 
as  far  as  the  external  abdominal  ring,  and  if  the  vas  is  long  enough 
to  permit  of  the  testis  being  brought  down  to  the  bottom  of  the 
scrotum. 

The  early  stages  of  the  operation  are  identical  with  those  of  the 
operation  for  the  radical  cure  of  an  inguinal  hernia.  As  soon  as 
the  testis  and  the  structures  of  the  cord  are  found  and  isolated,  the 
first  thing  to  do  is  to  separate  the  hernial  sac  and  ligature  it  at  its 
upper  extremity,  near  the  internal  abdominal  ring.  The  sac  is 
nearly  always  congenital  in  type,  and  its  lower  attachment  should 
be  cut  through  as  near  as  possible  to  the  testis.  It  is  not  necessary 
to  suture  the  remains  together  and  so  form  a  false  tunica  vaginalis. 
The  sac  should  then  be  removed.  Now  comes  the  all-important 
question  :  are  the  structures  of  the  cord  long  enough  to  allow  the 
testis  to  come  down  into  the  scrotum?  Ee-position  of  the  testis  in 
the  scrotum  is  rarely,  if  ever,  resisted  by  shortness  of  the  vas 
itself.  It  is  the  vessels  of  the  cord  which  cause  the  trouble.  But 
these  may  safely  be  cut  without  any  fear  that  the  testis  will  have  an 
insufficient  blood-supply ;  the  vessels  which  surround  the  vas  itself 
will  be  quite  adequate  to  carry  on  its  circulation. 

Another  difficulty  is  due  to  the  fact  that  the  corresponding  half  of 
the  scrotum  is  ill-developed,  and  often  incapable  of  accommodating 
a  testis  to  whose  presence  it  has  been  unaccustomed.  A  bed  for  the 
testis  must  therefore  be  made  by  thrusting  the  index  finger  through 
from  the  wound  down  into  the  bottom  of  the  scrotum.  This  gives 
sufficient  room  for  the  testis  to  be  inserted,  but  it  will  not  remain 
there  unless  some  method  of  mechanically  fixing  it  in  its  new  posi- 
tion be  employed.  This  may  be  done  by  passing  silk  sutures 
through  the  tunica  albuginea  and  through  the  scrotum,  and  then 
either  fixing  them  to  the  skin  of  the  thigh,  or  to  a  wire  frame  which 
has  been  specially  devised  by  Sir  Watson  Cheyne  to  fit  the  front  of 
the  thigh,  and  which  is  incorporated  in  the  dressings.  The  sutures 
may  be  removed  after  about  twenty  days,  when  it  will  be  found 
that  there  is  no  immediate  tendency  on  the  part  of  the  testis  to 
retract.  Some  authorities  say  that  the  testis  may  begin  to  undergo 
development  in  its  new  surroundings,  while  others  assert  that  the 
manipulation  required  to  bring  the  testis  down  into  the  scrotum 
may  determine  the  onset  of  degenerative  changes. 

I  am  so  convinced  of  the  unsatisfactory  nature  of  the  late  results 


904          Imperfect  Descent  of  the  Testis. 

of  orchidopexy  that  I  have  adopted  the  following  practice  as  a 
routine  when  I  have  performed  an  operation  for  the  radical  cure  of 
the  congenital  hernia. 

If  the  testis  has  descended  through  the  external  abdominal  ring, 
it  is  best  left  alone ;  but  if  it  lies  in  the  inguinal  canal  or  against 
the  internal  abdominal  ring,  I  replace  it  in  the  abdomen  and  close 
the  abdominal  ring.  The  testicle  is  pushed  well  into  the  abdomen, 
so  that  it  lies  retro-peritoneally  upon  the  iliacus  muscle  at  some 
distance  from  the  internal  abdominal  ring.  The  inguinal  canal 
is  then  closed  with  kangaroo-tendon  sutures.  I  have  not  yet  seen  a 
case  of  peritonitis  arising  from  inflammation  in  a  testicle  so 
replaced,  though  I  am  aware,  as  has  been  already  mentioned,  that 
such  a  complication  has  been  recorded.  But  the  risk  must  be  an 
exceedingly  small  one. 

The  testicle  should  on  no  account  be  removed  entirely  unless  it 
is  obviously  diseased.  The  fact  that  it  is  atrophic  and  apparently 
functionless  is  not  a  sufficient  indication.  Such  testes  have  before 
now  been  removed,  and  have  been  proved  on  histological  examina- 
tion to  have  been  capable  of  producing  active  spermatozoa, 
and  further,  a  testis  which  is  genitally  functionless  produces  a  very 
important  internal  secretion.  If,  however,  the  testis  is  obviously 
diseased,  e.g.,  if  it  is  the  seat  of  carcinoma  or  of  tuberculosis,  or  if 
it  is  becoming  gangrenous  from  acute  torsion  of  the  cord,  there 
should,  of  course,  be  no  hesitation  in  performing  castration 
forthwith. 

If,  as  not  infrequently  is  the  case,  the  condition  is  bilateral,  it  is 
still  more  difficult  to  decide  on  the  best  line  of  treatment.  In  such 
cases  it  is  usually  best  to  do  nothing  ;  but  should  an  operation  be 
demanded  by  any  of  the  complications  already  mentioned,  one  side 
only  should  be  done  in  the  first  instance,  and  a  long  interval 
allowed  to  elapse  before  the  second  testis  is  submitted  to  surgical 
interference ;  and  then  this  must  only  be  done  if  the  result  of  the 
first  operation  proves  satisfactory. 

The  operation  should  be  done  for  preference  between  the  sixth 
and  tenth  years.  Before  this  it  is  difficult  to  perform  a  satisfac- 
tory radical  cure,  and  after  puberty  orchidopexy  is  rendered  difficult 
by  the  retraction  of  the  cord  and  re-position  in  the  abdomen  by  the 
size  of  the  testis. 

In  Ectopia  the  testis  may  be  found  in  the  perineum  behind  the 
scrotum,  in  the  pubic  region  at  the  base  of  the  penis,  or  below 
Poupart's  ligament,  having  passed  through  the  crural  canal.  The 
decision  as  to  whether  any  operation  shall  be  performed  in  these 
cases  must  be  influenced  by  the  liability  of  the  testicle  to  injury  in 


Imperfect  Descent  of  the  Testis.          905 

its  abnormal  position,  and  by  the  condition  of  the  one  on  the 
opposite  side.  If  there  be  a  history,  of  pain  and  attacks  of  inflam- 
mation in  the  ectopic  testicle,  castration  should  be  performed,  and 
in  the  case  of  femoral  ectopia  a  radical  cure  done  if  a  femoral 
hernia  co-exists.  But  in  the  absence  of  any  definite  symptoms  it 
is  better  to  leave  these  cases  alone. 

To  sum  up,  the  principal  argument  in  favour  of  performing 
an  operation  in  these  cases  is,  that  the  congenital  hernia  which 
nearly  always  co-exists  can  be  subjected  to  a  radical  cure.  In  my 
opinion,  the  procedure  which  will  generally  give  the  most  satisfac- 
tory results  is  to  replace  the  testicle  within  the  abdomen.  I  am 
not  in  favour  of  orchidopexy  as  a  routine  operation,  for  the  reasons 
which  have  already  been  put  forward,  and  castration  is  only 
indicated  by  some  secondary  change  in  the  testicle  in  its  abnormal 
position. 

IVOR   BACK. 


906 


INFLAMMATION    OF   THE   TESTIS. 

Acute  Orchitis  and  Epididymitis  will  be  considered  together, 
since  one  rarely  occurs  absolutely  independently  of  the  other.  In 
the  great  majority  of  cases  this  condition  results  from  gonorrhrea 
(see  under  Gonorrhea).  But  it  may  also  result  from  the  passage 
of  an  instrument  which  is  not  aseptic,  or  in  acute  infective 
diseases,  such  as  mumps  and  typhoid,  or  an  infection  may  spread 
from  small  abscesses  round  prostatic  calculi. 

The  treatment  is  somewhat  similar  to  that  of  traumatic  orchitis, 
already  mentioned.  The  patient  must  be  put  to  bed,  the  scrotum 
elevated,  and  lotio  plumbi  cum  opio  applied  to  it.  Adequate 
purgation  is  extremely  important.  In  severe  cases,  with  extreme 
enlargement,  venesection  may  be  necessary.  Leeches  should  not 
be  applied  to  the  scrotum,  because  the  wounds  which  they  produce 
do  not  heal  readily.  It  is  better  to  open  one  or  more  vessels  with  a 
scalpel.  In  a  favourable  case  the  inflammation  will  subside  in  a 
week  or  ten  days.  The  scrotum  should  be  supported  in  a  suspender 
for  another  fortnight,  and  then,  if  resolution  is  not  complete, 
strapping  may  be  resorted  to.  In  other  cases  the  disease  does 
not  pursue  such  a  favourable  course.  Abscess  formation  may 
occur,  as  evidenced  by  the  appearance  of  a  soft  fluctuating  area 
at  some  spot  in  the  testicle  or  epididymis.  This  must  be  imme- 
diately incised  and  its  contents  evacuated,  and  a  fomentation 
applied.  More  rarely  the  whole  organ  becomes  the  seat  of 
multiple  abscesses,  and  in  this  case  the  testicle  must  be  removed. 

IVOR   BACK. 


9oy 


INJURIES   OF   THE   TESTIS. 

THE  testis,  from  its  position,  is  peculiarly  liable  to  blows, 
squeezes  and  contusions.  These,  if  severe,  give  rise  to  sickening 
pain,  and  after  a  time  the  whole  organ  becomes  enlarged  and 
inflamed.  The  patient  must  be  put  to  bed,  and  the  scrotum 
elevated  on  a  pad  which  is  crescentic  in  shape  and  covered  with 
jaconet.  It  is  placed  under  the  scrotum  and  kept  in  position  by 
tapes,  which  come  from  either  angle  and  are  attached  to  a  bandage 
round  the  waist.  The  application  of  lotio  plumbi  cum  opio  fomenta- 
tions is  efficacious  and  soothing.  In  most  cases  the  inflammation 
will  subside  in  a  week  or  ten  days  under  this  treatment.  If  at  the 
end  of  this  time  the  testis  still  remains  somewhat  enlarged  and 
hard,  it  may  with  advantage  be  strapped  for  another  week  or  two. 

Penetrating  Wounds  of  the  testis  should  be  sewn  up,  with  the 
usual  antiseptic  precautions.  As  a  rule  they  heal  readily. 

IVOR    BACK. 


SYPHILITIC    DISEASE    OF   THE   TESTIS. 

SYPHILIS  may  attack  the  testis  in  the  secondary  stage,  causing 
an  enlargement  of  the  epididymis,  with  a  concomitant  hydrocele. 
But  this  is  uncommon.  Tertiary  syphilitic  disease  of  the  testis,  on 
the  other  hand,  is  frequently  met  with.  It  should  be  treated 
with  the  usual  anti-syphilitic  remedies.  Surgical  interference  is 
only  required  when  a  small  gummatous  abscess  makes  its  way  to 
the  surface  and  causes  a  hernia  testis.  (See  Hernia  Testis.) 

IVOR    BACK. 


TORSION   OF   THE   TESTIS. 

i 

THIS  condition  occurs  as  a  result  of  acute  twisting  of  the  cord. 
In  a  remarkably  short  time  the  organ  undergoes  necrosis,  because 
it  is  completely  deprived  of  its  blood-supply.  Castration  is  almost 
always  necessary,  although  one  or  two  cases  have  been  recorded  in 
which  the  testis  has  survived  after  the  cord  has  been  untwisted  by 
operation.  This,  however,  can  only  be  done  if  the  condition  is  seen 
and  recognised  in  the  very  earliest  stages. 

IVOR    BACK. 


TUBERCULOUS   DISEASE    OF    THE   TESTIS. 

TUBEKCULOUS  disease  of  the  testis  may  be  divided  into  two 
varieties,  acute  and  chronic.  In  the  acute  form  the  course  of 
the  disease  is  extremely  rapid,  and  the  early  formation  of  abscess 
is  a  characteristic  sign.  The  accessory  organs,  the  vas  deferens 
and  the  vesiculae  seminales,  and  even  the  prostate,  are  attacked 
with  astonishing  rapidity.  As  soon  as  the  diagnosis  has  been 
definitely  made,  the  testis  should  be  removed  at  the  earliest 
possible  opportunity,  with  as  much  of  the  cord  as  is  possible. 
No  palliative  measures  hold  out  any  hope  of  success.  The 
very  nature  of  the  process  is  proof  that  the  patient  has  no  resist- 
ance to  the  tubercle  bacillus,  and  delay  will  only  result  in  the  whole 
genital  apparatus  becoming  progressively  involved.  In  the  chronic 
form  the  epididymis  is  first  attacked,  and  the  body  of  the  testis  is 
involved  later,  if  at  all.  On  examination  the  epididymis  will  be  felt 
to  be  hard  and  nodular,  and  the  organ  tender  on  pressure.  In  the 
earliest  stages  the  disease  may  be  cured  by  the  general  measures  with 
•which  we  combat  tuberculosis,  with  a  view  to  improving  the  resistance 
of  the  patient.  He  should  be  instructed  to  lead  a  quiet  life,  to  live  in 
the  fresh  air  as  much  as  possible,  and  to  take  a  generous  diet,  with 
an  excess  of  fatty  foods.  In  addition  to  this,  tuberculin  may  be 
administered,  starting  with  a  small  dose,  e.g.,  1  /40,000th  of  a  milli- 
gramme of  tuberculin  (T.K.).  If  the  patient  improves  after  the  first 
dose,  it  may  be  increased  in  a  fortnight  to  l/20,000th,  and  so  on 
until  that  dose  is  experimentally  found  which  produces  in  him  the 
most  beneficial  effect.  Under  this  treatment  some  cases  undergo 
spontaneous  resolution  ;  but  if  in  spite  of  it  the  testis  and  epididymis 
become  progressively  larger,  some  form  of  operative  treatment  must 
be  undertaken,  and  the  question  arises  as  to  whether  the  testis 
itself  can  be  saved.  It  is  extremely  important  to  do  this  whenever 
it  is  possible,  because  the  testis  is  the  source  of  an  internal  secretion 
which  is  of  value  to  the  individual.  If,  therefore,  the  epididymis  alone 
is  involved  and  there  is  no  evidence  of  a  central  abscess  in  the  body 
of  the  testis,  the  operation  of  epididymectomy  should  be  performed. 
An  incision  is  made  extending  from  the  inguinal  canal  on  the 
affected  side,  down  the  scrotum,  of  such  a  length  that  the  swollen 
organ  may  be  conveniently  delivered  through  it.  An  incision  is 
then  made  through  the  tunica  on  either  side  of  the  epididymis,  and 


Tuberculous  Disease  of  the  Testis.        909 

this  structure  carefully  separated  from  the  testis.  The  important 
point  in  the  operation  is  to  avoid  damage  to  the  vessels  which  lie 
on  the  inner  side  of  the  epididymis.  If  these  are  injured,  the  blood- 
supply  to  the  testis  will  be  interfered  with  and  necrosis  will  ensue 
necessitating  castration  later.  The  epididymis  is  separated  from 
the  testis  from  below,  starting  at  the  globus  minor,  and  it  is 
removed  with  as  much  of  the  vas  deferens  as  can  be  isolated.  At 
the  time  of  the  operation  the  body  of  the  testis  should  be  examined 
for  the  presence  of  any  tuberculous  foci.  To  facilitate  this, 
Mr.  Burghard  advocates  opening  the  testis  from  behind  for  one- 
third  of  its  depth.  If  it  is  not  diseased,  it  may  be  sewn  up  again, 
but  if  any  little  abscess  is  found  it  should  be  scraped  out.  In  this 
way  one  can  be  sure  that  one  has  removed  the  whole  of  the  tuber- 
culous disease.  In  a  fair  proportion  of  cases  this  procedure  results 
in  a  permanent  cure. 

If  the  body  of  the  testis  is  already  involved  and  is  the  seat  of  one 
or  more  abscesses,  the  outlook  is  not  so  hopeful.  But  unless  it  is 
hopelessly  disorganised  and  a  source  of  inconvenience  to  the 
patient,  it  should  not  even  then  be  removed,  but  the  abscess  or 
abscesses  opened  and  scraped  on  the  chance  that  after  the  removal 
of  the  main  foci  the  disease  will  subsequently  undergo  a  spon- 
taneous cure.  Unfortunately  it  is  necessary  to  admit  that  this 
rarely  occurs,  and  the  usual  termination  of  such  a  case  is  castra- 
tion. Castration  as  performed  for  tuberculous  disease  does  not 
differ  from  the  set  operation,  except  that  it  is  necessary  to  remove 
as  much  of  the  cord  and  vas  deferens  as  can  be  isolated.  If  a  high 
incision  is  made  over  the  inguinal  canal,  this  can  be  done  as  far 
up  as  the  internal  ring.  If  at  the  time  of  operation  an  abscess 
has  come  to  the  surface  and  involved  the  scrotum,  the  affected 
portion  of  this  must  be  included  in  the  incision  and  removed.  Some 
surgeons  have  advocated  an  even  more  radical  operation  by  means 
of  two  incisions,  scrotal  and  perineal,  through  which  the  whole  cord 
of  the  affected  side,  including  the  vesicula  seminalis,  can  be  taken 
away.  But  this  is  not  a  sound  surgical  procedure.  The  perineum 
should  only  be  opened  when  it  is  certain  that  there  is  a  definite 
tuberculous  abscess  in  the  vesicula  seminalis. 

IVOR   BACK. 


9io 


TUMOURS   OF   THE  TESTIS. 

Innocent  Growths  of  the  testis  are  rare.  The  only  one  which 
is  commonly  met  with  is  fibro- cystic  disease  (also  known  as 
adenoma  testis  and  cystic  sarcocele).  The  affected  organ  should 
be  removed,  because  the  growth  deprives  it  of  its  function,  and 
there  is  the  further  danger  that,  if  left,  the  disease  may 
become  malignant.  Carcinoma  and  sarcoma  occur  in  about 
equal  proportions.  Castration  should  be  performed  as  soon  as 
the  diagnosis  is  made,  but  even  then  the  outlook  is  extremely 
gloomy,  because  in  this  position  malignant  disease  is  peculiarly 
virulent,  and  the  lumbar  glands  are  involved  at  a  very  earl}' 
stage.  The  steps  of  the  operation  are  as  follows :  An  incision 
is  made  which  extends  from  the  upper  border  of  the  inguinal  canal 
to  a  point  half-way  down  the  scrotum.  The  testicle  is  delivered 
through  this.  In  order  to  make  the  diagnosis  absolute  it  is  as  well 
to  make  a  preliminary  incision  into  the  testis.  If  the  growth  is 
malignant,  a  large  Spencer  Wells  forceps  should  be  put  upon  the 
structures  of  the  cord  and  the  testis  removed  forthwith,  for  fear  of 
infecting  the  neighbouring  tissues.  All  the  structures  of  the  cord 
should  then  be  isolated  as  far  as  possible,  that  is  to  say,  as  far  as, 
or  possibly  beyond,  the  internal  abdominal  ring,  and  ligatured  and 
removed.  The  wound  is  then  sewn  up.  Mr.  Bland  Button  has 
published  an  account  of  an  operation  for  malignant  disease  of  the 
testis,  in  which  he  extirpated  the  glands  at  the  same  time  as  he 
removed  the  organ.  He  did  this  by  means  of  an  incision  through 
the  linea  semilunaris,  which  extended  from  the  costal  arch  to  the 
inguinal  canal,  and  the  infected  abdominal  and  lumbar  glands  were 
removed  by  stripping  up  the  whole  of  the  lateral  aspect  of  the 
peritoneum.  If  the  malignant  disease  has  invaded  the  scrotum  at 
any  point,  it  goes  without  saying  that  the  inguinal  glands  must  also 
be  thoroughly  extirpated. 

IVOR  BACK. 


IMPOTENCE. 

IMPOTENCE  may  be  due  to  physical  defects  in  the  organs  of 
generation,  may  be  symptomatic  of  other  morbid  conditions,  or 
may  be  of  nervous  origin,  so  that  three  varieties  of  impotence  are 
described,  viz.,  physical,  symptomatic  and  nervous  or  psychical. 

The  Physical  Causes  of  impotence  are  malformations  and  cur- 
vatures of  the  penis  ;  varix  of  the  dorsal  vein  of  the  penis ; 
cryptorchidism ;  atrophy  of  the  testes ;  large  inguinal  hernise, 
hydrocele  and  elephantiasis  scroti.  Some  of  these  conditions, 
such  as  congenital  malformations  of  the  penis  or  the  scrotal 
tumours,  will  yield  to  appropriate  surgical  measures  such  as  plastic 
operations,  radical  treatment  of  the  hernia  or  hydrocele,  or  removal 
of  the  affected  tissue  in  elephantiasis  scroti ;  but,  in  bilateral 
atrophy  of  the  testes  due  to  gonorrhoea,  syphilis  or  mumps, 
treatment  is  of  but  little  avail. 

Symptomatic  Impotence  may  be  caused  by  the  prolonged  use 
of  drugs,  such  as  bromide  or  iodide  of  potassium,  the  salicylates, 
conium,  opium,  morphia,  and  by  alcoholism  and  excessive  smoking  ; 
by  diseases  such  as  phthisis,  Bright's  disease  or  diabetes,  and  by 
injuries  to  the  brain  and  spinal  cord.  Here  the  treatment  must  be 
dependent  on  the  cause,  and  in  cases  of  the  drug  habit,  alcoholism 
or  tobacco  poisoning  the  condition  is  capable  of  great  improvement. 
Psychical  Impotence  is  caused  by  sexual  excesses,  by  per- 
verted sexual  impulses,  by  mental  shock  or  strain,  and  may  be 
associated  with  varicocele,  chronic  prostatitis,  prostatorrhoea  and 
spermatorrho3a,  all  of  which  are  accompanied  with  severe  mental 
depression  and  morbid  sensitiveness,  and  which  give  rise  to  the 
condition  known  as  sexual  neurasthenia. 

The  treatment  of  these  forms  of  impotence  is  one  of  the  most 
difficult  problems  the  practitioner  may  be  called  upon  to  face,  as 
these  patients  are  timid,  distrustful,  and  are  unable  to  detach  their 
thoughts  from  their  condition,  which  they  believe  to  be  incurable. 
The  first  object  is  to  obtain  the  confidence  of  the  patient  by  a 
sympathetic  manner  and  by  taking  a  friendly  interest  in  his  case, 
assuring  him  that  his  condition  is  susceptible  of  improvement  if 
not  of  complete  cure.  A  cold  morning  bath  and  cold  sponging  of 
the  perineum  and  scrotum  will  act  as  a  tonic  to  the  genital  organs, 
which  may  also  be  stimulated  by  electricity  in  the  form  of  the 
constant  current,  one  electrode  being  applied  to  the  lumbar  region 
of  the  spinal  column  and  the  other  to  the  perineum,  scrotum  and 


912  Impotence. 

dorsum  of  the  penis.  Efforts  should  be  made  to  distract  the 
attention  of  the  patient  from  his  sexual  disabilities  by  a  routine  of 
exercise  and  diversions  which  will  prevent  him  from  brooding  on 
his  condition.  His  diet  must  be  plain  and  nourishing,  the  last 
meal  should  be  taken  at  least  three  hours  before  going  to  bed,  and 
stimulants  must  be  administered  sparingly  and  with  discretion 
according  to  the  past  history  and  present  requirements  of  the 
individual.  To  prescribe  total  abstention  from  alcohol  to  those 
who  have  hitherto  been  accustomed  to  it  may  tend  to  increase  the 
mental  depression,  and  to  such  patients  a  strictly  limited  allowance 
of  mild  alcoholic  beverages,  such  as  hock,  moselle  or  claret,  may  be 
permitted  at  meal-times  ;  no  liquids  should  be  taken  after  the 
evening  meal,  as  an  accumulation  of  urine  in  the  bladder  at  night- 
time may  lead  to  excitation  of  the  sexual  organs  and  possibly  to 
nocturnal  emissions.  Constipation  and  the  consequent  straining 
during  defaecation  must  be  avoided,  since  that  condition  may  lead 
to  the  escape  of  some  seminal  or  prostatic  secretion,  the  presence  of 
which  is  calculated  further  to  distress  the  patient.  He  should  sleep 
on  a  hard  bed  and  be  covered  with  a  minimum  amount  of  bedclothes, 
and  if  there  is  a  tendency  to  nocturnal  emissions  he  should  be  in- 
structed to  empty  the  bladder  if  he  wakes  in  the  course  of  the  night. 
In  cases  of  sexual  hypochondriasis  due  to  chronic  prostatitis, 
prostatorrhoea,  spermatorrho3a,  incomplete  erection  and  premature 
ejaculation,  a  large  sound  should  be  passed  once  a  week,  and 
applications  of  solutions  of  nitrate  of  silver  (10  to  30  gr.  ad  33) 
should  be  made  to  the  prostatic  urethra ;  sexual  intercourse  and 
even  association  with  the  opposite  sex  should  be  prohibited.  In 
cases  in  which  the  genital  centre  of  the  spinal  cord  is  deemed  to  be 
in  an  irritable  condition,  sedatives,  such  as  bromide  of  potassium, 
hyoscyamus,  camphor,  conium,  hyoscine  and  the  liquid  extract  of 
salix  niger,  may  be  prescribed.  If  the  spinal  centre  has  been 
rendered  inactive,  either  by  prolonged  abstention  from  sexual 
intercourse  or  from  excesses  in  that  direction,  aphrodisiacal  drugs 
may  be  of  benefit,  e.g.,  phosphorus  in  pills  of  T£Q  to  J$  gr.,  or 
preparations  such  as  the  syrupus  glycerophosphatum  co.  or  the 
syrupus  hypophosphitum  co. ;  muiracethin  pills,  composed  of 
extract  of  muira-puama  wood  and  lecithin,  four  pills  to  be  taken 
daily  ;  sol.  yohimbine  hydrochlor.  (1  per  cent.  5  to  15  min.),  three 
times  a  day  ;  testicular  extracts,  such  as  spermin,  administered  by 
the  mouth  or  subcutaneously,  or  a  pill  such  as  the  following: 
^ .  Phosphori,  gr.  T^  ad  ^;  Extract.  Nucis  Voni.,  gr.  ^;  Ext. 
Damianae,  gr.  2  ;  Jit.  pit ;  t.d.s. 

).  ERNEST  LANE. 


DISEASES  AND  AFFECTIONS  OF  THE 
TUNICA  VAGINALIS. 

H^MATOCELE. 

THIS  is  an  effusion  of  blood  into  the  tunica  vaginalis.  Like 
a  hydrocele,  it  may  be  connected  with  disease  of  the  testis 
itself;  but  the  typical  hsematocele  is  independent  of  this,  and 
is  in  most  cases  the  direct  result  of  injury.  The  treatment  will 
depend  upon  whether  the  haematocele  is  recent  or  of  old  stand- 
ing. A  recent  haematocele  which  is  definitely  traumatic  in  origin 
should  be  treated  with  complete  rest,  suspension  of  the  scrotum, 
and  the  application  of  an  ice-bag  or  evaporating  lotion  to 
the  part.  The  following  evaporating  lotion  will  be  found  extremely 
efficacious :  Ammonium  Chloride,  1  oz. ;  Dilute  Acetic  Acid, 
2  drachms  ;  Rectified  Spirit,  2  oz. ;  Distilled  Water,  to  1  pint. 
If  the  swelling  is  not  absorbed,  a  small  incision  should  be  made 
and  the  blood  evacuated.  Rigid  asepsis  is  essential.  Nothing 
is  more  easily  infected  with  pathogenic  micro-organisms  than  a 
collection  of  effused  blood,  and  in  scrotal  cases  the  risk  is  doubly 
great.  In  old-standing  haematoceles  with  thick  walls  it  is  hopeless 
to  expect  a  cure  by  merely  incising  them  and  turning  out  the  con- 
tained blood-clot.  The  cavity  will  merely  refill.  Nothing  short  of 
complete  excision  of  the  whole  parietal  layer  of  the  tunica  vaginalis 
is  of  any  avail.  Great  care  must  be  taken  not  to  injure  the  vas. 
In  the  altered  condition  of  the  part  it  may  be  difficult  to  recognise. 
If  the  wall  is  calcareous,  as  sometimes  happens  in  cases  of  very 
long  standing,  it  is  probably  best  to  perform  castration,  since  the 
pressure  of  the  swelling  on  the  testis  has  probably  been  sufficient  to 
render  that  organ  functionless. 

IVOR  BACK. 


S.T. VOL.  II.  58 


9H 


HYDROCELE. 

BY  hydrocele  we  mean  a  collection  of  fluid  in  the  tunica 
vaginalis  itself,  or  in  a  sac  connected  with  it.  This  may  be 
associated  with  disease  of  the  testis  itself,  or  may  be  independent 
of  this,  the  so-called  idiopathic  hydrocele.  Of  the  latter  we 
recognise  four  varieties :  (1)  Vaginal  hydrocele  proper,  in  which 
the  tunica  vaginalis  alone  is  distended  with  fluid ;  (2)  congenital 
hydrocele,  in  which  the  tunica  vaginalis  contains  fluid,  but  the 
cavity  opens  at  its  upper  extremity  into  that  of  the  peritoneum ; 
(3)  infantile  hydrocele,  in  which  not  only  the  tunica  vaginalis,  but  the 
funicular  process  also  is  distended  with  fluid  ;  this  is  shut  off  from 
the  peritoneum  by  a  constriction  at  some  point  on  the  cord, 
generally  at  the  external  abdominal  ring ;  (4)  hydrocele  in  the 
tunica  of  a  retained  testis. 

The  treatment  is  either  palliative  or  radical. 

The  palliative  treatment  consists  of  periodically  removing  the 
contents  of  the  hydrocele  with  a  trocar  and  cannula.  After 
removal  of  the  fluid  the  hydrocele  refills  in  from  three  to  six 
months ;  and  for  this  reason,  and  because  operative  treatment 
gives  such  good  results,  tapping  is  falling  into  disuse.  Inasmuch, 
however,  as  there  are  patients  who  refuse  radical  treatment,  or 
whose  general  condition  centra-indicates  operation,  its  technique 
will  be  shortly  described. 

The  patient  should  be  seated  on  the  edge  of  a  chair  in  front  of 
the  surgeon,  who  himself  occupies  another  one.  A  hydrocele 
should  never  be  tapped  with  the  patient  in  the  standing  position ;  for 
two  reasons:  (1)  In  case,  as  sometimes  happens,  the  patient  faints  from 
the  pain  of  the  puncture ;  (2)  in  order  that  the  patient  shall  be  unable  to 
draw  himself  away  from  the  surgeon  when  he  feels  the  point  of  the 
trocar.  The  scrotum  should  be  grasped  with  the  left  hand,  and  the 
skin  over  it  made  tense,  while  the  right  hand  holds  the  trocar, 
the  end  of  the  right  index  finger  being  held  about  1  inch  from 
the  point,  to  prevent  the  instrument  being  pushed  in  too  far.  A 
position  on  the  surface  is  chosen  which  is  free  from  veins,  and  the 
trocar  is  pushed  in  rapidly,  in  a  direction  backwards  and  slightly 
upwards.  The  trocar  itself  is  now  withdrawn,  leaving  the  cannula 
in  position  ;  through  this  all  the  fluid  drains  away.  When  the 
hydrocele  is  quite  emptied  the  cannula  is  withdrawn,  and  the  site 


Hydrocele.  915 

of  the  puncture  covered  over  with  a  small  piece  of  gauze  and 
collodion.  The  scrotum  should  be  supported  for  a  day  or  two  with 
a  suspender  or  bandage.  Asepsis  is,  of  course,  essential ;  otherwise 
cellulitis  or  gangrene  of  the  scrotum  and  testis  may  result.  Another 
important  point  is  that  the  position  of  the  testis  must  be  accurately 
denned,  before  tapping,  by  means  of  trans-illumination.  It  some- 
times lies  in  front  of,  instead  of  behind,  the  hydrocele  as  in  a 
normal  case,  and  the  results  of  driving  the  trocar  into  the  testis  are 
sickening  pain,  and  possibly  the  supervention  of  a  hernia  testis. 
This  method  hardly  ever  leads  to  a  permanent  cure  of  a  hydrocele. 
Very  few  such  authentic  cases  have  been  recorded,  and  several 
modifications  have  therefore  been  devised  with  this  object.  The 
commonest  is  the  introduction  into  the  sac  of  the  hydrocele,  after 
the  removal  of  the  fluid  with  a  trocar  and  cannula,  of  an  irritant 
fluid,  which  causes  a  low  form  of  inflammation  of  the  sac  wall,  so 
that  its  surfaces  adhere  together.  The  fluids  generally  relied  on  to 
produce  this  result  are  iodine  or  carbolic  acid.  If  iodine  is  used,  the 
hydrocele  should  be  completely  emptied,  exactly  as  in  the  palliative 
operation,  but  before  the  cannula  is  withdrawn  from  2  to  4  drachms  of 
the  Edinburgh  tincture  of  iodine  [U.S. P.  1  of  iodine  in  16  of  alcohol] 
are  inserted  with  a  syringe.  The  scrotum  is  then  manipulated  so 
that  the  iodine  comes  into  contact  with  the  entire  tunica  vaginalis. 
After  this  about  half  the  iodine  is  allowed  to  escape,  the  cannula  is 
carefully  withdrawn,  and  gauze  and  collodion  applied.  The 
reaction  to  the  fluid  generally  occurs  in  a  few  hours,  and  it  is  well 
to  keep  the  patient  in  bed  with  the  scrotum  suspended  for  a  day  or 
two.  After  about  four  days  the  inflammation  begins  to  subside, 
and  the  patient  may  begin  to  walk  about ;  but  the  scrotum  should 
be  strapped  for  two  or  three  weeks.  At  the  end  of  this  time  the 
inflammation  should  have  subsided  completely.  Carbolic  acid  is 
employed  in  exactly  the  same  way.  From  |  to  1  drachm  of 
glycerine,  which  is  saturated  with  carbolic  acid,  is  injected. 
These  methods  must  never  be  used  in  hydroceles  in  infants.  In 
the  first  place,  the  hydrocele  is  nearly  always  of  the  congenital 
variety,  and  communicates  with  the  peritoneum,  although  the 
opening  may  be  so  small  that  the  fluid  cannot  be  reduced  by 
manipulation  (the  proof  of  this  is,  that  if  the  child  lies  up,  the 
hydrocele  often  disappears  temporarily) ;  and  secondly,  the  tissues 
are  unable  to  stand  strong  irritants,  as  are  those  of  adults,  and 
there  is  a  grave  danger  of  sloughing  of  the  whole  scrotum  if  they 
are  employed.  Hydrocele  in  an  infant  can  very  often  be  cured  by 
keeping  the  child  on  his  back  and  applying  an  evaporating  lotion. 
If  this  fails,  the  hydrocele  should  be  punctured  in  a  number  of 

58—2 


9i  6  Hydrocele. 

places  with  a  sterilised  needle,  so  that  the  fluid  can  run  away  into 
the  tissues  of  the  scrotum.  If  it  recurs,  recourse  should  be  had  to 
an  open  operation,  in  which  the  sac  of  the  hydrocele  is  dissected 
out  and  removed. 

Radical  Cure  by  Open  Operation. — The  ideal  form  of  treat- 
ment for  vaginal  hydrocele,  which  is  now  slowly  but  surely 
supplanting  all  other  methods,  is  the  removal  of  the  whole  parietal 
portion  of  the  tunica  vaginalis  by  open  operation.  A  small  incision 
is  made  over  the  external  abdominal  ring  of  the  corresponding  side, 
so  as  to  expose  the  upper  pole  of  the  hydrocele  by  pressing  it  up 
into  the  wound.  The  fluid  is  then  evacuated  with  a  trocar  and 
cannula.  The  testis  and  collapsed  hydrocele  can  now  be  delivered 
out  of  quite  a  small  wound.  The  sac  of  the  hydrocele  is  opened 
with  scissors,  and  the  whole  of  the  parietal  portion  removed  by 
cutting  it  round  half  an  inch  from  the  testis.  A  large  number  of 
small  vessels  bleed  in  the  cut  edge.  These  must  be  carefully 
tied,  it  being  very  important  that  all  haemorrhage  should  be  arrested 
before  the  testis  is  returned  to  the  scrotum.  If  this  precaution  is 
not  taken,  a  scrotal  hsematoma  may  easily  result.  It  is  impossible 
that  there  can  be  any  recurrence  after  this  operation,  because  the 
whole  secreting  wall  of  the  sac  is  removed.  It  is  much  preferable 
to  incising  the  tunica,  completely  inverting  it  round  the  testis,  and 
bringing  its  edges  together  with  catgut ;  or  to  partial  excision  of  the 
parietal  layer,  and  suture  of  the  portions  left,  so  that  a  new  tunica 
vaginalis  is  formed. 

The  radical  operation  which  has  just  been  described  is  applicable 
to  all  the  other  forms  of  idiopathic  hydrocele  which  have  been 
mentioned. 

The  treatment  of  hydrocele  as  it  occurs  in  connection  with 
with  disease  of  the  testis  itself  will  be  considered  under  the 
separate  headings  of  testicular  disease. 

IVOR  BACK. 


DISEASES   AND   AFFECTIONS  OF  THE  CORD. 

H^EMATOMA. 

H^MATOMA  of  the  cord  may  result  from  blows  or,  more  rarely, 
from  a  spasm  of  the  cremaster  muscle.  An  elongated  swelling  is 
found  in  the  position  of  the  cord,  which  is  usually  somewhat 
tender.  Resolution  commonly  occurs  as  the  result  of  rest  in  bed, 
and  the  application  of  an  evaporating  lotion.  Occasionally,  if  the 
condition  resists  this  treatment,  it  may  be  necessary  to  make 
a  small  incision  and  let  out  the  effused  blood. 

IVOR  BACK. 


ENCYSTED    HYDROCELE. 

ENCYSTED  hydrocele  of  the  cord  is  a  dilatation  of  a  portion  of 
the  processus  vaginalis.  which  does  not  communicate  either  with 
the  testis  or  with  the  peritoneal  cavity.  The  only  satisfactory 
treatment  is  to  make  an  incision  over  the  external  abdominal  ring, 
and  dissect  out  the  hydrocele  completely. 

IVOR  BACK. 


VARICOCELE. 

See  Affections  of  Veins,  Vol.  I.,  p.  1323. 


918 


DISEASES  AND  AFFECTIONS  OF  THE 
PROSTATE  GLAND. 

CALCULI  OF  THE  PROSTATE. 

STONES  in  the  substance  of  the  prostate  must  be  distinguished 
from  stones  in  the  prostatic  urethra. 

Multiple  small  calculi  are  of  extremely  common  occurrence  in 
adenomatous  prostates.  They  are  not  usually  found  deep  in 
the  substance  of  the  adenomatous  tumour,  but  most  frequently 
either  just  below  the  mucous  membrane  of  the  urethra  or  at  the 
periphery  of  the  gland.  As  a  rule  they  give  rise  to  very  little 
trouble,  and  are  commonly  only  detected  during  the  examination 
of  a  patient  with  symptoms  of  enlarged  prostate,  or  during  the 
operation  upon  such  a  case. 

These  stones  can  be  quite  easily  removed  through  a  median 
perineal  incision  made  upon  a  grooved  staff  in  the  urethra.  The 
staff  is  removed  and  the  finger  is  passed  into  the  prostatic  urethra. 
The  mucous  membrane  is  scratched  through  by  the  finger-nail, 
and  the  stones  removed  by  a  suitable  scoop  or  forceps,  their 
removal  being  assisted  by  a  finger  of  the  left  hand  in  the  rectum. 

A  large  soft  perineal  tube  should  be  inserted  and  tied  in  for  a 
few  days,  after  which  it  is  removed  and  a  catheter  is  passed  the 
whole  length  of  the  urethra,  and  tied  in  for  a  week  or  so  to 
facilitate  the  closure  of  the  perineal  incision. 

It  is  occasionally  necessary  to  remove  prostatic  calculi  when  of 
larger  size  through  the  same  incision  in  the  perineum  as  is  recom- 
mended for  prostatic  abscess  (vide  suprafto  avoid  undue  laceration 
of  the  urethra.  Such  large  stones  in  the  substance  of  the  prostate 
are  extremely  rare. 

Phosphatic  calculi  form  in  the  cavity  left  after  removal  of  an 
adenomatous  prostate.  This  subject  is  dealt  with  in  the  section 
devoted  to  Adenoma  of  the  Prostate  (see  p.  940). 

JOHN  PAR  DOE. 


919 


INJURIES  OF  THE  PROSTATE. 


INJURIES  of  the  prostate  may  be  inflicted  from  without  or 
from  within,  the  former  being  of  extremely  rare  occurrence,  the 
latter  taking  place  frequently. 

(1)  Injuries  from  without  may  be  caused  by  falls  upon  some 
sharp  object,  by  wounds  from  bullets,  and,  exceedingly  rarely, 
from  severe  injuries  to  the  pelvic  girdle  of  bones.     In  the  last- 
mentioned  cases  rupture  of  the  bladder  above,  or  of  the  urethra 
below  the  prostate  is  much  more  common,  but  the  writer  has 
seen  the  prostate  lacerated  by  sharp  fragments  of   bone  driven 
in  by  a  crushing  accident. 

Simple  contusions  and  blows  upon  the  perineum  do  not  directly 
injure  the  prostate,  though  they  may  start  an  inflammation  of  that 
organ,  causing  so  much  swelling  as  to  lead  to  retention  of  urine. 

(2)  Injuries  from  within  are  exceedingly  common  in  the  act 
of    passing   instruments    along    the    urethra   into    the    bladder, 
especially  when  the  prostate  is  much  enlarged,  and  particularly 
when  the  enlargement  takes  the  form  of  a  median  projection  from 
one  or  other  lateral  lobe. 

The  treatment  of  injuries  to  the  prostate  depends  upon 
the  severity  of  the  injury,  the  presence  or  absence  of  sepsis, 
and  the  amount  of  obstruction  to  micturition  which  may  result. 

In  the  simple  lacerations  and  contusions  nothing  more  is 
needed  than  rest  in  bed,  hot  hip-baths  and  the  administration  of 
such  urinary  antiseptics  as  urotropine,  helmitol,  cystamine,  and 
the  like,  to  minimise  the  risk  of  sepsis.  In  the  cases  of  injury 
involving  rupture  of  the  prostatic  urethra  or  bladder  the  treat- 
ment is  directed  to  secure  free  drainage  of  the  bladder  by  a  supra- 
pubic  cystostomy  and  the  insertion  of  drainage  tubes  by  the  side 
of  the  bladder  to  the  bottom  of  the  pelvis,  upon  exactly  the  same 
lines  as  are  adopted  for  the  treatment  of  extra-peritoneal  ruptures 
of  the  bladder. 

In  cases  in  which  the  injury  to  the  prostate  is  produced  by 
instrumentation  the  damage  is  usually  done  during  an  attempt 
to  pass  a  catheter,  and  the  treatment  is  generally  that  for  the 
relief  of  the  condition  for  which  the  catheter  was  passed.  In 
these  cases,  if  possible,  a  flexible  silk  web  or  gum-elastic  catheter 
should  be  passed  and  tied  in  ;  but  if  this  is  impossible  the  bladder 
should  be  opened  and  drained  above  the  pubes,  the  enlarged 
prostate  being  removed  at  once  or  at  a  subsequent  operation. 

JOHN  PARDOE. 


920 


ACUTE  PROSTATITIS. 

THE  most  common  cause  of  this  condition  is  infection  from 
without  by  the  gonococcus,  associated  with  a  purulent  urethritis. 
The  onset  of  this  condition  is  signalled  by  increasing  pain, 
difficulty  and  frequency  of  micturition,  with  a  feeling  of  tenesmus 
and  a  sensation  of  heaviness  and  weight  about  the  perineum  and 
rectum.  The  urethral  discharge  is  very  commonly  much 
diminished  at  the  onset  of  acute  prostatitis,  and  very  frequently 
the  urine  is  scanty  and  slightly  bloodstained.  There  is  little  or 
no  rise  of  temperature  unless  an  abscess  forms,  when  very  com- 
monly a  rigor  occurs  and  the  temperature  follows  the  course 
usual  in  the  case  of  acute  pus  formation  under  pressure. 

It  must  not  be  forgotten  that  acute  prostatitis  may  be  caused 
by  other  organisms  than  the  gonococcus.  It  is  not  uncommonly 
the  first  symptom  of  an  acute  infection  by  a  bacillus  of  the  colon 
group,  accompanied,  followed,  or  not  attended  by  a  purulent 
urethral  discharge.  No  opinion  should  therefore  be  expressed 
as  to  the  nature  of  the  disease  until  after  a  bacteriological  examina- 
tion has  been  made  of  any  pus  obtainable,  or  in  the  absence  of 
pus,  of  the  centrifuged  deposit  from  the  urine.  The  writer  has 
seen  several  cases  where  a  too  hasty  expression  of  opinion  has 
given  rise  to  doubts  of  the  patient's  chastity,  doubts  quite  unjus- 
tified as  the  cases  proved  to  be  acute  bacillus  coli  infections. 

Treatment. — In  the  earlier  stages  of  acute  prostatic  inflam- 
mation rest  in  bed  is  essential.  Hot  hip-baths  should  be  given 
twice  a  day,  and  it  is  often  exceedingly  comforting  to  the  patient 
to  employ  hot  lavage  of  the  rectum.  This  should  be  carried  out 
by  means  of  a  double  tube,  which  can  be  easily  extemporised  by 
using  two  Jacques'  rubber  catheters,  the  inlet  catheter  being  of 
No.  12  calibre  and  the  outlet  tube  of  No.  14  or  16  calibre. 
The  tubes  are  well  smeared  with  vaseline  and  gently  introduced 
into  the  rectum,  the  inlet  tube  being  introduced  about  5  or 
6  inches  and  the  outlet  tube  pushed  just  above  the  internal 
sphincter.  The  inlet  tube  is  attached  to  an  irrigator  tank  holding 
at  least  1  quart  suspended  about  1  foot  above  the  patient's  body, 
which  should  rest  upon  one  side,  the  buttocks  being  brought  close 
to  the  edge  of  the  bed,  the  outlet  tube  hangs  down  over  the 
edge  into  a  receiver.  By  means  of  a  suitable  clip  upon  the 


Acute  Prostatitis.  921 

irrigator  tube,  or  a  small  vulcanite  tap,  the  flow  can  be  regulated 
to  any  desired  speed.  The  fluid  should  be  kept  at  a  temperature 
of  105°  to  110°  F.,  and  the  flow  should  not  be  too  fast  or  con- 
traction of  the  rectum  will  result  and  the  tubes  will  be  forced  out. 
When  the  irrigation  is  over,  a  suppository  should  be  introduced 
of  the  f ollowing  formula  :  R^ .  Extracti  Conii,  gr.  1  ;  Extracti 
Belladonna,  gr.  | ;  Olei  Theobromatis,  q.s.  [U.S.P.,  ty.  Extracti 
Conii,  gr.  1  ;  Extracti  Belladonnae  Foliorum,  gr.  £  ;  Olei  Theo- 
bromatis, q.s.].  M.  ft.  supposit. 

The  bowels  must  be  regularly  emptied  by  the  use  of  simple 
laxatives.  If  pain  is  severe  it  may  be  relieved  and  sleep  induced 
by  the  use  of  suppositories  containing  from  |  to  |  gr.  of  morphia, 
added  to  the  ingredients  given  above.  The  more  popular  modern 
urinary  antiseptics  are  not  of  much  avail  in  this  condition,  but 
a  free  flow  of  urine  should  be  induced  by  means  of  diuretics  such 
as  acetate  of  ammonium,  spirit  of  nitrous  ether,  and  the  diuretic 
waters  of  Vichy,  Contrexeville  or  Vittel.  In  some  cases  sandal- 
wood  oil  proves  of  value  as  a  sedative  to  the  prostatic  mucous 
membrane  and  that  of  the  neck  of  the  bladder,  which  always  shares 
in  this  condition.  It  can  be  given  in  capsules,  but  is  much  more 
active  if  administered  in  the  form  of  an  emulsion  with  the  follow- 
ing formula  :  R.  Ol.  Santal.  Flav.  Puriss.,  T^IO  ;  Potass.  Bicarb., 
gr.  20  ;  Pulv.  Acaciae,  gr.  30 ;  Spt.  Menth.  Pip.,  111 3  ;  Aq.,  ad  ^j. 
Ft.  emuls.  Sig.  :  1  oz.  to  be  taken  three  or  four  times  a  day. 

Complete  retention  of  urine  may  occur  during  an  attack  of 
acute  prostatitis,  and  opinion  is  much  divided  as  to  the  use  of  the 
catheter  or  resort  to  supra-pubic  aspiration  of  the  bladder, 
especially  in  cases  due  to  gonococcal  infection.  The  objection 
that  is  urged  to  the  use  of  the  catheter  in  these  cases  is  the  risk 
of  introducing  gonococci  into  the  bladder  ;  but  when  it  is  under- 
stood that  in  these  cases  the  infection  invariably  reaches  the 
neck  of  the  bladder,  the  validity  of  this  objection  is  much 
diminished. 

The  writer  never  hesitates  to  use  a  flexible  catheter  after 
thoroughly  irrigating  the  bulbo-penile  urethra  with  a  solution  of 
permanganate  of  potassium  (1  in  5,000)  and  injecting  30  to  40 
minims  of  a  2  per  cent,  solution  of  novocaine.  When  the  bladder 
has  been  emptied  it  should  be  washed  out  with  a  weak  solution 
of  nitrate  of  silver  (1  in  5,000),  and  a  little  of  this  solution  should 
be  allowed  to  remain  after  the  catheter  is  withdrawn. 

Prostatic  Abscess. — If  the  abscess  does  not  rupture  into  the 
urethra  either  spontaneously  or  from  pressure  of  a  ringer  in  the 
rectum,  it  must  be  opened. 


922  Acute  Prostatitis. 

Two  warnings  must  be  given  :  Firstly,  the  abscess  should  never 
be  opened  from  the  rectum.  When  the  abscess  is  large  and 
projecting  backwards  it  is  exceedingly  tempting  and  very  easy 
to  pass  a  guarded  bistoury  or  a  trocar  into  the  abscess  through  the 
anterior  wall  of  the  rectum,  but  the  temptation  should  be  resisted, 
for  in  the  first  place  the  pus  often  re-accumulates,  and,  also, 
there  is  great  danger  of  a  chronic  and  persistent  recto-prostatic 
fistula  forming.  Secondly,  the  abscess  should  not  be  opened  by 
an  incision  into  the  urethra  as  for  median  or  lateral  lithotomy. 
It  is  quite  unnecessary  to  open  the  urethra,  and  by  so  doing 
convalescence  is  unnecessarily  protracted. 

The  Operation. — The  patient  is  placed  in  the  lithotomy  position, 
and  a  transverse  incision  1|  inches  in  length  is  made  half-way 
between  the  anus  and  the  bulb  of  the  urethra.  The  incision 
should  be  slightly  curved  with  the  convexity  towards  the  bulb. 
As  soon  as  the  skin  has  been  incised,  the  median  raphe  of 
the  perineum  is  exposed,  and  is  picked  up  in  forceps  and 
divided  by  a  snip  with  a  pair  of  scissors.  The  pre-rectal  fat 
bulges  immediately,  and  no  more  cutting  instruments  are  now 
required. 

The  forefinger  of  the  left  hand  is  passed  into  the  rectum  and 
touches  the  anterior  wall  over  the  abscess.  A  pair  of  long 
Spencer  Wells  sinus  forceps  is  now  pushed  through  the  wound 
into  the  fatty  space  in  front  of  the  rectum,  and  is  deliberately 
pushed  onwards  in  front  of  the  rectum,  guided  by  the  finger  in  that 
cavity,  until  the  capsule  of  the  prostate  is  reached.  The  resist- 
ance encountered  here  gives  way  suddenly  under  steady  pressure 
of  the  point  of  the  closed  forceps,  the  blades  are  widely  separated 
and  the  pus  escapes  along  them.  The  right  forefinger  is  then 
introduced  along  the  forceps  into  the  abscess  cavity,  and  all  septa 
and  bands  are  broken  down.  This  is  a  most  important  step  in  the 
operation,  as  these  abscesses  are  often  loculated,  and  if  the  septa 
are  not  broken  down,  convalescence  may  be  tedious.  A  rubber 
drainage  tube  is  introduced  alongside  the  forceps,  and  these  are 
now  withdrawn.  The  tube  is  stitched  to  the  edges  of  the  wound, 
which  is  closed  by  a  few  points  of  suture.  A  pad  of  gauze  and 
a  T  bandage  complete  the  operation. 

After  Treatment. — The  cavity  should  be  syringed  with  a 
solution  of  peroxide  of  hydrogen  in  water  (1  oz.  of  the  20  volume 
solution  of  hydrogen  peroxide  to  10  oz.  of  water)  once  a  day  for 
three  or  four  days.  The  tube  should  then  be  removed  and  the 
opening  allowed  to  close.  Complete  healing  usually  occurs  in 
from  ten  to  fourteen  days. 


Acute  Prostatitis.  923 

Recto-Urethral  Fistula. — Very  rarely  the  prostatic  abscess 
bursts  into  the  rectum  before  the  patient  is  brought  to  the 
surgeon,  or  the  abscess  is  improperly  opened  through  the  rectum. 
In  either  case  a  recto-prostatic  fistula  results,  which  may  be  slow 
in  healing  or  may  communicate  with  the  urethra. 

If  no  leakage  of  urine  into  the  rectum  takes  place,  the  sphincter 
should  be  dilated  as  for  an  operation  for  haemorrhoids.  A  bi-valve 
speculum  should  be  inserted,  the  opening  in  the  anterior  wall  of 
the  rectum  localised  and  thoroughly  scraped  with  a  sharp  spoon. 
The  cavity  should  be  swabbed  out  with  a  solution  of  chloride  of 
zinc  (20  gr.  to  1  oz.  of  water),  or  nitrate  of  silver  (20  to  30  gr.  to 
1  oz.),  and  packed  loosely  with  gauze. 

If  a  recto-urethral  fistula  of  long  standing  is  present,  the  opera- 
tion for  its  cure  may  prove  to  be  a  somewhat  delicate  and 
difficult  one. 

The  same  incision  is  made  in  the  perineum  as  for  opening  a 
prostatic  abscess.  A  solid  curved  staff  is  then  passed  along  the 
urethra  into  the  bladder,  and  held  in  position  by  an  assistant. 

The  incision  is  then  deepened  carefully  by  blunt  dissection, 
until  a  probe  can  be  felt  which  has  been  passed  from  the  rectum 
into  the  prostatic  urethra,  impinging  upon  the  metal  staff  in  that 
canal.  The  fistulous  track  is  then  divided  between  the  rectum 
and  the  prostate.  There  is  often  very  little  tissue  here  available 
for  splitting,  as  the  anterior  wall  of  the  rectum  is  firmly  adherent 
to  the  capsule  of  the  prostate.  After  the  division  has  been 
accomplished  a  hole  remains  in  the  anterior  wall  of  the  rectum 
which  must  be  closed  by  two  layers  of  catgut  sutures. 

The  prostatic  side  of  the  fistula  must  now  be  thoroughly  scraped 
with  a  sharp  spoon.  The  space  between  the  rectum  and  the 
prostate  is  lightly  packed  with  gauze,  the  metal  staff  is  with- 
drawn from  the  urethra,  and  a  silk  web  catheter  introduced  in  its 
place  and  tied  in  for  a  week  or  ten  days.  The  gauze  packing  is 
removed  after  forty -eight  hours  and  the  cavity  allowed  to  heal  by 
granulation. 

JOHN  PARDOE. 


924 


CHRONIC  PROSTATITIS. 

CHRONIC  inflammation  of  the  prostate  is  most  commonly  a 
sequel  of  acute  gonorrhoea,  in  which  the  infection  has  penetrated 
to  the  membrano-prostatic  urethra  and  thence  to  the  follicles  of 
the  prostate.  It  may  be  one  of  the  most  intractable  and 
obstinate  affections,  and  is  often  attended  by  a  mental  depression 
quite  out  of  proportion  to  the  gravity  of  the  symptoms. 

As  a  rule  but  little  physical  inconvenience  is  suffered  by  the 
patient  beyond  some  perineal  and  rectal  discomfort  off  and  on, 
occasional  discomfort  during  and  at  the  close  of  micturition,  and 
a  little  undue  frequency  of  desire  to  pass  urine. 

In  a  small  proportion  of  cases,  however,  the  pain  occasioned  by 
the  condition  is  more  severe,  affecting  the  sciatic  and  obturator 
nerves,  and  whilst  present  really  unfitting  the  patient  for  his 
usual  occupations. 

As  already  stated,  chronic  prostatitis  is  most  often  an  aftermath 
of  gonorrhoea.  The  gonococcus  does  sometimes  linger  in  the 
prostatic  follicles  for  months  and  even  years  after  the  acute 
attack  has  passed  away,  but  usually  the  infection  in  acute 
gonorrhoea  is  a  mixed  one,  a  variety  of  other  organisms  being 
found  in  the  discharge,  and  long  after  the  acute  stage  is  passed 
and  all  gonococci  have  disappeared  the  secondary  infection  may 
persist  and  remain'  the  cause  of  a  chronic  inflammation  of  the 
prostate. 

It  must  also  be  stated  most  definitely  that  chronic  prostatitis, 
with  its  usual  accompaniment  of  "  gleet,"  may  be  due  to  infection 
by  numerous  organisms  other  than  the  gonococcus  ab  initio. 
The  writer  has  met  with  various  kinds  of  staphylococcf,  strep- 
tococci, bacillus  pyocyaneus,  bacillus  faecalis,  and  various  members 
of  the  "  coliform  "  group  of  organisms  as  the  active  causes  of  a 
chronic  prostatitis. 

The  treatment  of  chronic  prostatitis  falls  more  naturally  to 
be  dealt  with  in  the  section  upon  diseases  of  the  urethra,  but 
certain  considerations  must  be  mentioned  here. 

The  mucous  membrane  of  the  prostatic  urethra  must  be  treated 
as  advised  in  the  section  dealing  with  chronic  posterior  urethritis. 

In  treating  infection  of  the  gland  substance  the  first  essential 
is  to  empty  the  follicles  of  their  infected  contents.  This  is 


Chronic   Prostatitis.  925 

effected  by  means  of  prostatic  massage,  with  the  patient  in  the 
knee-elbow  position.  At  the  first  two  or  three  sittings  the 
massage  must  be  done  with  gentleness,  but  gradually  more  pres- 
sure can  be  employed,  and  the  follicles  can  thus  be  emptied  quite 
thoroughly.  When  the  massage  is  completed,  the  urethra  should 
be  thoroughly  irrigated  by  means  of  Janet's  method  of  posterior 
irrigation.  This  is  given  in  the  following  way  : 

The  patient  is  placed  in  the  recumbent  position  with  the  legs 
apart  and  the  clothes  drawn  down  below  the  knees.  At  the  first 
two  or  three  sittings  it  is  well  to  inject  into  the  anterior  urethra 
by  means  of  a  small  syringe  a  4  to  5  per  cent,  solution  of  novo- 
caine.  Twenty  to  thirty  minims  is  sufficient.  This  solution  is 
"  stripped  "  down  into  the  bulb  by  milking  the  urethra  backwards, 
and  then  firm  backward  pressure  along  the  urethra  in  the  perineum 
forces  the  solution  into  the  membrano-prostatic  urethra.  By  this 
method  the  resistance  of  the  compressor  urethras  is  overcome  if 
the  solution  is  allowed  to  remain  for  four  or  five  minutes  before 
f  the  irrigation  is  commenced. 

An  irrigator  tank  containing  1  quart  of  solution  is  suspended 
5  or  6  feet  above  the  recumbent  patient.  The  tube  leading  from 
the  tank  is  fitted  with  a  suitable  urethral  nozzle  and  shield  to 
protect  patient  and  surgeon  from  splashing. 

The  meatus  is  blocked  by  the  conical  nozzle  and  the  solution 
allowed  to  gently  flow  into  the  urethra,  which  is  felt  to  balloon 
under  the  fingers  of  the  left  hand.  The  pressure  is  gradually 
increased  until  the  fluid  forces  the  compressor  urethras  and  passes 
into  the  bladder  (the  sphincter  offers  no  resistance),  a  thrill  being 
communicated  to  the  fingers  holding  the  penis.  When  the 
patient  feels  that  the  bladder  is  full,  he  is  allowed  to  stand  and 
pass  the  solution  into  a  receiver. 

By  this  method  the  whole  urethra  and  bladder  is  irrigated  under 
pressure  without  the  introduction  of  a  catheter. 

This  massage  and  irrigation  should  not  be  given  more  than 
once  in  every  three  days,  and  any  sign  of  irritation  should  be  taken 
as  a  signal  to  increase  the  intervals  between  treatments. 

A  variety  of  solutions  may  be  employed,  of  which  perhaps  the 
best  are  the  following  : 

Permanganate  of  potassium  (1  in  5,000  to  1  in  2,000)  ;  or 
nitrate  of  silver  (1  in  5,000  to  1  in  2,000)  ;  or  oxycyanide  of 
mercury  (1  in  10,000  to  1  in  2,000)  [this  must  be  used  with  caution, 
as  some  urethrse  are  very  intolerant  of  any  form  of  mercury] ;  or 
lysol  (5|  to  5J  to  Oj).  Protargol,  argyrol  and  other  silver  salts  find 
supporters,  but  it  is  unnecessary  to  enumerate  further  solutions. 


926  Chronic  Prostatitis. 

Great  assistance  is  sometimes  afforded  by  performing  the 
massage  upon  a  full-sized  metal  bougie,  or  better  still  a  Koll- 
mann's  or  Oberlander's  four  or  six-blade  prostatic  dilator.  This 
instrument  is  fitted  with  a  screw  handle  upon  which  is  a  dial 
registering  the  amount  of  dilatation  (on  the  Charriere  scale) 
which  is  being  employed.  The  blades  only  expand  in  the  deep 
urethra  when  the  instrument  is  in  position,  an  obvious  advantage 
when  large  dilatation  of  the  anterior  urethra  is  not  required. 

Vaccine  therapy  is  of  great  assistance  in  many  cases  of  chronic 
prostatitis.  If  the  gonococcus  is  present,  a  stock  gonococcus 
vaccine  should  be  combined  with  an  autogenous  vaccine  made 
from  cultures  of  the  patient's  own  bacteria. 

JOHN  PARDOE. 


GOUTY    PROSTATITIS. 

CONSIDERABLE  swelling  of  the  prostate  not  infrequently  com- 
plicates an  attack  of  gout,  but  we  have  not  seen  deposits  of  urate 
of  soda  in  the  substance  of  the  prostate  such  as  occur  in  joints, 
cartilages,  and  in  the  corpora  cavernosa  of  the  penis. 

The  treatment  of  such  swellings  follows  the  lines  of  general 
treatment  of  the  gout  and  of  acute  prostatitis. 

The  prostates  which  suffer  in  this  manner  are  almost  invariably 
adenomatous,  and  require  treatment  for  that  condition  sooner  or 
later. 

JOHN  PARDOE. 


927 


ONANITIC    PROSTATITIS. 

A  CLASS  of  case  which  should  be  better  recognised  than  it  is  at 
present  is  the  bulky  congestion  due  to  onanism  on  the  one  hand, 
and  excessive  sexual  intercourse  on  the  other. 

It  can  hardly  be  called  an  inflammation  of  the  gland,  as  it  is  not 
due  to  infection  by  micro-organisms. 

The  prostate  is  very  large,  tender  to  the  touch,  and  causes 
increased  and  much  too  easily  aroused  sexual  excitement,  thus 
leading  in  a  vicious  circle  to  the  very  cause  which  produced  it. 

Treatment  is  simple,  consisting  in  an  immediate  cessation  of 
the  causative  factors,  combined  with  a  very  simple  diet,  rest 
and  prohibition  of  alcohol. 

JOHN  PARDOE. 


SYPHILIS  OF  THE  PROSTATE. 

SYPHILIS  of  the  prostate  is  met  with  in  two  forms.  A  diffuse 
swelling  of  the  gland  is  sometimes  observed  in  the  secondary  stage 
of  acquired  syphilis.  The  symptoms  resemble  those  of  a  subacute 
prostatitis,  namely,  a  little  urgency,  frequency  and  discomfort 
on  micturating,  and  some  sensations  of  perineal  and  rectal  dis- 
comfort between  the  acts  of  passing  urine.  The  prostate  feels 
large  to  the  examining  finger,  and  is  a  little  tender  on  pressure. 
This  condition  quickly  yields  to  specific  treatment. 

Gumma  of  the  prostate  is  very  rare,  but  occurs  sufficiently 
often  to  make  it  a  recognisable  condition.  Fortunately  there  are 
tell-tale  signs  about  the  patient  as  a  rule  which  assist  the  diagnosis. 

All  the  cases  which  the  writer  has  seen  have  quickly  yielded  to 
treatment  by  iodide  of  potassium  and  mercury,  no  local  treatment 

being  required. 

JOHN  PARDOE. 


928 


TUBERCULOUS  PROSTATITIS. 

TUBERCULOSIS  of  the  prostate  is  almost  invariably  a  secondary 
infection  from  the  urinary  tract,  or  from  some  other  portion  of 
the  genital  tract.  The  latter  mode  of  origin  is  by  far  the  more 
common,  as  is  only  to  be  expected  from  a  consideration  of  the 
anatomical  relationship  of  the  vasa  deferentia,  common  ejacula- 
tory  ducts,  and  the  prostate.  The  strongest  argument  for  early 
extirpation  of  a  tuberculous  epididymis  is  the  rapidity  with  which 
infection  of  the  corresponding  vas  deferens,  seminal  vesicle  and 
prostate  takes  place. 

Infection  from  a  primarily  tuberculous  kidney,  ureter,  and 
bladder  is  much  more  uncommon,  but  it  undoubtedly  occurs  in 
some  few  cases  where  there  is  no  evidence  whatever  of'  tuber- 
culosis of  other  parts  of  the  genital  system.  Primary  tuberculosis 
of  the  prostate  is  exceedingly  rare. 

Treatment. — The  treatment  of  this  condition  is  usually  only 
a  part  of  the  general  treatment  applied  to  the  original  infection 
of  bladder,  kidneys,  or  epididymis. 

There  can  be  no  question  that  thorough  removal  of  the  source 
of  the  infection,  such  as  is  gained  by  castration,  or  in  less  severe 
cases  epididymectomy  with  vasectomy,  by  cutting  off  the  supply 
of  infective  material,  is  often  followed  by  a  cure  of  the  prostatic 
trouble.  In  the  same  way  the  removal  of  a  grossly  infected 
kidney  which  is  acting  as  the  source  and  fount  of  infection  of  the 
bladder  is  followed  by  a  remarkable  improvement,  if  not  cure  of 
the  vesical  and  prostatic  tuberculosis  secondary  to  it.  In  the 
writer's  opinion  active  surgical  interference  with  a  tuberculous 
prostate  should  be  limited  to  those  cases  where  caseous  masses 
have  broken  down  into  an  abscess  which  is  unable  to  discharge 
its  contents  by  way  of  the  urethra.  In  such  cases  the  abscess 
should  be  approached  from  the  perineum  by  the  same  transverse 
incision  as  has  been  recommended  for  acute  abscess  of  the  gland, 
but  with  more  deliberation,  a  careful  blunt  dissection  being  made 
up  to  the  capsule  of  the  prostate,  and  the  cavity  opened  and 
scraped  out  under  the  guidance  of  the  eye  and  not  of  touch  alone. 
On  no  consideration  should  the  urethra  be  opened  if  it  is  possible 
to  avoid  doing  so,  as  a  most  troublesome  and  persistent  fistula  is 
sure  to  result. 


Tuberculous  Prostatitis.  929 

The  general  treatment  of  such  cases  must  follow  the  lines  laid 
down  for  dealing  with  vesical  tuberculosis. 

As  already  indicated,  however,  these  tuberculous  abscesses 
are  usually  met  with  in  cases  of  advanced  general  tuberculosis 
of  the  genito-urinary  system,  and  surgical  treatment  is  palliative 
rather  than  curative. 

JOHN  PARDOE. 


S.T.— VOL.  II.  59 


930 


TUMOURS  OF  THE  PROSTATE. 

IT  will  tend  to  a  much  clearer  understanding  of  enlargement 
of  the  prostate  if  it  is  once  and  for  all  understood  that  this  condi- 
tion, setting  aside  inflammatory  changes,  is  always  due  to  some 
form  or  other  of  neoplasm.  The  old  term  "  hypertrophy  "  is  an 
absolute  misnomer,  for  the  writer  has  failed  to  find  a  single  in- 
stance of  true  hypertrophy  of  this  organ  in  an  examination  of 
many  hundreds  of  cases.  The  constituents  of  the  gland  are  never 
enlarged  each  in  their  relative  proportion  to  the  whole,  but  the 
enlargement  is  due  to  an  increase  either  of  the  epithelial  or  of 
the  connective  tissue  elements  at  the  expense  of  the  rest  of  the 
organ. 

A  convenient  classification  of  these  enlargements  is  into  innocent 
and  malignant  types. 

,'  .  j  i  Sarcoma 

T  Adenoma  \ 

Innocent    __..  Malignant  .  Carcinoma 

(Flbroma  '  Endothelioma 

Whatever  the  nature  of  the  enlargement  the  obstructive 
symptoms  are  common  to  them  all.  The  treatment,  however,  is 
widely  different,  and  it  will  be  well,  therefore,  to  examine  first  some 
general  considerations  before  passing  on  to  a  discussion  of  the 
best  methods  of  dealing  with  innocent  and  malignant  enlarge- 
ments respectively. 

Obstruction  to  micturition  due  to  permanent  enlargement 
of  the  Prostate. — With  very  few  exceptions  the  onset  of  obstruc- 
tive symptoms  is  very  gradual,  although  the  final  development  of 
complete  obstruction  may  be  very  acute.  The  development  of 
obstruction  in  its  early  stages  is  often  so  insidious  that  the 
patient  takes  little  or  no  notice  of  it,  or  if  he  does  occasionally 
think  that  all  is  not  as  it  used  to  be  he  attributes  it  to  his  age, 
there  being  a  very  widespread  impression  among  the  public  that 
the  power  of  retention  and  expulsion  of  urine  undergo  a  natural 
diminution  as  age  advances.  Needless  to  say,  this  is  not  the  pase 
unless  an  abnormal  condition  is  present. 

As  time  goes  on  and  the  gland  enlarges,  a  little  difficulty  is 
experienced  in  starting  the  stream ;  a  little  dribbling  and  failure 
of  the  final  expulsive  jet  is  noticed  at  the  conclusion.  Gradually 
the  force  of  the  stream  diminishes,  until  there  is  little  or  no  force 


Tumours  of  the  Prostate.  931 

at  all  and  the  urine  drops  from  the  end  of  the  urethra.  Coin- 
cidently  the  bladder  fails  to  completely  empty  itself,  and  a  gradu- 
ally increasing  quantity  of  "  residual  urine  "  accumulates.  The 
bladder  muscle  usually  hypertrophies  in  an  attempt  to  overcome 
the  resistance  ;  but  the  fight  is  an  unequal  one,  and  gradually  the 
muscle  gives  way  and  the  bladder  distends. 

Should  this  gradual  back  pressure  be  long  continued,  the 
sphincters  at  the  orifices  of  the  ureters  gradually  give  way,  the 
ureters  distend,  the  pelves  of  the  kidneys  distend,  and  eventually 
the  kidneys  may  be  converted  into  large  thin-walled  sacs,  the 
cortical  substance  showing  marked  changes  of  interstitial  nephritis. 

These  backward  pressure  changes  are  attended  by  a  typical 
series  of  symptoms  denoting  renal  inadequacy. 

The  urine  is  secreted  in  great  abundance,  and  the  total  excretion 
may  be  very  large  notwithstanding  the  difficulty  with  which  it 
is  voided.  It  is  pale,  of  very  low  specific  gravity  (1002  to  1005), 
very  deficient  in  solids,  particularly  in  urea,  and  showing  a  very 
small  trace  of  albumen. 

The  symptoms  are  backache,  often  called  lumbago,  general 
malaise  and  loss  of  appetite,  marked  thirst,  a  dry  mouth  and 
tongue,  cessation  of  sweating,  and  progressive  loss  of  weight. 

The  patient  frequently  lays  stress  upon  these  symptoms  and  never 
mentions  his  urinary  difficulties,  which  seem  to  him  of  slight  im- 
portance, so  that  it  is  very  common  for  such  cases  to  be  treated  as 
dyspepsia,  diabetes  mellitus,  and  chronic  interstitial  nephritis,  the 
true  cause  being  often  overlooked,  especially  in  stout  individuals, 
where  the  marked  distension  of  the  bladder  is  not  apparent.  This 
distension  is  sometimes  enormous,  even  up  to  the  ensiform  carti- 
lage ;  but  it  must  not  be  forgotten  that  the  back  pressure  upon  the 
kidneys  sometimes  takes  place  with  a  very  moderate  degree  of 
vesical  distension,  the  ureteric  sphincters  giving  way  although  the 
rest  of  the  bladder  muscle  succeeds  in  partially  resisting  the 
pressure. 

In  some  cases  even  of  extreme  distension,  frequency  of  micturi- 
tion is  not  very  marked,  the  bladder  apparently  tolerating  the 
presence  of  an  enormous  quantity  of  urine.  This,  however,  is 
only  the  case  so  long  as  the  urine  remains  aseptic.  The  introduc- 
tion of  sepsis  immediately  causes  greatly  increased  frequency  of 
micturition,  with  other  much  more  serious  symptoms.  In  quite 
a  large  number  of  cases,  however,  this  increasing  difficulty  of 
micturition,  does  not  result  in  backward  pressure  changes,  and 
here  the  condition  is  not  nearly  so  serious  though  the  discomfort 
may  be  greater.  In  some  of  these  cases  the  vesical  sphincter  and 

59—2 


932        Malignant  Tumours  of  the  Prostate. 

the  compressor  urethras  give  way  to  a  certain  extent,  and  a 
condition  of  false  incontinence  is  produced,  the  patient  being 
constantly  wet  in  addition  to  the  small  amount  of  urine  that  he 
passes  by  voluntary  expulsive  efforts.  This  condition  is  known  as 
retention  with  overflow,  and  is  not  peculiar  to  cases  of  prostatic 
obstruction,  for  it  is  seen  in  disease  of  the  central  nervous  system 
and  some  cases  of  stricture,  sometimes  it  is  associated  with  vesical 
calculus,  and  it  is  observed  in  cases  of  retention  due  to  the  pressure 
of  a  retro  verted  gravid  uterus  or  of  uterine  fibroids. 

Serious  danger  commences  for  the  patient  when  the  ureteric 
sphincters  give  way  and  the  backward  pressure  dilates  them  and 
the  kidneys.  It  is  then  that  the  train  of  symptoms  above  described 
is  made  manifest,  and  there  are  definite  and  unmistakable  indica- 
tions of  the  necessity  of  extreme  caution  in  dealing  with  such 
cases. 

It  should  be  laid  down  as  a  hard-and-fast  rule  in  all  treatises 
upon  surgery  that  in  cases  of  this  nature  the  bladder  should  never 
be  suddenly  emptied,  but  the  urine  should  be  drawn  off  very  slowly, 
very  aseptically,  and  with  the  patient  at  absolute  rest  in  bed. 

The  best  method  of  emptying  these  bladders  is  by  tying  in  a 
small  silk  web  catheter  fitted  with  a  small  vulcanite  or  metal 
tap,  which  is  turned  on  to  such  a  point  that  the  urine  only  escapes 
a  little  quicker  than  it  is  secreted.  At  least  twenty-four  hours 
should  be  taken  to  complete  the  evacuation,  and  it  is  wise  to  take 
even  longer. 

The  strictest  asepsis  should  be  observed,  as  an  acute  infection 
with  a  coliform  organism  is  only  too  common.  Even  with  every 
precaution  an  infection  from  within  cannot  be  avoided  in  some 
cases,  and  in  such  cases  the  patient  frequently  loses  his  life  or 
only  escapes  after  a  most  desperate  illness,  for  the  infection  attacks 
the  whole  urinary  tract  with  the  greatest  severity. 

Severe  haemorrhage  from  both  bladder  and  kidneys  often 
follows  a  sudden  emptying  of  these  bladders ;  whilst  in  other  cases, 
if  neither  haemorrhage  nor  sepsis  occur,  the  patient  passes  into  a 
condition  of  uraemia,  with  gradually  decreasing  excretion  of  urine 
and  ultimate  suppression  and  death.  These  calamitous  results 
are  avoided  or  minimised  by  very  slow  evacuation  of  the  urine 
combined  with  a  rigid  asepsis. 

MALIGNANT  TUMOURS  OF  THE   PROSTATE. 
Sarcoma  and  Endothelioma  of  the  prostate  are  at  present 

the  pale  of  curative  surgery. 
The  bladder  must  be  emptied  by  the  catheter  so  long  as  that 


Carcinoma  of  the  Prostate.  933 

is  possible,  and  when  it  becomes  impossible  by  reason  of  difficulty, 
pain  or  haemorrhage,  a  simple  supra-pubic  drainage  should  be 
done. 

The  Operation. — The  pubes  and  abdomen  are  shaved  and  pre- 
pared in  the  usual  manner.  The  bladder  is  thoroughly  washed 
out  with  sterile  warm  water  through  a  large  catheter,  and  is  then 
filled  to  its  utmost  capacity. 

A  straight  median  incision  is  made,  2  to  4  inches  in  length 
according  to  the  obesity  or  thinness  of  the  patient,  commencing 
just  above  the  pubes.  The  sheath  of  the  recti  muscles  is  opened 
in  the  mid-line  and  the  muscles  separated  by  the  ringer  or  the 
handle  of  the  scalpel.  In  this  situation  there  is  no  posterior 
sheath  to  the  recti,  so  the  pre-vesical  fat  immediately  appears. 
This  is  cleared  from  the  front  of  the  bladder,  and  the  attachment 
of  the  peritoneum  to  the  bladder  is  identified  and  pushed  upwards. 
The  bladder  wall  is  easily  recognised  by  the  appearance  of  the 
muscle  and  the  larger  veins  crossing  over  it. 

It  is  now  wrise  to  take  a  grip  of  the  bladder  wall  with  catch 
forceps  and  empty  it  of  lotion  by  means  of  the  catheter.  In  this 
way  septic  infection  of  the  abdominal  wound  is  avoided.  The 
bladder  is  then  opened  by  a  small  incision,  and,  if  clean,  a 
No.  12  or  14  (English  scale)  soft  rubber  catheter  is  inserted  and 
stitched  in  by  a  purse-string  suture  passing  through  the  catheter 
and  the  bladder  wall.  This  suture  should  be  of  catgut,  as  it  is 
not  desirable  that  it  should  remain  in  position  too  long,  and  it  is 
difficult  to  remove  if  of  silk.  Two  catgut  sutures  are  passed 
through  the  wall  of  the  bladder  on  either  side,  piercing  the  muscular 
coat  only,  and  are  then  passed  through  the  sheath  of  the  rectus 
and  tied  on  either  side,  thus  stitching  the  bladder  to  the  abdominal 
wall.  The  abdominal  wound  is  then  closed  around  the  catheter 
after  bringing  the  sheath  of  the  rectus  together  with  a  few  catgut 
sutures.  This  operation  is  only  applicable  to  cases  where  the 
urine  is  clear  and  the  bladder  aseptic.  When  purulent  cystitis 
is  present  it  is  better  to  insert  a  large  tube  into  the  bladder  of 
from  |  to  1  inch  in  diameter,  through  which  the  bladder  can  be 
thoroughly  irrigated.  This  tube  is  removed  in  a  few  days  and 
a  smaller  one  substituted,  the  wound  gradually  healing  by 
granulation.  As  in  these  cases  the  operation  is  only  resorted  to 
as  a  last  resource,  no  attempt  need  be  made  to  establish  a  valvular 
opening  and  to  dispense  eventually  with  a  drainage  tube. 

Carcinoma  of  the  Prostate.  —  In  the  writer's  experience 
carcinoma  of  the  prostate  is  always  of  the  hard  scirrhus  type 
(columnar  carcinoma),  very  slow  in  growth,  and  with  a  most 


934 


Carcinoma  of  the  Prostate. 


insidious  onset.  Unhappily  it  is  of  far  more  frequent  occurrence 
than  has  been  commonly  supposed.  Of  one  hundred  cases  of  diffi- 
cult micturition  or  retention  of  urine  due  to  enlargement  of  the 
prostate  the  writer  found  fourteen  cases  definitely  carcinomatous. 
In  these  cases  difficulty  of  micturition  is  by  no  means  always  the 
earliest  symptom.  Sensations  of  perineal  and  rectal  uneasiness, 
pain  referred  to  the  sciatic  or  obturator  nerves,  and  possibly 
some  hesitancy  or  lack  of  power  in  the  expulsion  of  urine  are 

far  more  common 
early  symptoms  than 
is  great  difficulty  in 
ejaculation.  Even 
when  the  malignant 
growth  is  quite  large, 
it  is  remarkable  how 
completely  sortie 
patients  are  able  to 
empty  the  bladder. 
This  is  due  to  the  fact 
that  in  most  cases  the 
growth  tends  to  spread 
in  the  direction  of  the 
common  ejaculatory 
ducts  and  up  the  base 
of,  and  therefore  out- 
side, the  bladder. 
Intra-vesical  projec- 
tion of  the  prostate  is 
very  rare  until  the 
last  stages  are  reached, 
whereas  in  the  case 
of  adenoma  of  the  prostate  intravesical  projection  is  often  an 
early  feature  and  very  common. 

From  the  insidiousness  of  its  onset  and  early  development  it 
is  generally  the  case  that  carcinoma  of  the  prostate  appears  before 
the  surgeon  when  no  hope  remains  of  a  curative  operation.  But 
occasionally  a  very  early  diagnosis  can  be  made,  and  then  the 
whole  prostate,  together  with  the  base  of  the  bladder  and  the 
common  ejaculatory  ducts  with  the  seminal  vesicles,  can  be 
removed  in  one  portion,  as  is  advised  and  practised  by  Professor 
Hugh  Young,  of  Baltimore.  The  following  description  of  the 
operation  and  illustrations  are  from  the  Johns  Hopkins  Hospital 
Reports  for  1906,  Vol.  XIV. 


FIG.  1. — After  transverse  section  of  urethra.  (From 
Johns  Hopkins  Hospital  Reports,  Vol.  XIV., 
1906.) 


Carcinoma  of  the  Prostate. 


935 


"  An  inverted  V  cutaneous  incision  was  made  in  the  perineum 
as  in  the  operation  employed  by  me  for  simple  hypertrophy  of 
the  prostate,  each  branch  of  the  incision  being  about  2  inches 
long.  By  blunt  dissection  the  end  of  the  bulb  and  central  tendon 
were  exposed  and  the  latter  divided,  exposing  in  turn  the  recto- 
urethralis  muscle,  the  division  of  which  gave  free  access  to  the 
membranous  urethra  behind  the  triangular  ligament.  Urethro- 
tomy  upon  a  grooved  staff  was  followed  by  introduction  of  the 
prostatic  tractor,  which  was  opened  out  after  it  reached  the 
bladder.  While  traction  was  made  upon  this  instrument,  the 
rectum  was  carefully 
separated  from  the 
prqstatic  capsule  by 
blunt  dissection  until 
the  entire  posterior 
surface  of  the  prostate 
was  brought  into 
view.  Up  to  this 
point  the  operator 
proceeded  exactly  as 
in  the  usual  prosta- 
tectomy operation. 
The  tissues  around 
the  prostate  were 
more  haemorrhagic 
and  the  wall  of  the 
rectum  more  closely 
adherent  to  the  cap- 
sule of  the  prostate 
than  usual.  Examina- 
tion of  the  prostate 
then  showed  much  greater  induration  than  I  had  ever  encoun- 
tered in  a  benign  prostate.  The  rectum  and  the  peri-prostatic 
tissues  were  free  from  invasion.  Complete  excision  was  carried 
out  as  follows  :  The  handle  of  the  tractor  was  depressed,  thus 
exposing  the  membranous  urethra  anterior  to  it,  where  it  was 
easily  divided  transversely  with  a  scalpel,  leaving  a  small  stump 
of  the  membranous  urethra  protruding  from  the  posterior -surf  ace 
of  the  triangular  ligament.  By  further  depressing  the  handle  of 
the  tractor  the  pubo-prostatic  ligament  was  exposed,  and,  being 
very  tautly  drawn,  easily  divided  by  scissors,  thus  completely 
severing  the  prostate  from  all  important  attachments  (except  pos- 
teriorly), as  shown  in  Fig.  1.  The  lateral  attachments,  which 


FIG.  2. — Exposure  and  division  of  trigone.  (From 
the  Johns  Hopkins  Hospital  Reports,  XIV., 
1906.) 


936 


Carcinoma  of  the  Prostate. 


are  slight,  were  easily  separated  by  the  finger.  The  posterior 
surface  of  the  seminal  vesicles  were  then  freed  by  blunt  dissection, 
the  now  mobile  prostate  being  drawn  well  out  of  the  wound. 

'  The  next  step  was  to  expose  the  anterior  surface  of  the 
bladder,  which  was  easily  done  by  depressing  the  tractor  and 
making  strong  traction.  By  this  procedure  the  bladder  was 
drawn  down  so  close  to  the  skin  wound  that  it  was  easily 
incised  at  a  point  in  the  middle  line  about  1  centimetre  above  the 
prostate- vesical  juncture.  By  means  of  scissors  the  division  was 

continued  on  each 
side  until  the  trigone 
was  exposed  (Fig.  2). 
After  swabbing  away 
the  blood  and  urine 
the  ureters  were  easily 
found,  and  the  line  of 
incision  carried  across 
the  trigone  with  the 
scalpel  so  as  to  pass 
about  1  centimetre  in 
front  of  the  ureteral 
orifices. 

"Whilst  still  mak- 
ing traction  upon  the 
prostate,  the  base 
of  the  bladder  was 
pushed  up  with  the 
handle  of  the  scal- 
pel, thus  exposing  the 
anterior  surface  of 
the  seminal  vesicles 
and  the  adjacent  vasa 

deferentia  (Fig.  3),  all  of  which  were  carefully  freed  by  blunt 
dissection  with  the  finger  as  high  up  as  possible,  so  as  to  remove 
with  the  vesicles  as  much  circumjacent  fat  and  areolar  tissue 
as  possible  on  account  of  the  lymphatics  which  they  contained. 
The  vasa  deferentia,  after  being  drawn  down  as  far  as  possible, 
were  picked  up  on  a  small  blunt  hook  and  divided  with  scissors 
high  up,  care  being  exercised  to  see  that  the  ureters  were  not  in 
danger.  After  division  of  the  vasa  the  seminal  vesicles  were 
found  to  come  down  more  readily,  and  the  deep  adhesions  were 
finally  divided  and  the  mass  removed. 

'  There  now  remained  a  large  defect  to  be  repaired.     The  vesical 


FIG.  3. — -Final  separation  of  seminal  vesicles  and 
division  of  vasa.  (From  the  Johns  Hopkins 
Hospital  Reports,  Vol.  XIV.,  1906.) 


Carcinoma  of  the  Prostate. 


937 


opening  was  about  8  centimetres  in  diameter  and  had  sunk  far  back 
into  the  depths.  The  stump  of  membranous  urethra  had  been 
obliterated  by  the  compression  of  the  anterior  retractor,  so  that 
it  was  necessary  to  insert  a  soft  rubber  catheter  through  the 
urethra  from  the  meatus  to  discover  it.  The  anterior  wall  of  the 
vesical  opening  was  then  caught  with  forceps,  and  with  no  great 
traction  I  was  surprised  to  find  how  easily  it  could  be  drawn  down 
to  the  membranous  urethra,  where  an  anastomosis  was  readily 
made.  The  first  suture  was  placed  by  inserting  the  needle  into 
the  triangular  ligament  above  the  urethra  and  out  through  the 
anterior  wall  of  the  membran- 
ous urethra,  then  through  the 
anterior  wall  of  the  bladder  in 
the  median  line,  from  within 
out,  care  being  taken  to  include 
only  the  submucosa  and  muscle. 
When  this  suture  was  tied  the 
median  line  of  the  anterior  wall 
of  the  bladder  was  drawn  to 
meet  the  median  line  of  the  roof 
of  the  remaining  membranous 
urethra,  the  knot  being  outside 
and  the  thread  left  long.  Fig.  4 
shows  diagrammatically  the 
plan  of  vesico-urethral  anasto- 
mosis described  above. 

"  Lateral    sutures,    similarly 
placed      (including     the     peri- 


Fig.  4.—  Diagram  showing  plan  of  vesico- 
urethral  anastomosis.  (From  the 
Johns  Hopkins  Hospital  Reports, 
Vol.  XIV.,  1906.) 


urethral  muscular  structures 
below),  and  two  posterior 
sutures  completed  the  anasto- 
mosis of  the  membranous  urethra,  with  a  small  ring  into  which 
the  anterior  portion  of  the  margin  of  the  vesical  wound  had  been 
fashioned  by  the  tying  of  the  sutures.  The  remainder  of  the 
vesical  wound  now  presented  as  a  longitudinal  opening,  which 
was  easily  closed  by  sutures,  thus  completely  closing  the  defect 
and  replacing  the  prostatic  urethra  with  a  funnel-shaped  process 
in  a  do  from  the  bladder  wall. 

"  The  sutures  used  were  silk,  one  end  of  each  being  left  long  and 
brought  out  of  the  wound  so  that  they  could  be  extracted  later 
(since  then  I  have  found  alternate  sutures  of  catgut  and  silkworm 
gut,  also  left  long,  the  best).  After  light  gauze  packing  had  been 
placed  in  various  portions  of  the  wound,  the  levator  ani  muscles 


938  Carcinoma  of  the  Prostate. 

were  drawn  together  with  catgut  (two  sutures)  in  front  of  the 
rectum,  and  the  skin  wound  closed  on  each  side  with  interrupted 
catgut  sutures,  leaving  only  a  small  portion  open  at  the  angle 
in  front  for  exit  of  the  gauze  drainage. 

"  The  retained  rubber  catheter   (which  was   of  considerable 
service  in  making  the  anastomosis  of  the  urethra  and  bladder) 


FIG.  5. — Author's  operation,  showing  supra-pubic  scar  and  valvular  fistula. 

was  fastened  in  place  by  adhesive  plaster  around  the  penis,  and 
the  patient  was  returned  to  the  ward." 

The  operation,  described  above  by  Professor  Young,  undoubtedly 
completely  extirpates  the  primary  growth  in  early  cases,  but 
unfortunately  recurrence  in  the  pelvic  cellular  tissue  is  only  too 
liable  to- occur,  and  the  operation  has  other  drawbacks.  Fistulous 
tracks  sometimes  remain  which  are  exceedingly  difficult  to  close. 

Complete  incontinence,  which  is  permanent,  has  occurred  in 
several  cases. 

The  operation  is  very  difficult  to  perform  and  is  one  of  great 
gravity,  especially  when  the  advanced  age  of  most  of  the  patients 
is  considered. 


Carcinoma  of  the  Prostate. 


939 


Permanent  Supra-pubic  Drainage. — In  advanced  cases  where 
there  can  be  no  hope  of  complete  removal  of  the  disease,  permanent 
supra-pubic  drainage  should  be  done,  when  catheterism  fails  owing 
either  to  difficulty,  pain,  or  haemorrhage  in  the  use  of  the  catheter. 

The  following  operation  devised  by  the  writer  and  used  in 


Fio.  6. — The  same  with  catheter  in  situ. 

twelve  cases  has  given  some  excellent  results  in  a  good  proportion 
of  cases : 

The  abdomen  is  opened  in  the  middle  line  by  vertical  incision 
3  inches  in  length  immediately  above  the  pubes.  The  recti 
are  separated  and  the  anterior  wall  of  the  bladder  is  exposed.  It 
is  advisable  to  place  the  patient  in  the  Trendelenburg  position,  as 
this  much  facilitates  the  operation. 

The  loose  lateral  ligaments  of  the  bladder  are  snipped  through 
by  scissors,  and  the  peritoneum  is  detached  and  pushed  back  as 
far  as  possible.  The  bladder  is  now  loose  and  free. 


94-Q  Adenoma  of  the  Prostate. 

The  skin  is  undercut  and  retracted  over  the  right  or  left  rectus, 
exposing  the  anterior  sheath  of  the  muscle,  in  which  a  small 
vertical  incision  is  made  about  2  inches  from  the  middle  line. 
The  muscle  is  then  split  from  the  mid-line  out  to  the  small  vertical 
incision  in  the  sheath.  As  large  a  cone  of  bladder  as  can  be 
obtained  is  then  pushed  through  the  split  muscle  and  brought  out 
through  the  small  vertical  incision  in  the  sheath,  to  the  edges  of 
which  it  is  firmly  stitched  by  several  sutures  of  catgut.  The 
cone  which  now  projects  should  be  of  sufficient  size  to  pull  easily 
through  a  small  vertical  incision  in  the  skin  corresponding  to  the 
vertical  incision  in  the  rectus  sheath.  The  cone  of  bladder  is  now 
stitched  to  the  skin.  An  opening  is  made  in  the  cone  just  large 
enough  to  admit  a  No.  12  or  14  (English  scale)  Pezzer  self-retaining 
catheter,  which  is  passed  into  the  bladder.  The  recti  and  skin  are 
now  closed  in  the  mid-line  and  a  collodion  dressing  is  applied. 

It  will  be  seen  that  this  operation  is  an  adaptation  to  the 
bladder  of  Frank's  method  of  gastrostomy. 

The  results  are  excellent.  The  self-retaining  catheter  can  be 
removed  in  a  few  days,  and  thereafter  a  soft  rubber  catheter  is 
passed  through  the  opening  as  occasion  requires. 

After  a  lew  weeks  the  new  meatus  is  represented  by  a  puckered 
dimple  in  the  skin.  If  a  little  urine  leaks  through  the  orifice,  it 
can  easily  be  checked  by  applying  a  light  truss  fitted  with  a  small 
rubber  or  artificial  ivory  pad. 

This  operation  is  not  applicable  to  very  contracted  bladders. 
The  best  results  are  obtained  in  those  bladders  distended  by 
long-continued  back  pressure. 

Conclusions. — (1)  It  is  justifiable  to  offer  the  chance  of  cure 
by  a  radical  operation  to  those  patients  in  whom  the  disease  is 
diagnosed  very  early.  Even  if  the  operation  fails,  it  is  no  bar  to 
permanent  supra-pubic  drainage  later  on. 

(2)  An  "  enucleation  "  by  the  supra-pubic  method  as  advised 
for  adenoma  of  the  prostate  should  never  be  attempted.     Recur- 
rence is  certain. 

(3)  It   is    best   in  more  advanced    cases   to    practise    aseptic 
catheterism  until  that  becomes  impossible  owing  to  pain,  difficulty 
or  the  incidence  of  severe  haemorrhages  dependent  upon  the  use 
of  the  catheter,   when  a  permanent  drainage  by  the   method 
described  above  should  be  done. 

ADENOMA  OF  THE  PROSTATE. 

Adenoma  of  the  prostate  is  the  condition  to  which  the  term 
"  hypertrophy "  of  the  prostate  is  commonly  applied.  As 


Adenoma  of  the  Prostate.  941 

already  stated,  it  is  a  new  growth  of  the  prostate  and  in  no  sense 
a  true  hypertrophy.  It  forms  by  far  the  largest  proportion  of 
enlargements  of  the  prostate,  giving  rise  to  obstruction  of 
micturition. 

Palliative  Treatment. — This  involves  the  habitual  use  of  the 
catheter,  and  though  it  cannot  be  denied  that  quite  a  number  of 
patients  arrive  at  a  degree  of  tolerance  of  catheterism  quite 
astonishing  to  observe,  it  must  be  admitted  by  all  who  have  had 
a  considerable  experience  of  patients  with  prostatic  obstruction 
that  sooner  or  later  the  habitual  use  of  the  catheter,  however 
skilfully  applied,  is  attended  by  a  greater  or  less  degree  of  infection 
of  the  urinary  system,  with  its  coincident  dangers  and  distresses, 
such  as  cystitis,  epididymitis,  pyelitis,  and  haemorrhage  from  the 
inflamed  and  irritated  adenomatous  prostate.  In  a  considerable 
number  of  cases  self-catheterism  is  difficult  or  impossible  owing 
to  the  size  of  the  gland,  the  tortuousness  of  the  prostatic  urethra, 
and  not  uncommonly  the  nervousness  or  personal  inaptitude  of 
the  patient. 

In  the  case  of  extremely  aged  men  who  have  used  the  catheter 
for  some  years,  and  are  still  using  it  with  perfect  success,  it  is  quite 
justifiable  to  permit  them  to  continue  in  this  manner. 

In  such  cases  transient  attacks  of  cystitis  should  be  treated  by 
irrigation  of  the  bladder  with  mild  antiseptic  solutions,  such  as 
have  already  been  suggested  in  the  section  devoted  to  cystitis ; 
by  the  use  of  urinary  antiseptics  by  the  mouth,  such  as  urotropine, 
benzoate  of  ammonium  or  sodium,  cystamin,  helmitol,  or  salol ; 
by  a  wise  regulation  of  the  mode  of  life,  with  particular  regard 
to  a  simple  diet,  abstinence  from  alcohol,  and  avoidance  of 
exposure  to  extremes  of  heat  and  cold,  and  undue  exertion  and 
fatigue. 

But  in  those  cases  where  there  is  a  considerable  expectation  of 
life  apart  from  the  prostatic  trouble,  we  now  consider  it  to  be  the 
duty  of  the  surgeon  to  advise  removal  of  the  obstruction  at  as 
early  a  stage  of  the  case  as  possible,  before  the  use  of  the  catheter 
has  led  to  those  complications,  most  of  them  due  to  sepsis;  which 
have  been  already  indicated. 

Restoration  of  function  can  be  promised  emphatically.  Recur- 
rence of  the  growth  is  absolutely  unknown  if  the  operation  is 
properly  performed,  and  the  risk  in  cases  uncomplicated  by  sepsis 
and  its  results,  is,  in  the  case  of  an  otherwise  healthy  man,  scarcely 
to  be  considered. 

The  prostate  can  be  approached  and  removed  either  by  the 
supra-pubic  or  by  the  perineal  route. 


942  Adenoma  of  the  Prostate. 

Supra-pubic  Prostatectomy. — The  bladder  is  first  thoroughly 
washed  out  with  sterile  warm  water  or  normal  saline  solution  and 
is  then  filled  to  its  maximum  capacity.  The  abdomen  is  opened 
in  the  median  line  above  the  pubes,  the  length  of  the  incision 
depending  upon  the  thinness  or  obesity  of  the  patient.  In  very 
stout  patients,  especially  when  the  pelvis  is  very  deep,  it  is  some- 
times necessary  to  insert  the  whole  hand  into  the  pelvis,  the  fore- 
finger only  passing  through  the  incision  in  the  bladder  to  perform 
the  enucleation.  In  thin  patients  with  flaccid  muscles  a  very 
small  incision  will  suffice,  as  the  forefinger  is  all  that  need  be 
inserted,  the  clenched  fingers  of  the  hand  pushing  the  wall  of  the 
belly  down  into  the  pelvis. 

The  pre-vesical  fat  and  peritoneum  are  stripped  upwards  by 
blunt  dissection  and  the  anterior  wall  of  the  bladder  is  exposed. 
An  incision  is  now  made  in  the  bladder,  either  vertical  or  trans- 
verse, and  the  fluid  allowed  to  escape. 

Marion,  of  Paris,  recommends  that  the  bladder  should  be  filled 
with  air  rather  than  water,  as  he  considers  the  peri-vesical  tissues 
are  less  liable  to  be  infected  when  the  bladder  is  opened.  The 
writer  prefers  to  catch  the  wall  of  the  bladder  in  forceps,  then  to 
empty  it  by  the  catheter,  and  make  the  incision  in  the  anterior 
wall  when  it  is  empty. 

The  bladder  is  now  carefully  explored  with  the  finger,  and  any 
calculi  which  may  be  present  are  removed  with  scoop  or  forceps. 
It  is  now  easy  to  feel  whether  or  no  there  is  any  intra-vesical 
projection  of  the  prostate.  If  the  projection  is  marked,  the  prostate 
in  that  situation  is  covered  only  by  mucous  membrane,  as  this 
so-called  middle  lobe  has  "  pushed  "  upwards  through  the  vesical 
sphincter,  widely  stretching  the  orifice  of  the  bladder.  It  is  in 
this  situation  that  the  enucleation  of  the  gland  should  be  com- 
menced, by  scratching  through  the  mucous  membrane  with  the 
forefinger  nail.  It  is  quite  unnecessary  to  use  knife  or  scissors 
to  incise  the  mucous  membrane.  It  gives  way  quite  easily  to  the 
pressure  of  the  finger.  Immediately  the  mucous  membrane  is 
penetrated  the  finger  is  in  the  proper  plane  of  cleavage  to  perform 
the  enucleation.  It  is  immaterial  in  which  direction  this  is  carried 
out,  as,  if  the  finger  is  pushed  steadily  onwards,  the  adenomatous 
gland  shells  out  exactly  as  encapsuled  adenomata  do  in  other 
situations.  The  stripping  process  is  continued  all  round  the 
gland  until  it  is  left  hanging  by  the  urethra  in  front,  very  much 
like  an  apple  on  its  stalk.  The  finger  is  then  hooked  under  the 
urethra  and  it  is  torn  through.  The  prostate  is  now  lying  loose 
in  its  cavity,  and  is  pulled  out  by  suitably  shaped  forceps.  This 


Adenoma  of  the  Prostate. 


943 


manoeuvre  is  often  much  assisted  by  starting  strong  irrigation 
through  the  catheter.  Sometimes .  the  prostate  is  so  large  in 
proportion  to  the  opening  from  the  bladder  that  it  must  be  broken 
into  two  or  three  pieces  prior  to  removal.  In  a  few  cases  where 
there  is  no  median  projection,  the  two  lateral  lobes  can  be 
removed  separately,  being  stripped  off  the  urethra,  which,  how- 
ever, is  always  more  or  less  torn  in  this  operation.  If  the  haemor- 
rhage is  slight  the  writer  does  not  employ  irrigation  after  the 
enucleation,  but  if  the  bleeding  is  profuse  irrigation  with  sterile 


FIG.  7. — Showing  Hamilton  Ir\ing's  "  box  "  applied. 

water  at  120°F  suffices  in  most  cases  to  stop  the  loss.  In  a  very 
few  cases  the  haemorrhage  is  so  profuse  that  it  is  necessary  to 
pack  the  cavity  with  a  long  strip  of  sterile  gauze,  the  end  of  which 
is  brought  out  through  the  abdominal  wound.  This  gauze  can 
be  safely  and  easily  withdrawn  thirty-six  to  forty-eight  hours 
after  operation. 

The  writer  always  stitches  the  edges  of  the  bladder  incision  to 
the  sheath  of  the  rectus  on  either  side  by  a  strong  catgut  suture. 
A  large  drainage  tube  is  then  introduced  (f  to  1  inch  in  diameter), 
and  the  edges  of  the  rectus,  sheath  brought  together  by  two  or  three 


944  Adenoma  of  the  Prostate. 

catgut  sutures.     The  skin  wound  is  then  closed  by  interrupted 
salmon-gut  sutures. 

The  dressing  to  be  employed  has  been  very  much  discussed, 
but  after  prolonged  trial  of  various  methods  the  writer  at  present 
finds  the  following  method  most  satisfactory  : 

For  the  first  twenty-four  hours  the  urine  is  allowed  to  drain  into 
pads  of  woodwool  or  of  cellulose,  which  are  frequently  changed.  At 
the  end  of  that  time  most  of  the  clots  have  been  discharged,  and  a 
Hamilton  Irving's  box  is  applied.  This  box  is  made  of  celluloid 
and  fits  close  to  the  skin  all  round  the  wound.  From  the  lower 
part  of  it  two  rubber  tubes  convey  the  urine  into  an  ordinary 
glass  urine  bottle  lying  between  the  patient's  thighs. 

The  box  is  kept  in  position  by  means  of  an  elastic  belt  round 
the  waist,  and  two  perineal  tapes  passing  round  each  thigh 
prevent  the  box  slipping  up  upon  the  abdomen.  The  box  is 
removed  once  or  twice  a  day  for  cleansing.  Before  applying  the 
box  the  whole  wound  and  the  skin  around  are  thickly  coated  with 
an  ointment  composed  of  30  gr.  of  zinc  oxide  to  1  oz.  of  sterile 
lanoline.  If  this  is  applied  twice  a  day  the  skin  is  kept  in  per- 
fectly good  condition,  notwithstanding  the  fact  that  urine  is  in 
contact  with  it  until  the  supra-pubic  wound  closes.  The  wound 
must  be  stitched  tightly  and  the  stitches  must  not  be  removed 
until  the  wound  is  quite  solid,  or  the  pressure  of  the  box  will 
cause  some  gaping,  and  healing  will  be  a  little  delayed. 

A  little  care  and  attention  should  be  exercised  in  fitting  the 
box  to  the  patient.  If  this  is  done,  the  patient  is  kept  perfectly 
dry  and  comfortable  throughout  the  whole  period  of  convalescence. 

The  bladder  should  be  thoroughly  irrigated  by  passing  a  large 
catheter  down  the  supra-pubic  tube.  The  writer  prefers,  if  possible, 
not  to  pass  a  catheter  through  the  urethra  until  ten  to  fourteen 
days  have  elapsed.  The  danger  of  epididymitis  is  thus  lessened. 

Complications. —  (1)  Cystitis. — If  a  very  purulent  cystitis  is 
present  it  is  wise  to  do  the  operation  in  two  stages.  A  median 
supra-pubic  cystotomy  is  performed  and  a  large  tube  is  inserted, 
no  attempt  being  made  to  remove  the  prostate.  Through  this 
tube  the  bladder  is  thoroughly  irrigated  two  or  three  times  a  day, 
urinary  antiseptics  being  given  by  the  mouth,  and  forced  hydro- 
therapy  instituted  by  causing  the  patient  to  drink  large  quantities 
of  water,  barley-water,  milk  and  soda-water,  and  so  forth. 

It  is  surprising  how  marked  is  the  improvement  in  both  the 
local  and  general  conditions  in  a  very  short  time  after  the  drainage 
has  been  performed.  It  gives  rest  to  the  bladder.  The  patient 
is  not  disturbed  at  night  by  innumerable  calls  to  micturate  either 


Adenoma  of  the  Prostate.  945 

in  forced  driblets  naturally  or  by  the  catheter.  He  sleeps,  eats, 
and  feels  a  different  man.  In  ten  days  or  a  fortnight  the  wound 
in  the  wall  of  the  abdomen  has  consolidated  around  the  central 
fistula,  and  through  this  orifice,  which  only  needs  dilatation  by 
the  finger,  the  enucleation  of  the  prostate  can  be  carried  out. 

Many  seemingly  desperate  cases  can  be  converted  by  this  pre- 
liminary drainage  and  hydrotherapy  into  quite  favourable  cases 
for  prostatectomy. 

Very  few  cases  need  now  be  refused  prostatectomy,  however 
septic  they  may  appear,  provided  this  preliminary  treatment  is 
carried  out  and  one  feels  satisfied  that  pyelonephritis  is  not 
present.  We  are  satisfied  that  this  procedure  has  reduced  the 
mortality  of  the  operation  by  at  least  5  per  cent. 

(2)  Haemorrhage. — Severe  bleeding  occurring  during  or  at  the 
close  of  the  operation  has  already  been  dealt  with.    In  a  small  pro- 
portion of  cases  secondary  haemorrhage  occurring  from  a  few  days 
to  a  week  or  ten  days  after  operation  is  an  alarming  complication. 
If  it  cannot  be  stopped  without  much  delay  by  the  use  of  copious 
hot  irrigation  and  the  hypodermic  administration  of  T^Q  gr.  of 
ergotin,  together  with  raising  the  foot  of  the  bed  on  high  blocks, 
the  prostatic  cavity  should  be  packed  with  gauze,  as  already 
described.     This  can  be  rapidly  performed  either  under  nitrous- 
oxide  gas  anaesthesia,  or  even  without  an  anaesthetic.     The  gauze 
is  removed  in  twenty-four  to  forty-eight  hours.     The  writer  has 
never  known  a  recurrence  of  the  haemorrhage. 

(3)  Failure   of   Closure   of  the   Supra-pubic   Fistula. — If    the 
enucleation  has  been  complete  the  fistula  very  rarely  fails  to 
close.     In  over  four  hundred  cases  the  writer  has  only  found 
occasion  in  two  cases  to  excise  the  wound  and  stitch  the  bladder 
and  abdominal  wall. 

In  a  small  proportion  of  cases,  where  the  general  vitality  is  low 
and  powers  of  healing  are  bad,  it  will  be  found  necessary  to  pass 
a  catheter  into  the  bladder  by  the  urethra  and  tie  it  in  for  a  few 
days,  so  as  to  drain  the  bladder  by  that  channel  and  keep  the 
fistula  dry.  The  fistula  can  be  stimulated  by  the  application  of 
solid  silver  nitrate. 

(4)  Epididymitis  occurs  in  about  10  per  cent,  of  all  cases.     It 
very  rarely  goes  on  to  suppuration,  and  should  be  treated  by  sus- 
pension of  the  testicles  and  the  application  of  the  usual  remedies. 

(5)  Formation   of    Calculus    in  the   Bed    of    the    Prostate. — 
Phosphatic    calculi    sometimes   form   in  the   cavity  left  by  the 
removal    of    the    prostate.      They   can   be   removed    either  by 
re-opening  the  bladder  through  the  supra-pubic  scar,  or   by  a 

S.T. — VOL.  n.  60 


946  Adenoma  of  the  Prostate. 

median  perinea!  lithotomy  (see  section  on  Vesical  Calculus).  If 
the  latter  method  is  employed,  great  care  must  be  taken  to  injure 
the  compressor  urethras  as  little  as  possible,  for  after  supra-pubic 
prostatectomy  this  muscle  is  practically  the  only  sphincter  that 
the  bladder  possesses. 

Prognosis.  —  Prognosis  as  regards  restoration  of  function  is 
extremely  good.  If  the  operation  is  properly  performed  (i.e.,  if 
enucleation  is  complete),  an  absolute  dependence  upon  the  catheter 
for  from  ten  to  twenty  years  before  operation  is  followed  by  easy 
and  natural  and  complete  emptying  of  the  bladder.  The  objection 
that  the  bladder  muscle  lost  its  tone  as  the  result  of  long-continued 
catheterism  has  thus  been  completely  disproved. 

Advanced  age  is  no  bar  to  operation  ;  if  it  were,  the  operation 
would  be  seldom  performed.  Aged  men  who  are  otherwise 
healthy  bear  the  operation  remarkably  well.  In  the  writer's 
practice  the  earliest  age  at  which  the  operation  was  performed 
was  forty-nine  and  the  oldest  ninety-four. 

The  death-rate  of  the  operation  may  now  be  said  to  be  about 
stationary.  In  352  cases  operated  upon  at  St.  Peter's  Hospital  in  the 
past  five  years  the  mortality  fairly  attributable  to  the  operation 
has  been  7'9  per  cent.  These  cases  were  in  no  sense  "  selected." 
Many  of  them  were  in  an  excessively  feeble  and  septic  condition, 
worn  out  by  years  of  suffering.  If  none  but  selected  cases  were 
taken  the  mortality  would  be  less  than  2  per  cent. 

Perineal  Prostatectomy.  —  Prostatectomy  by  the  perineal 
route  has  -been  a  favourite  operation  upon  the  Continent  and  in 
the  United  States  of  America  for  many  years,  but  it  has  never 
gained  any  great  measure  of  support  in  this  country.  The 
operation  is  undeniably  a  very  successful  procedure,  but  it  demands 
much  greater  skill  and  the  possession  of  more  surgical  technique 
than  supra-pubic  prostatectomy.  Many  different  methods  of  per- 
forming the  operation  have  been  employed,  but  the  operation  now 
to  be  described  combines  the  best  features  of  various  procedures, 
and  with  the  exception  of  a  few  trifling  technicalities  favoured  by 
various  operators  it  may  be  considered  the  standard  perineal 
prostatectomy  now  in  vogue. 

The  Operation. — The  patient  is  placed  in  the  exaggerated  litho- 
tomy position,  and  a  solid  metal  staff  is  introduced  into  the  bladder. 
An  inverted  V  incision  is  made  in  the  perineum,  the  apex  of  the 
V  lying  just  behind  the  bulb,  and  the  two  limbs  extending  backwards 
on  either  side  to  a  point  midway  between  the  anus  and  the  tuber 
ischii  on  either  side.  When  the  wound  gapes  the  perineal  raphe 
is  seen  passing  from  the  anus  behind  to  the  bulb  in  front.  This 


Adenoma  of  the  Prostate.  947 

raphe  contains  some  bundles  of  muscles  known  as  the  recto- 
urethralis.  It  is  picked  up  in  forceps  and  divided  with  scissors. 
The  pre-rectal  fat  immediately  bulges  in  the  wound,  and  the 
space  between  the  rectum  and  the  prostate  is  opened  up.  This  is 
called  by  the  French  the  espece  decollable,  a  very  apt  description, 
as  it  can  be  cleared  by  the  finger  and  forceps,  no  cutting  being 
required.  The  fat  is  now  cleared  away  from  the  membranous 
urethra  and  the  capsule  of  the  prostate,  great  care  being  taken  to 
avoid  injuring  the  rectum.  A  suitable  broad  retractor  can  be 
placed  in  front  of  the  rectum,  pulling  it  back  towards  the  sacrum. 
A  small  incision  is  now  made  in  the  urethra  just  behind  the  bulb, 
through  which  Young's  prostatic  tractor  is  introduced  into  the 
bladder,  and  the  blades  widely  opened.  By  pulling  upon  the 
tractor  the  prostate  can  be  dragged  almost  up  to  the  level  of  the 
perineum.  The  capsule  is  now  carefully  cleaned  of  fat,  and  large 
veins  are  pushed  out  of  the  way.  Two  incisions  are  made  through 
the  capsule,  one  on  either  side  of  the  middle  line,  converging  from 
above  downwards.  Hugh  Young  advises  this  mode  of  incision  to 
avoid  injuring  the  common  ejaculatory  ducts  which  pierce  the 
prostate,  converging  to  empty  into  the  sinus  pocularis  on  the 
floor  of  the  prostatic  urethra.  The  two  lateral  lobes  of  the 
prostate  are  then  enucleated  by  the  finger,  aided  by  the  handle 
of  the  scapel  or  a  periosteal  elevator.  An  attempt  is  made  to 
avoid  injuring  the  urethra,  but  the  writer  must  confess  that  he 
has  never  been  able  to  satisfy  himself  that  in  cases  where  the 
growth  is  large  it  is  possible  to  avoid  tearing  through  the  mucous 
membrane.  When  there  is  a  large  intra-vesical  projection,  he 
believes  it  to  be  an  impossibility. 

The  enucleation  being  complete,  the  cavity  is  well  flushed  with 
hot  saline  solution,  the  tractor  is  withdrawn,  and  a  larger  soft 
catheter  introduced  through  the  wound  of  the  urethra  into  the 
bladder  and  stitched  in.  This  tube  must  have  a  large  lumen  or 
it  will  be  blocked  by  blood  clot.  The  small  incision  in  the 
urethra  just  behind  the  bulb  is  now  closed  by  two  or  three  catgut 
sutures.  The  cavity  whence  the  prostate  has  been  removed  is 
lightly  packed  with  gauze  and  the  skin  closed  by  salmon-gut 
sutures,  but  not  tightly,  as  some  drainage  is  to  be  expected. 

Ajtcr-tn'iitiin'nt. — The  after-treatment  is  very  simple.  The 
bladder  should  be  washed  out  once  or  twice  a  day  with  mild 
antiseptic  lotions. 

The  gauze  plugging  is  removed  in  forty-eight  hours,  and  the 
cavity  re-plugged  less  and  less  firmly  each  day  until  it  has  con- 
tracted and  closed  by  granulation. 

60—2 


948  Adenoma  of  the  Prostate. 

Hugh  Young  uses  a  two-way  tube,  and  employs  continuous 
saline  irrigation  of  the  bladder  for  thirty-six  to  forty-eight  hours. 
The  gauze  packing  is  removed  on  the  second  day  and  no  more 
applied,  and  the  tubes  are  removed  also  within  forty-eight  hours. 
No  sounds  are  passed,  and  the  patient  can  usually  be  placed  in  a 
chair  within  four  days  of  operation. 

Plenty  of  fluid  should  be  given  by  the  mouth,  and  urotropin 
should  be  given  from  the  start. 

Most  of  the  urine  is  passed  by  the  perineal  wound  for  some  days, 
and  absolute  incontinence  is  often  present  for  some  days  also. 
Permanent  incontinence  is  a  danger  if  great  care  is  not  taken  to 
avoid  injury  of  the  compressor  urethras  muscle. 

Complications. — Injury  to  the  rectum  with  formation  of  a 
rectal  fistula  is  the  most  dangerous  complication.  It  should  be 
avoided  if  great  care  is  taken  to  pull  the  rectum  well  back  and  to 
identify  all  parts  of  the  field  of  operation  before  commencing  the 
enucleation.  A  careful  examination  of  the  anterior  wall  of  the 
rectum  should  be  made  before  the  wound  is  closed,  and  if  any 
tear  is  detected  it  should  be  closed  immediately  by  catgut  sutures. 
The  gauze  packing  of  the  cavities  should  be  done  deliberately, 
and  should  not  press  on  the  rectum  in  the  recto-prostatic 
space. 

Haemorrhage. — Bleeding  is  usually  free  but  easily  controlled. 
If  secondary  haemorrhage  occurs  it  can  be  controlled  by  replacing 
with  gauze. 

Advantages  of  the  Operation. — This  operation  possesses  two 
great  attractions.  Firstly,  all  drainage  conforms  to  the  usual 
requirements  of  surgery,  being  in  the  dependent  position. 
Secondly,  the  patients  can  be  got  out  of  bed  very  much  earlier 
than  in  the  case  of  supra-pubic  prostatectomy. 

Disadvantages  of  the  Operation.  —  Firstly,  it  takes  con- 
siderably longer  to  perform  than  the  supra-pubic  operation. 
Secondly,  the  technique  required  is  of  a  much  higher  order,  and 
more  difficult  to  acquire.  Thirdly,  in  the  case  of  very  large 
prostates,  it  is  impossible,  in  the  writer's  opinion,  to  avoid  serious 
damage  to  the  neck  of  the  bladder  and  to  the  compressor  urethrae, 
resulting  in  a  small  proportion  of  cases  in  permanent  incon- 
tinence. 

Conclusions.  -  •  The  mortality  of  the  two  operations  being 
about  equal  in  skilled  hands,  this  point  need  not  trouble  us  in 
making  our  choice.  For  all  adenomata  of  large  size  the*  writer 
unhesitatingly  recommends  supra-pubic  prostatectomy.  For 
moderate-sized  growths  it  may  very  well  be  left  to  the  personal 


Adenoma  of  the  Prostate.  949 

preference  of  the  operating  surgeon.  For  small  adenomata  the 
writer  believes  that  the  supra-pubic  route  will  be  found  the  better, 
as  it  is  much  easier  to  be  quite  certain  that  no  growth  is  left 
behind  than  by  the  perineal  operation. 

JOHN  PARDOE. 


950 


FIBROUS   ENLARGEMENT  OF  THE  PROSTATE. 

THERE  is  found,  in  a  small  proportion  of  cases  of  difficult  mic- 
turition and  retention  of  urine,  a  form  of  enlargement  of  the 
prostate  which  is  hardly  in  the  nature  of  a  new  growth.  To  this 
the  term  fibrous  enlargement  is  given. 

The  prostate,  when  examined  per  rectum,  is  not  very  large  ;  it 
is  firm,  smooth,  and  painless. 

The  cystoscope  shows  a  slight,  collar-like  elevation  of  the 
internal  meatus  all  round  its  circumference,  and  the  lumen  of 
the  prostatic  urethra  is  often  so  much  narrowed  that  it  is  difficult 
to  pass  any  but  a  small  catheter.  These  are  the  cases  in  which  the 
operation  of  Bottini  or  of  Freudenberg,  where  cuts  are  made  in 
the  neck  of  the  bladder  by  means  of  the  galvano-cautery  pros- 
tatome,  met  with  much  success. 

This  operation  has  been  practically  abandoned  as  considerable 
mortality  attended  it,  and  quite  equally  good  results  can  be 
obtained  by  much  safer  methods. 

Three  operations  are  now  chiefly  practised  :  (1)  Supra-pubic 
prostatectomy  ;  (2)  perineal  prostatectomy  ;  (3)  perineal  pros- 
tatotomy. 

The  first  two  operations  follow  the  lines  of  the  procedures 
already  described ;  but  enucleation  is  impossible,  and  a  piecemeal 
excision  must  be  done. 

In  attempting  to  enucleate  these  prostates  with  the  finger 
supra-pubically  the  writer  has  seen  much  damage  done  to  the 
neck  of  the  bladder,  resulting  in  stricture  and  great  trouble  in 
after-life. 

Perineal  Prostatotomy. — In  the  writer's  opinion  this  is  the 
operation  of  choice  for  this  limited  class  of  case. 

A  median  grooved  staff  is  passed  into  the  bladder  with  the 
patient  in  the  lithotomy  position,  and  a  small  median  perineal 
incision  is  made  into  the  urethra  immediately  behind  the  bulb. 
A  long  gorget  is  then  run  along  the  groove  of  the  staff  into  the 
bladder,  dilating  the  compressor  and  the  prostatic  urethra.  The 
staff  is  withdrawn  and  the  finger  introduced  along  the  gorget. 
Very  considerable  force  is  often  required  to  introduce  the  finger 
in  these  cases,  as  the  neck  of  the  bladder  is  so  tightly  contracted. 
The  gorget  is  now  withdrawn  and  the  forefinger  of  the  left  hand 


Fibrous  Enlargement  of  the  Prostate.      951 

is  passed  into  the  rectum.  The  mucous  membrane  on  the  floor 
of  the  prostatic  urethra  is  split  by  the  finger-nail,  and  the  whole 
ring  of  the  prostate  is  then  split  in  a  backward  direction  by  the 
finger  in  the  urethra  working  against  the  finger  in  the  rectum  until 
the  neck  of  the  bladder  is  quite  free  and  loose  and  the  finger 
passes  in  and  out  quite  easily.  As  large  a  perineal  drainage  tube 
as  the  passage  will  take  easily  is  now  stitched  in  and  the  patient 
returned  to  bed.  The  tube  can  be  removed  in  two  or  three  days, 
and  the  patient  can  then  be  allowed  to  get  up  and  move  about 
freely. 

Very  often  there  is  complete  incontinence  for  some  days  after 
the  removal  of  the  tube  ;  but  this  soon  ceases,  and  the  patient  not 
only  retains  but  is  also  able  to  void  his  urine  completely.  The 
permanence  of  this  operation  is  beyond  doubt,  for  the  writer  has 
patients  now  alive  and  well  who  were  operated  upon  by  this 
method  more  than  ten  years  ago,  being  then  in  a  condition 
requiring  the  constant  and  frequent  use  of  the  catheter. 

JOHN    PARDOE. 


952 


DISEASES    AND    AFFECTIONS    OF    THE 
BREAST. 

CYSTS. 

MAMMARY  cysts  may  be  divided  into  the  following'  groups : 
(1)  Simple  solitary  cysts,  irritation  acinous  cysts,  serous  inter- 
acinous  cysts ;  (2)  multiple  cysts  associated  with  chronic  interstitial 
mastitis,  so-called  involution  cysts;  (3)  galactoceles ;  (4)  hydatid 
cysts;  (5)  cystic  tumours,  cyst-adenoma,  "cystic  sarcoma,"  cysts 
connected  with  duct  papilloma  and  duct  carcinoma. 

Simple  Cysts. — The  most  satisfactory  treatment  is  excision  of 
the  cyst,  for  although  tapping  and  injection  with  pure  carbolic 
may  bring  about  a  cure,  the  result  is  uncertain.  Moreover,  an 
apparently  simple  cyst  may  be  associated  with  a  growth. 

The  incision  is  made  directly  over  the  cyst,  which  is  then 
enucleated,  if  this  can  be  done  easily.  Should  there  be  any 
difficulty  in  separating  the  cyst  from  the  glandular  tissue,  a  portion 
of  the  latter  should  be  excised  with  the  cyst,  for  otherwise  the  cyst 
is  liable  to  be  opened  and  a  part  of  its  wall  may  be  left  behind. 
The  walls  of  the  cavity  resulting  from  removal  of  the  cyst  are 
brought  into  apposition  by  buried  catgut  sutures,  the  skin  edges 
are  stitched,  and  a  drainage  tube  is  inserted  for  twenty -four  hours. 

In  all  cases  the  walls  of  the  cyst  and  the  surrounding  mammary 
tissue  should  be  examined  microscopically. 

If  for  any  reason  excision  of  the  cyst  is  impossible,  a  cure  may 
be  attempted  by  withdrawing  the  fluid  from  the  cyst  and  allowing 
3  or  4  drops  of  pure  carbolic  acid  to  run  in ;  the  swelling  is  then 
gently  massaged  and  a  firm  bandage  is  applied.  The  inflammation 
excited  by  the  carbolic  acid  may  be  sufficient  to  cause  obliteration 
of  the  cyst,  but  the  method  is  uncertain  and  recurrence  is  common. 

Multiple  Cystic  Disease. — This  disease  often  affects  both 
breasts,  and  is  the  result  of  chronic  interstitial  mastitis,  usually  in 
patients  over  forty  years  of  age. 

Clinically  a  single  cyst  only  may  be  apparent,  and  it  is  important 
to  warn  the  patient  that  other  cysts  may  be  discovered  which 
will  necessitate  removal  of  the  main  part  of  the  breast ;  permission 
should  be  obtained  to  do  whatever  may  be  found  necessary. 

Operation  should  always  be  recommended  in  these  cases  for  the 


Cysts  of  the  Breast.  953 

following  reasons :  (1)  There  must  always  be  an  element  of  doubt 
as  to  the  diagnosis ;  carcinoma  may  co-exist  with  cysts ;  (2)  the 
disease  is  usually  progressive  until  the  breast  becomes  a  mass  of 
cystic  swellings  and  a  cause  of  anxiety  to  the  patient,  which  must 
tell  on  her  general  health  ;  (3)  some  authorities  believe  that  carci- 
noma is  more  likely  to  develop  in  a  cystic  breast  than  in  a 
normal  breast :  this  is  a  matter  of  doubt,  but  doubt  is  an  argument 
in  favour  of  operation. 

Operation. — An  incision  is  made  over  the  cyst,  which  is  then 
excised  with  a  layer  of  the  surrounding  breast  tissue  ;  the  latter 
will  be  noticed  to  be  unusually  hard  but  of  uniform  consistence, 
which  is  quite  distinct  from  the  consistence  of  growth.  The  cyst 
is  usually  recognisable  as  such  from  its  blue  surface,  and  incision 
into  it  is  unnecessary.  The  surrounding  breast  tissue  is  carefully 
examined,  and  in  many  cases  one  or  more  other  cysts  become 
apparent ;  in  these  cases  the  wisest  course  is  to  remove  the  main 
mass  of  breast  tissue.  This  can  be  done  through  a  comparatively 
small  incision  ;  the  nipple  is,  of  course,  left  undisturbed,  and  the 
periphery  of  the  breast,  which  very  rarely  develops  cysts,  is  also 
untouched.  Bleeding  should  be  arrested  as  far  as  possible,  and 
a  drainage  tube  is  inserted  for  twenty-four  to  thirty-six  hours ;  firm 
pressure  is  applied,  and  this  is  most  effectually  done  by  the  use  of 
elastic-cotton  bandages.  Sometimes  it  is  wise  to  approximate  the 
cut  surfaces  of  the  gland  with  catgut  sutures. 

In  my  experience  this  proceeding  will  remove  the  whole  of  the 
cystic  area,  and  the  results  are  excellent ;  comparatively  little 
deformity  is  left,  especially  compared  with  that  of  the  ordinary 
formal  amputation. 

If  open  operation  is  contra-indicated  or  is  refused  by  the  patient, 
the  cysts  may  be  tapped  and  injected  as  they  arise.  This  proceeding 
is  unsatisfactory ;  it  has  to  be  repeated  from  time  to  time,  and  there 
is  no  sense  of  security  or  cure. 

Complete  amputation  of  the  breast  may  be  necessary  when  the 
whole  of  the  breast  is  extensively  involved. 

Galactocele. — A  galactocele  is  a  cyst  containing  inspissated 
milk,  which  arises  during  lactation  and  occasionally  during 
pregnancy.  Treatment  should  not  be  instituted  until  lactation  has 
ceased. 

If  the  cyst  is  small,  it  may  be  treated  by  gentle  massage  daily, 
after  which  the  breast  is  firmly  bandaged.  In  all  other  cases 
excision  is  the  most  satisfactory  treatment,  and  usually  the  cyst 
shells  out  quite  easily.  Tapping  and  injection  rarely  do  any  good. 
An  alternative  but  less  satisfactory  method  of  treatment  is  to  lay 


954  Duct  Papilloma. 

the  cyst  freely  open,  scrape  its  walls  thoroughly,  and  stuff  the  cavity 
with  gauze. 

A  suppurating  galactocele  should  be  treated  as  an  ordinary 
abscess. 

Hydatid  Cysts  are  rare  in  this  country  ;  they  should  be  treated 
by  excision. 

Cysts  with  Intra-cystic  Growths. — These  cysts  are  of  the 
nature  of  cystic  adenomata  and  duct  papillomata,  and  should  be 
treated  as  such.  Excision  of  the  breast  is  usually  advisable,  and  if 
there  is  any  suspicion  of  infiltration  of  the  cyst  wall  by  the  growth, 
the  radical  operation  should  be  performed. 

T.  CRISP  ENGLISH. 


DUCT    PAPILLOMA. 

A  SMALL  duct  papilloma  may  be  excised  locally,  care  being  taken 
that  the  incisions  are  carried  well  free  of  the  growth. 

In  the  majority  of  cases  it  is  wiser  to  amputate  the  breast,  for 
this  tumour  must  be  regarded  as  a  pre-cancerous  condition,  and  the 
full  operation  will  ensure  a  certain  cure.  Amputation  of  the  breast 
for  innocent  tumours  is  a  simple  operation. 

T.  CRISP  ENGLISH. 


955 


FIBRO-ADENOMATA   OF    THE    BREASTS. 

VEKY  small  fibre-adenomata  may  be  left  undisturbed  if  giving  rise 
to  no  symptoms.  Otherwise  removal  of  these  tumours  should  be 
recommended  for  the  following  reasons :  (1)  Neuralgic  pain 
develops  in  connection  with  most  of  the  tumours,  and  this, 
combined  with  the  knowledge  of  the  presence  of  a  tumour,  may 
materially  affect  the  patient's  general  health ;  (2)  if  the  patient 
marries  and  becomes  pregnant,  considerable  increase  in  the  size 
of  the  tumour  occurs  during  pregnancy  and  lactation ;  (3)  slow 
but  steady  growth,  unaffected  by  any  treatment,  is  th'e  rule  in  these 
cases,  and  ultimately  visible  deformity  may  result ;  (4)  occasionally 
a  tumour,  thought  to  be  an  innocent  fibro-adenoma,  proves  to  be  an 
early  sarcoma  or  carcinoma:  I  have  seen  two  such  cases  in  patients 
under  thirty  years  of  age  ;  in  elderly  patients  the  difficulty  of 
positive  diagnosis  is  obviously  greater ;  (5)  it  is  possible  that  in  the 
course  of  time  a  fibro-adenoma  may  prove  the  starting-point  of  a 
malignant  growth. 

For  these  reasons,  if  a  patient  discovers  that  she  has  a  mammary 
tumour,  it  is  for  her  best  interests  that  the  tumour  should  be 
removed,  and  that  she  should  understand  that  the  tumour  is 
innocent  and  non-recurring.  Both  breasts  should  be  carefully 
examined,  for  other  small  tumours  may  be  present,  in  addition 
to  the  one  to  which  attention  has  been  drawn  ;  if  so,  these  should 
be  removed  at  the  same  time. 

Outward  applications,  X-rays  and  the  administration  of  drugs 
have  not  the  slightest  effect  on  fibro-adenomata. 

Operation. — A  full  general  anaesthetic  should  be  given,  unless 
contra-indicated  ;  attempts  to  remove  the  tumour  under  nitrous 
oxide  often  result  in  hurried  and  imperfect  operations.  Local 
anaesthesia  may  be  employed,  if  a  general  anaesthetic  is  contra- 
indicated. 

The  incision  should  usually  be  made  directly  over  the  tumour  in 
a  line  radiating  from  the  nipple.  If  the  tumour  lies  above  the 
nipple  and  it  is  desired  to  place  the  scar  as  low  as  possible,  the 
incision  may  be  made  1  inch  or  more  below  and  to  the  outer  side 
of  the  tumour  ;  the  skin  above  the  incision  is  dissected  up  until 
the  tumour  is  reached. 

AYith  a  few  touches  of  the  knife  the  tumour  is  then  isolated  from 


956 


Fibro- Adenomata. 


the  surrounding  mammary  tissue,  care  being  taken  that  no  small 
lobule  is  left  behind,  for  this  would  lead  to  a  recurrence.  If  there  is 
any  difficulty  in  separating  the  tumour,  it  is  best  to  remove  a  zone  of 
the  surrounding  glandular  tissue  with  it.  All  bleeding  points  should 
be  dealt  with.  The  cavity  is  then  carefully  closed  with  sutures 
passed  deeply,  so  that  it  is  as  far  as  possible  obliterated.  When  the 
tumour  is  deeply  placed  in  the  breast,  it  is  advisable  to  insert  a 
small  drainage  tube,  a  suture  being  placed  on  each  side  of  the  tube 
and  not  tied  until  the  removal  of  the  tube  twenty-four  hours  after 
the  operation  (Fig.  1).  Unless  a  tube  is  inserted,  blood  clot 
tends  to  collect  in  the  wound  and  may  interfere  with  healing. 
The  patient  should,  if  possible,  remain  in  bed  for  three  or  four 

days,  the  arm  being  kept  at  rest 
with  a  sling.  Sutures  should 
be  removed  on  the  sixth  or 
seventh  day.  If  the  wound  is 
a  long  one  and  placed  horizon- 
tally, it  should  be  supported 
with  strapping  or  gauze  and 
collodion,  for  otherwise  the 
weight  of  the  breast  may 
cause  it  to  gape  after  the 
stitches  have  been  taken  out. 
Guillard  Thomas's  operation 

was  devised  for  the  purpose  of  avoiding  a  scar  in  the 
upper  part  of  the  breast.  A  large  incision  is  made  in  the 
submammary  fold,  and  the  breast  is  dissected  up  from  the 
pectoral  fascia;  the  tumour  is  reached  by  incision  through 
the  breast  tissue  from  its  deep  aspect.  All  bleeding  is  carefully 
stopped,  and  the  wound  is  drained  for  twenty-four  hours ;  the 
resulting  scar  lies  in  the  submammary  fold  and  is  unnoticeable.  In 
practice  it  is  found  that  this  procedure  often  involves  a  large  and 
troublesome  operation  for  a  small  tumour.  It  is  almost  always 
possible  by  direct  incision  from  the  front  to  place  the  scar  so  that 
it  does  not  interfere  with  the  wearing  of  evening  dress. 


FIG.  i. 


T.  CRISP  ENGLISH. 


957 


HYPERTROPHY  OF  THE  BREASTS. 

THIS  affection  is  usually  bilateral.  In  moderate  degrees  of  the 
condition  some  good  may  be  done  by  firmly  supporting  the  breasts 
with  elastic  bandaging,  by  the  application  of  mercurial  ointment, 
and  by  the  internal  administration  of  full  doses  of  iodides ;  under 
this  treatment  the  hypertrophy  is  sometimes  arrested,  and  there 
may  even  be  some  diminution  in  the  size  of  the  breasts. 

Many  cases  of  so-called  hypertrophy  of  the  breast  are  really  cases 
of  diffuse  adenomatous  tumours,  for  which  the  only  treatment  is 
excision ;  when  the  nature  of  the  condition  is  recognised,  it  is  some- 
times possible  to  remove  the  tumours  without  sacrificing  the  breast. 

In  marked  cases  of  true  hypertrophy  of  the  breast,  the  only 
treatment  available  is  amputation,  and  this  is  justifiable  when  the 
enlargement  is  so  great  as  to  cause  great  discomfort  and  disfigure- 
ment. There  is  no  particular  difficulty  about  the  operation  as  a 
rule ;  haemorrhage  may  sometimes  be  troublesome,  especially  from 
large  superficial  veins.  As  far  as  possible,  vessels  should  be  secured 
before  division. 

T.  CRISP  ENGLISH. 


958 


INFLAMMATORY    AFFECTIONS    OF    THE     BREAST. 

PAINFUL  engorgement  of  the  breast  is  not  uncommon  during  the 
first  few  days  of  lactation,  and  is  usually  the  result  of  inefficient 
suckling.  A  large  fomentation  should  be  applied  to  the  breast, 

which  should  be  firmly  supported 
by  a  bandage  ;  if  necessary,  the 
breast-pump  may  be  used  to 
relieve  the  tension,  after  which 
efforts  must  be  made  to  induce 
the  infant  to  efficiently  empty 
the  breast,  if  suckling  is  to  be 
continued. 

When  inflammatory  signs 
appear,  prompt  measures  should 
be  taken  to  prevent  the  forma- 
tion of  an  abscess.  Any  cracks 
or  fissures  of  the  nipples  should 
be  treated  vigorously.  Hot 
fomentations  should  be  applied 
every  three  hours,  and  a  firm 
bandage  should  support  the 
breast  and  fix  the  arms  ;  a  brisk 
purge  should  be  given  at  once, 
and  any  undue  tension  in  the 
breast  should  be  reduced  by  the  use  of  the  breast-pump. 

Poultices  should  not  be  used,  for  they  make  asepsis  difficult  if  an 
incision  for  an  abscess  becomes  necessary. 

Mammary  Abscess — Prophylaxis  consists  in  the  proper  atten- 
tion to  the  nipples  and  the  breasts,  and  especially  in  the  thorough 
treatment  of  cracks  and  fissures  of  the  nipples. 

A  mammary  abscess  should  be  opened  as  early  as  possible ;  the 
results  of  delay  are  extensive  destruction  of  breast  tissue,  the  forma- 
tion of  sinuses,  and  a  tedious  convalescence.  In  the  worst  cases  in 
which  an  abscess  has  been  allowed  to  burst  through  the  skin 
amputation  of  the  breast  often  becomes  necessary. 

There  may  be  some  difficulty  in  deciding  whether  an  acute 
mastitis  has  led  to  the  formation  of  pus.  The  following  symptoms 


FIG.  1. 


Inflammatory  Affections  of  the  Breast.     959 


indicate  the  presence  of  pus,  and  justify  incision  :  (1)  Insomnia  ;  (2) 
fixation  or  cedema  of  the  skin  over  the  inflamed  area ;  (3)  continued 
rise  of  temperature  ;  and  (4)  failure  of  the  inflammation  to  resolve 
under  the  treatment  described  for  mastitis. 

The  incision  should  be  free,  and  should  be  placed  over  the  lowest 
part  of  the  abscess  ;  if  it  passes  through  breast  tissue,  it  should 
radiate  from  the  nipple  to  avoid  division  of  the  main  ducts.  Its 
exact  position  depends  upon  the  situation  of  the  abscess,  and  the 
annexed  diagrams  show  the  best 
positions  for  incisions  (Figs.  1 
and  2). 

Most  mammary  abscesses  are 
multi-locular ;  therefore,  as  soon 
as  the  abscess  is  opened,  a  finger 
should  be  introduced  and  the 
walls  between  the  loculi  should  be 
broken  down,  so  that  a  single 
open  cavity  is  made.  This  cavity 
should  not  be  scraped,  rubbed  with 
gauze,  or  irrigated.  A  large 
drainage  tube  is  inserted ;  one 
f  inch  in  diameter  is  best,  but  if 
this  is  not  available,  two  smaller 
tubes  may  be  used  ;  tubes  are  best 
retained  in  position  by  stitches. 
A  fomentation  of  gauze  is  then 
applied.  The  fomentation  is  re- 
applied  two  or  three  hours  later, 
and  should  be  repeated  every  three 
hours  during  the  first  two  days ; 

after  this  the  dressing  is  changed  two  or  three  times  a  day  according 
to  the  amount  of  discharge.  It  is  sometimes  advisable  to  excise  a 
portion  of  the  breast  tissue  to  ensure  a  free  opening  into  the  abscess 
cavity,  and  in  neglected  cases  several  incisions  may  be  necessary. 

The  breast  should  be  well  supported  by  the  bandage,  and  the  arm 
should  be  placed  in  a  sling  in  order  to  rest  the  pectoral  muscles. 
The  patient  is  propped  up  in  bed  to  encourage  free  drainage  ;  diet 
should  be  light  and  fluids  should  be  restricted.  Free  action  of  the 
bowels  is  important,  and  regular  doses  of  magnesium  sulphate 
may  be  given.  The  tube  is  gradually  shortened  as  the  discharge 
diminishes,  and  later  is  replaced  by  a  plug  of  gauze. 

During  convalescence  attention  must  be  paid  to  the  general 
health.  Good  food,  plenty  of  fresh  air  and  tonics  are  of  importance ; 


FIG.  2. 


960     Inflammatory  Affections  of  the  Breast. 

iron,  quinine,  nux  vomica  and  purgatives  are  useful.     If  progress 
is  slow,  the  patient  may  be  sent  to  the  seaside. 

An  alternative  line  of  treatment  is  that  by  Bier's  vacuum  cups  ;  a 
comparatively  small  incision  is  made  into  the  abscess,  and  a  vacuum 
cup  is  applied  to  the  incision  three  times  a  day.  It  is  claimed  that 
more  rapid  healing  occurs  with  this  proceeding.  (For  details  see 
Bier's  Treatment  by  "  Hyperaemia,"  Vol.  III.) 

Mastitis  in  Infants. — Fomentations  should  be  applied,  and  an 
incision  must  be  made  at  once  if  there  are  signs  of  suppuration,  for 
otherwise  a  general  infection  is  apt  to  occur. 

Mastitis  at  Puberty. — A  mild  form  of  mastitis  is  not  uncommon 
at  puberty,  and  occasionally  terminates  in  suppuration.  It  should 
be  treated  on  the  lines  already  described.  Irritation  by  corsets  or 
by  brace-buckles  should  be  avoided. 

Supra-mammary  Abscess. — This  is  usually  due  to  infection  of 
a  superficial  lobule  of  the  mammary  gland,  and  should  be  treated 
by  free  incision. 

Infra-mammary  Abscess. — This  affection  shows  itself  by  for- 
ward projection  of  the  breast,  and  by  oedema  or  fluctuation  at  its 
periphery,  usually  at  the  lower  and  outer  aspect.  Most  of  the 
cases  are  chronic  and  of  tuberculous  origin,  the  result  of  tuberculosis 
of  an  underlying  rib. 

An  acute  abscess  should  be  opened  freely  from  the  lower  and 
outer  aspect  of  the  breast;  if  drainage  is  efficient,  rapid  healing 
usually  follows. 

A  chronic  tuberculous  abscess  should  be  approached  from  the 
same  region,  and  should  be  treated  like  other  tuberculous  abscesses. 
In  most  cases  drainage  must  be  established,  and  rest  of  the  neigh- 
bouring parts  by  fixation  of  the  arm  and  firm  support  of  the  breast 
is  essential.  When  a  rib  is  diseased,  it  may  be  necessary  to 
excise  the  affected  portion.  In  this  case  the  incision  is  enlarged 
and  the  breast  is  reflected  upwards  in  order  to  expose  the  diseased 
bone. 

Persistent  Sinuses. — It  sometimes  happens  that  sinuses  follow 
a  mammary  abscess  and  show  little  sign  of  healing.  This  is 
usually  evidence  of  poor  general  health,  or  of  inefficient  treatment 
and  drainage  of  the  abscess. 

The  sinuses  should  be  freely  opened  up.  The  walls  of  each  sinus 
are  then  thoroughly  scraped  or  excised,  and  the  parts  are  swabbed 
with  pure  carbolic,  the  excess  of  the  acid  being  washed  away  with 
boracic  lotion ;  gauze  plugging  is  then  firmly  inserted. 

Treatment  of  the  general  health  by  fresh  air,  abundance  of  nutri- 
tious food  and  tonics  is  essential.  Vaccines  may  help  in  these  cases  : 


Inflammatory  Affections  of  the  Breast.     961 

the  vaccine  should,  if  possible,  he  prepared  from  the  actual  organisms 
found  in  the  sinus. 

In  long-standing  cases,  where  the  sinuses  are  many  and  indurated, 
amputation  of  the  breast  may  be  necessary.  The  operation  needs 
careful  performance ;  as  little  skin  as  possible  should  be  sacrificed, 
and  free  drainage  should  be  established,  especially  as  union  of  the 
skin  flaps  is  often  unsatisfactory. 

Chronic  Lobar  Mastitis. — This  affection  involves  one  or  two 
lobes  of  the  breast  only,  and  is  seen  most  often  after  lactation  as 
the  result  of  imperfect  involution.  It  also  follows  injuries  and  the 
irritation  of  ill-fitting  corsets. 

Treatment  consists  in  the  removal  of  any  source  of  irritation  and 
the  application  of  a  belladonna  or  mercurial  plaster.  Rest  is  also 
secured  by  wearing  the  arm  in  a  sling.  If  the  condition  is  very 
painful  a  blister  should  be  applied,  and  may  be  repeated  if  neces- 
sary. Attention  should  always  be  paid  to  the  patient's  general 
health.  Excision  of  the  affected  portion  of  the  breast  should  be 
recommended,  if  these  measures  fail  to  cause  improvement. 

The  effect  of  ill-fitting  corsets  in  producing  a  chronic  traumatic 
mastitis  has  been  drawn  attention  to  by  Mr.  G.  Lenthal  Cheatle.1 
In  the  cases  described  by  him  the  mastitis  was  found  in  the  lower  and 
outer  part  of  the  breasts,  usually  on  both  sides,  and  was  obviously 
due  to  the  irritation  of  the  stay-bones  or  steels  when  the  patient 
bends  forward  or  laterally.  This  condition  may  be  prevented  and 
cured  by  the  wearing  of  properly  made  corsets. 

Chronic  Interstitial  Mastitis  (Chronic  Lobular  Mastitis). — 
This  form  of  mastitis  occurs  chiefly  in  women  between  forty  and 
fifty  years  of  age,  and  often  affects  both  breasts. 

Treatment  varies  considerably  in  different  cases.  In  mild  cases 
it  is  sufficient  to  order  gentle  rubbing  with  belladonna  liniment, 
and  to  see  that  the  breasts  are  well  supported  by  the  corsets. 
Ill-fitting  corsets  are  often  responsible  for  the  condition.  In  more 
marked  cases  the  breast  should  be  strapped  with  mecurial  plaster, 
and  iodides  and  iron  should  be  administered  internally.  Treatment 
by  X-rays  is  recommended  by  Mr.  Sampson  Handley.3 

In  obstinate  cases  in  which  the  condition  is  extensive  and  causes 
the  patient  much  pain  and  worry,  the  wisest  course  is  to  excise  the 
affected  portion  of  the  breast.  This  can  be  done  through  a  8-inch 
incision  in  the  lower  part  of  the  breast,  the  nipple  and  the  periphery 
of  the  breast  being  spared.  Some  authorities  recommend  that  the 
breast  should  always  be  excised  in  these  cases,  on  the  grounds  that 
the  condition  is  pre-cancerous.  It  is,  however,  very  doubtful  whether 
chronic  mastitis  renders  a  breast  more  liable  to  malignant  disease. 

S.T. — VOL.  ii.  61 


962     Inflammatory  Affections  of  the  Breast. 

Chronic  Mammary  Abscess  occurs  occasionally  during  preg- 
nancy, and  more  often  during  the  latter  part  of  lactation  or  after 
weaning.  The  possibility  of  a  tuberculous,  origin  should  always  be 
remembered.  The  abscess  cavity  should  be  freely  laid  open,  its 
walls  thoroughly  scraped,  and  the  cavity  should  be  packed  with 
gauze  and  be  allowed  to  heal  from  the  bottom. 

Convalescence  may  be  considerably  shortened  by  excision  of  the 
walls  of  the  abscess.  The  resulting  cavity  is  swabbed  out  with  a 
1  in  1,000  solution  of  mercuric  chloride  or  1  per  cent,  formalin, 
and  is  freely  drained. 

T.  CRISP  ENGLISH. 

REFERENCES. 

1  Cheatle,  G.  Lenthal,  "  Chronic  Traumatic  Mastitis,"  Brit.   Med.  Journ., 
1911,  L,  p.  492. 

2  Handley,  W.  Sampson,  Practitioner,  1910,  LXXXIV.,  p.  463. 


963 


MALIGNANT  DISEASE  OF  THE  BREAST. 

INDICATIONS  FOR  OPERATION. 

IN  many  cases  it  is  at  once  clear  that  operation  is  the  only 
practicable  course ;  in  others  it  is  equally  certain  that  operation 
would  be  futile  or  even  harmful.  But  there  are  a  large  number  of 
border-line  cases  in  which  it  is  exceedingly  difficult  to  say  whether 
or  not  an  operation  should  be  advised. 

Operation  should  always  be  urged  as  early  as  it  can  be  arranged, 
unless  there  is  some  definite  centra-indication  in  the  local  or 
general  condition.  Under  no  circumstances  should  the  medical 
attendant  consent  to  a  policy  of  delay  or  to  the  trial  of  any  non- 
operative  measure  when  operation  offers  a  reasonable  chance  of 
eradicating  the  disease. 

Results  of  Operative  Treatment. — About  70  per  cent,  of  the 
cases  which  come  under  observation  are  suitable  for  the  radical 
operation,  and  with  earlier  recognition  of  the  disease  this  pro- 
portion is  increasing. 

Surgeons  who  have  practised  the  radical  operations  are  agreed 
that  permanent  cure  follows  in  40  to  50  per  cent,  of  the  cases. 
The  most  careful  investigation  has  been  made  of  the  after-results 
of  the  cases  operated  upon  by  Professor  Halsted  in  the  Johns 
Hopkins  Hospital.  These  results  emphasise  how  much  can  be 
done  by  thorough  operating  : 


Well  for 

Permanent 

Per  cent. 

Per  cent. 

Axillary  glands  not  affected  microscopically 

85 

74 

Axillary  glands  affected          ...... 

31 

24 

Supra-clavicular  gland*  removed  and  found  affected 

10 

7 

The   mortality   of  the   operation   in   this   series   of   cases    was 

2  per  cent.,  but  in  the  later  cases  less  than  '8  per  cent. ;  when  the 
supra-clavicular   glands   also   were    removed,   the    mortality   was 

3  per  cent.      Local  recurrences  after  the  radical  operation  were 
only  met  with  in  10  per  cent,  of  Professor  Halsted's  cases,  and 
were  never  seen  after  the  lapse  of  three  years. 

61—2 


964          Malignant  Disease  of  the  Breast. 

The  prognosis  depends  upon  many  factors :  the  nature,  situation 
and  extent  of  the  growth,  the  age  and  physical  condition  of  the 
patient.  The  figures  quoted  above  show  that  no  factor  is  of  more 
importance  than  the  condition  of  the  axillary  glands  ;  when  they 
were  unaffected,  three  patients  out  of  four  were  cured,  but  when 
they  were  found  to  be  diseased,  only  one  patient  out  of  four  was 
saved.  There  could  be  no  stronger  argument  than  this  in  favour 
of  operation  at  the  earliest  possible  date. 

Certain  local  conditions  obviously  negative  any  attempt  at  a 
radical  operation.  These  are :  (1)  Fixation  of  the  growth  to  the 
chest  wall ;  (2)  extensive  implication  of  the  skin,  either  in  the 
form  of  widely  scattered  nodules,  or  of  extensive  brawny  infil- 
tration— "cancer  en  cuirasse  "  ;  (3)  definite  lymphatic  oedema  of 
the  arm ;  (4)  implication  of  the  axillary  vessels  and  nerves ; 
(5)  deposits  in  the  viscera  or  bones ;  (6)  extensive  involvement  of 
the  supra-clavicular  glands. 

Enlargement  of  the  Supra-clavicular  Glands  is  usually,  but 
not  necessarily,  a  contra-indication  to  the  radical  operation.  As 
a  rule,  when  the  disease  has  reached  the  supra-clavicular  glands 
and  their  enlargement  is  palpable,  there  is  already  growth  in  the 
mediastinum  or  in  other  inaccessible  parts,  so  that  operation  is 
futile.  When  the  glandular  enlargement  takes  the  form  of  a  fixed 
mass  dipping  down  behind  the  sterno-mastoid,  operation  is  quite 
useless  ;  removal  of  the  mass  is  exceedingly  difficult,  if  possible  at 
all,  and  there  is  always  further  disease  out  of  reach.  On  the  other 
hand,  when  the  glands  are  only  slightly  enlarged  and  are  not  fixed, 
it  may  be  possible  to  eradicate  completely  the  disease.  Eemoval 
of  these  glands  often  proves  quite  easy,  and  it  may  happen  that 
there  are  no  other  glands  involved. 

Each  case  must,  therefore,  be  considered  on  its  merits.  It  is 
obvious  that  glands  are  palpable  at  an  earlier  date  in  those  who  are 
naturally  thin,  whereas  palpable  glands  in  those  who  are  very  stout 
usually  mean  that  the  disease  in  the  neck  is  advanced  and 
beyond  complete  removal.  It  should  also  be  remembered  that 
the  enlargement  of  glands  is  not  necessarily ,  malignant ;  slightly 
enlarged  and  movable  glands  often  prove  to  be  free  of  growth. 

Atrophic  Scirrhus  is  thought  by  some  surgeons  to  be  unsuit- 
able for  operation,  on  the  ground  that  the  course  of  this  type  of  the 
disease  is  usually  very  slow.  The  majority  of  patients  with 
atrophic  scirrhus,  however,  ultimately  die  from  internal  deposits  ; 
many  of  them  suffer  from  a  great  deal  of  local  pain  and  discom- 
fort, and  the  knowledge  that  they  have  a  tumour  of  the  breast  is  a 
constant  source  of  mental  distress.  Moreover,  these  tumours, 


Malignant  Disease  of  the  Breast.          965 

which  are  apparently  atrophic,  may  suddenly  take  on  rapid 
growth,  and  they  then  soon  become  irremovable. 

On  the  other  hand,  thorough  operation  offers  these  patients  a 
particularly  good  chance  of  permanent  cure,  and  it  at  once  relieves 
the  local  symptoms  and  mental  distress.  There  may  be  some 
obvious  contra-indication  to  operation,  such  as  visceral  disease  or 
advanced  age  of  the  patient,  but  most  of  the  patients  suffering 
from  atrophic  scirrhus  would  not  be  considered  too  old  for 
operation  if  the  growth  were  of  the  ordinary  type. 

Therefore,  cases  of  atrophic  scirrhus  should  be  submitted  to 
early  and  thorough  operation,  unless  the  patient  is  very  old  or 
very  feeble,  or  unless  there  is  some  other  definite  contra-indication. 

Carcinoma  of  both  Breasts  obviously  presents  a  serious 
prognosis,  but  does  not  necessarily  contra-indicate  operation.  The 
question  may  be  decided  in  the  following  way :  Each  breast  should 
be  considered  by  itself,  and  a  decision  should  be  made  as  to  whether 
operation  would  be  advised  for  the  disease  in  that  particular 
breast,  if  the  other  breast  were  not  affected  ;  if  one  can  answer  in 
the  affirmative  as  regards  each  breast  individually,  then  operation 
for  both  sides  should  be  recommended. 

If  operation  is  decided  upon,  the  best  plan  as  a  rule  is  first  to 
deal  with  the  more  seriously  affected  breast,  and  then  to  allow  a 
fortnight  or  so  to  elapse  before  the  other  breast  is  removed ;  in  this 
way  a  more  thdrough  and  complete  removal  of  the  disease  is 
possible  than  if  both  sides  are  dealt  with  at  once.  In  fact,  it  is 
doubtful  whether,  under  any  circumstances,  it  is  justifiable  to 
perform  the  radical  operation  on  both  breasts  on  the  same 
day. 

Pregnancy  is  a  grave  complication  in  mammary  cancer,  but  it 
should  never  be  made  a  reason  for  postponement  of  operation.  In 
considering  the  question  of  treatment,  two  main  facts  present 
themselves :  The  fearful  rapidity  with  which  mammary  cancer 
grows  during  pregnancy  and  lactation,  and  the  risk  of  miscarriage 
after  the  necessarily  extensive  operation.  The  case  should  be 
treated  exactly  as  if  the  pregnancy  did  not  exist ;  delay  means  rapid 
increase  in  the  growth,  and  probably  early  death.  Moreover,  there 
is  still  the  liability  to  miscarriage  or  non-survival  of  the  child.  On 
the  other  hand,  the  risks  of  miscarriage  after  operation  are  not  great. 
I  have  several  times  operated  on  these  cases  without  disturbance  of 
pregnancy.  If  the  patient  is  in  the  last  month  of  pregnancy, 
labour  should  be  induced  at  once,  and  the  growth  should  be  removed 
a  short  time  after. 

The  Age  of  the  Patient  is  a  factor  of  importance.     In  young 


966          Malignant  Disease  of  the  Breast. 

subjects,  the  prognosis  is  grave.  As  a  rule,  the  growth  spreads 
rapidly,  and  visceral  deposits  are  often  present  when  the  case  first 
conies  under  observation  ;  for  this  reason,  a  very  searching 
examination  is  imperative  before  the  complete  operation  is  decided 
upon. 

In  very  old  patients — say  those  over  seventy  years  of  age — many 
points  must  be  considered  before  a  decision  is  reached  as  to  the 
extent  of  operation,  if  any.  An  estimate  should  first  be  made  of 
the  patient's  practical  age,  for  a  patient  is  often,  for  surgical  pur- 
poses, much  younger  or  older  than  the  actual  number  of  years  she 
has  lived.  Therefore,  a  thorough  general  examination  should  be 
made,  especial  attention  being  paid  to  the  condition  of  the  heart, 
lungs,  arteries  and  urine.  An  estimate  should  also  be  made  of  the 
rate  at  which  the  tumour  is  growing,  and  the  length  of  time  which 
is  likely  to  elapse  before  the  patient  dies  if  no  operation  is  per- 
formed. Accuracy  in  a  matter  of  this  kind  is  obviously  impossible, 
but  with  care  and  experience  an  approximate  result  may  be  obtained. 
Usually,  carcinoma  grows  very  slowly  in  old  subjects,  and  soineT 
times  it  is  obvious  that  the  patient  is  more  likely  to  die  from  other 
causes  before  the  growth  is  sufficiently  advanced  to  cause  more 
trouble  or  to  kill  her. 

In  patients  over  seventy  it  is  usually  advisable  to  perform  a 
modified  operation,  limiting  its  duration  to  half  an  hour. 

Diabetes  was  formerly  considered  a  centra-indication  to  any 
extensive  operation,  owing  to  the  risks  of  sepsis.  Nowadays  this 
risk  should  be  of  little  account ;  but  it  is  necessary  to  avoid  as  far 
as  possible  making  extensive  skin  flaps,  as  these  are  likely  to  slough. 
A  careful  quantitative  analysis  of  the  sugar  in  the  urine  should  be 
made,  and  time  should  be  devoted  to  the  reduction  of  the  amount 
as  far  as  possible  by  rigorous  dieting  and  medical  treatment.  A 
full  course  of  alkalies  should  also  be  given,  in  order  to  minimise  the 
risk  of  coma  following  the  operation.  In  fact,  if  possible,  it  is 
advisable  to  wait  until  the  urine  is  alkaline  before  operating. 

Chronic  Alcoholism  and  Cirrhosis  may  contra-indicate 
operation.  If  operation  is  decided  upon,  the  patient  should  be 
placed  under  strict  medical  treatment  for  at  least  a  fortnight.  It  is 
often  wise  to  modify  the  extent  of  the  operation.  It  should  be 
rapidly  performed,  and  especial  care  should  be  taken  to  secure  all 
bleeding  points  before  closing  the  wound. 

Chronic  Bronchitis  is  a  serious  complication  in  stout  subjects. 
Acute  symptoms  are  liable  to  follow  the  anaesthetic  and  the  inter- 
ference with  the  movements  of  the  chest  caused  by  the  wound  and 
the  bandages.  Light  anaesthesia  and  quick  operating  are  essential. 


Malignant  Disease  of  the  Breast.          967 

OPERATIONS    FOR    MAMMARY    CANCER. 

(1)  The  Eadical  Operation  ;  (2)  Palliative  Operations ;  (3)  Ke- 
moval  of  "  Kecurrent  "  Growths. 

The  Radical  Operation.— The  term  "  radical  operation  "  is 
applied  to  the  operation  in  which  an  attempt  is  made  to  produce  a 
radical  cure  by  the  removal  of  the  whole  of  the  disease.  In  former 
days,  this  expression  would  scarcely  have  been  admissible  in  view 
of  the  large  number  of  cases  in  which  recurrence  took  place,  but  at 
the  present  time,  with  more  thorough  methods  of  operating,  it  is 
possible  in  a  large  proportion  of  cases  completely  to  remove  the 
disease  and  effect  a  permanent  cure. 

Preparation  of  the  Patient. — Two  evenings  before  the  day  of 
operation  the  patient  is  given  a  hot  bath,  after  which  she  is 
vigorously  rubbed  down,  so  that  the  skin  acts  freely.  On  the 
following  evening  the  bath  is  repeated,  the  axilla  is  shaved,  the 
operation  area  thoroughly  prepared,  and  a  large  sterilised  dressing 
is  applied.  The  nurse  should  be  given  careful  instructions  to  pre- 
pare the  skin  over  a  sufficiently  wide  area,  that  is  to  say,  from  the 
neck  above  to  the  umbilicus  below,  from  the  scapular  line  to  the 
opposite  breast,  and  also  the  whole  of  the  arm.  Unless  these 
directions  are  given,  it  is  likely  that  an  insufficient  area  of  skin  will 
be  prepared. 

The  iodine  method  may  be  used  for  the  preparation  of  the  skin  ; 
it  presents  a  special  advantage,  in  that  the  preparation  need  not  be 
started  until  the  morning  of  the  operation,  so  that  the  patient,  being 
free  from  the  discomforts  of  the  dressings  and  bandages,  is  more 
likely  to  sleep  well  during  the  night  before  operation.  Early  in  the 
morning  the  axilla  is  shaved  and  the  dry  skin  of  the  operation  area 
is  painted  with  a  2  per  cent,  solution  of  iodine  in  rectified  spirit, 
especial  attention  being  paid  to  the  axilla ;  a  dry  sterilised  towel  is 
then  applied.  As  soon  as  the  patient  is  under  the  anaesthetic,  the 
solution  is  re-applied. 

Considerable  shock  sometimes  follows  the  radical  operation  in 
feeble  subjects  ;  but  this  is  seldom  the  case  if  the  patient  is  properly 
prepared,  and  the  operation  is  performed  with  speed  and  care.  In  the 
prevention  of  shock,  the  following  points  are  of  special  importance : 
(1)  It  is  very  desirable  that  the  patient  should  have  a  good  night's 
rest  before  the  operation,  and  if  she  is  sleeping  badly,  a  hypodermic 
injection  of  morphia  and  atropine  may  be  given  on  the  night  before 
the  operation  ;  (2)  the  body  warmth  should  be  carefully  main- 
tained throughout  the  operation,  for  a  large  surface  is  exposed  ;  the 
lower  half  of  the  trunk  and  the  thighs  should  be  wrapped  in  wool, 


968          Malignant  Disease  of  the  Breast. 

and  the  legs  should  be  clad  in  thick  woollen  stockings ;  the  operat- 
ing table  should  be  kept  heated  throughout,  hot-water  bottles  being 
used  if  the  table  itself  cannot  be  heated  ;  the  temperature  of  the 
operating  room  must  be  watched  and  needless  opening  of  doors 
avoided ;  (3)  haemorrhage  should  be  avoided  as  far  as  possible  ; 
vessels  should  be  secured  before  division  whenever  possible,  and  a 
large  number  of  artery  forceps  should  be  in  readiness  :  at  least  two 
dozen  are  necessary. 

An&sthetic. — The  choice  of  anaesthetic  in  these  cases  is  specially 
discussed  in  the  section  on  Anaesthetics  (see  Vol.  III.).  Particular 
care  is  necessary,  for  the  extensive  wound  on  the  chest  wall  and  the 
subsequent  bandaging  are  liable  to  cause  pulmonary  complications, 
especially  in  stout,  elderly  women.  After  the  incisions  have  been 
made,  very  little  anaesthetic  is  required,  until  the  last  stage  of  the 
operation  when  the  wound  is  sutured. 

Position. — The  patient  lies  with  the  affected  side  well  over  the 
margin  of  the  operating  table,  and  with  the  shoulders  moderately 
raised  by  a  pillow,  and  her  head  turned  to  the  opposite  side.  The 
arm  is  fixed  by  a  bandage  at  a  right  angle  to  the  trunk.  This  is  a 
more  satisfactory  plan  than  having  it  held  by  an  assistant,  for  the 
slightest  alteration  in  position  produces  disturbances  in  the  rela- 
tions of  the  structures  in  the  axilla,  and  may  mislead  the  operator  ; 
moreover,  hyper-extension  may  give  rise  to  pressure  paralysis. 

Exploration  of  the  Tumour. — Whenever  there  is  the  slightest 
doubt  as  to  the  nature  of  the  tumour,  the  first  step  should  be  an 
exploratory  incision  into  or  on  to  the  tumour.  It  has  already  been 
pointed  out  that  the  diagnosis  often  presents  the  greatest  difficulty, 
and  that  malignant  disease  may  be  exactly  simulated  by  innocent 
conditions.  The  study  of  the  records  of  any  hospital  will  supply 
instances  of  cases  in  which  breasts  have  been  removed  for  chronic 
abscesses,  deep-seated  cysts  and  innocent  tumours.  In  all  doubtful 
cases,  therefore,  a  preliminary  incision  should  be  made.  This 
procedure  has  been  fully  discussed  above. 

There  are  two  small  points  to  remember  in  connection  with  this 
exploratory  incision.  In  the  first  place  care  must  be  taken  to  avoid 
carrying  the  incision  through  the  tumour  into  the  deeper  parts,  for 
cancer  cells  may  thus  be  engrafted  into  the  muscles  of  the  thoracic 
wall.  Secondly,  the  knife,  instruments  and  gloves  used  during  the 
incision  into  the  tumour  must  not  be  employed  to  continue  the 
operation ;  this  seems  a  very  obvious  precaution,  but  is  one  which 
is  not  infrequently  neglected. 

When  a  tumour  has  been  incised  and  is  found  to  be  malignant, 
all  bleeding  points  should  be  secured,  and  the  surface  of  the  wound 


Malignant  Disease  of  the  Breast.          969 

is  swabbed  over  with  pure  carbolic  acid  or  1  per  cent,  formalin  ; 
after  which  the  skin  incision  is  firmly  sutured,  and  the  complete 
operation  is  then  undertaken. 

The  operation  may  be  divided  into  three  stages  :  (1)  The  incision ; 
(2)  the  axillary  dissection ;  and  (3)  the  removal  of  the  breast  and 
pectoral  muscle?.  In  most  cases  it  is  best  to  dissect  away  the 
axillary  fascia  arid  lymphatics  before  the  breast  is  removed.  This 
procedure  has  many  advantages :  it  deals  with  the  highest  point  of 
possible  infection  first ;  blood-vessels  are  secured  early,  so  that  sub- 
sequent bleeding  is  less ;  the  large  area  laid  bare  by  the  removal  of 


FK;.  1. — Incisions  for  radical  operation.     Shaded  area  represents  position  of  growth. 

the  pectorals  is  exposed  for  a  comparatively  short  time,  and  thus 
shock  and  risk  of  infection  are  diminished. 

(1)  Incision. — The  incision  is  planned  according  to  the  position 
of  the  tumour  in  the  breast,  and  the  annexed  diagram  (Fig.  1) 
shows  those  most  frequently  used.  The  essential  point  in  making 
the  incision  is  the  inclusion  of  a  wide  area  of  skin  in  the  neighbour- 
hood of  the  growth,  and  this  in  view  of  the  fact  that  otherwise 
recurrences  are  very  common  in  the  region  of  the  scar ;  free 
removal  of  the  skin  is  imperative,  compared  with  which  the  closure 
of  the  wound  is  of  quite  secondary  importance. 

The  portion  of  skin  removed  should  be  more  or  less  circular,  and 


970          Malignant  Disease  of  the  Breast. 

at  least  5  inches  in  diameter.  Its  centre  should  correspond  with 
the  position  of  the  growth  and  not  with  that  of  the  nipple ;  in  fact 
the  nipple  should  be  ignored  in  the  planning  of  the  incisions. 

The  upper  portion  of  the  incision  is  carried  in  a  curve  over  the 
pectoralis  major,  so  that  ready  access  is  obtained  to  the  clavicle 
above  and  to  the  upper  part  of  the  brachial  artery  below.  The 
incision  should  be  carried  well  down  on  to  the  abdominal  wall,  so 
that  the  fat  and  fascia  over  the  lower  ribs  and  the  epigastrium  may 
be  thoroughly  removed.  Only  in  recent  years  has  it  been  recog- 
nised that  extension  of  the  disease  not  infrequently  occurs  in  this 
direction.  This  is  one  further  step  in  the  complete  operation, 
and  another  argument  against  the  very  imperfect  operations  so 
frequently  practised. 

(2)  The  Axillary  Dissection. — As  soon  as  these  incisions  have 
been  made,  the  skin  in  the  upper  part  is  dissected  up,  to  thoroughly 
expose  the  upper  part  of  the  pectoralis  major  and  the  anterior 
aspect  of  the  axilla.  The  tendinous  insertion  of  the  pectoralis 
major  into  the  humerus  is  then  divided  transversely,  a  finger 
placed  under  it  raising  it  to  avoid  injury  to  the  underlying  vessels  : 
the  main  portion  of  the  muscle  is  then  separated  from  the  clavicular 
portion,  and  the  insertion  of  the  pectoralis  minor  is  similarly 
divided.  Branches  of  the  acromio-thoracic  vessels  running  to  the 
under-surface  of  the  muscles  are  secured,  and  the  muscles  are  then 
reflected  downwards  and  inwards. 

The  highest  portion  of  the  axillary  vein  is  then  exposed,  and  the 
whole  of  the  axillary  fat  and  fascia  with  the  lymphatics  is  carefully 
dissected  off  the  main  vessels  from  above  downwards,  branches  of 
the  vessels  being  systematically  secured  before  division ;  a  blunt 
dissector  is  very  useful  at  this  stage,  and  Kelly's  comb  or 
a  gauze-covered  finger  is  of  great  assistance.  Nerves  must  be 
sacrificed  when  they  cannot  be  isolated  easily,  and  when  their 
preservation  increases  risk  of  leaving  any  infected  tissue  behind  ; 
the  intercosto-humeral  is  usually  divided,  but  if  possible  sub- 
scapular  nerves  should  be  spared. 

The  dissection  includes  the  tissues  around  the  upper  part  of  the 
brachial  artery  and  about  the  subscapular  vessels ;  especial  care  is 
needed  in  removal  of  prolongations  of  fascia  in  front  of  and  behind 
the  axillary  vessels  and  that  lying  over  the  serratus  magnus,  and 
between  this  muscle  and  the  subscapularis.  In  many  of  the  more 
advanced  cases  it  will  be  found  that  infected  glands  are  adherent  to 
the  axillary  vein,  and  in  such  cases  it  is  useless  to  attempt  to  dis- 
sect them  from  the  vessel,  for  this  proceeding  will  certainly  fail  to 
remove  the  whole  of  the  infected  tissue ;  a  portion  of  the  vein  must 


Malignant  Disease  of  the  Breast.  971 

be  excised  after  ligatures  have  been  placed  above  and  below  the 
involved  area. 

The  dissected  axillary  tissues  are  now  attached  to  the  mammary 
area  only,  all  vessels  are  tied,  and  a  cloth  wrung  out  of  hot  saline 
solution  is  inserted  in  the  axilla. 

(3)  Removal  of  the  Breast  and  Pectoral  Muscles. — The  skin  flaps 
are  now  dissected  up  below :  internally  as  far  as  the  sternum, 
externally  to  the  latissimus  dorsi,  and  below  to  the  middle  of  the 
epigastrium.  The  mass  to  be  removed  is  raised,  and  the  inner 
attachments  of  the  pectoral  muscles  are  severed ;  the  perforating 
branches  of  the  internal  mammary  artery  are  encountered  here 
and  should  be  secured  before  division,  otherwise  they  are  liable  .to 
retract  and  cause  some  difficulty.  The  whole  mass  is  then  removed, 
as  large  an  area  as  possible  of  deep  fascia  being  included. 

The  wound  is  then  flushed  out  with  hot  saline  solution,  and  all 
bleeding  points  are  tied  with  fine  catgut ;  forci-pressure  alone  should 
not  be  trusted  to.  Particular  care  must  be  taken  in  ligature  of 
branches  of  the  axillary  vein. 

Throughout  the  operation  hot  sterilised  cloths  should  cover 
those  parts  of  the  wound  on  which  the  operator  is  not  working  at 
the  time. 

I)raina<i<'.— Drainage  is  provided  for  by  an  indiarubber  tube 
(about  2|  inches  long)  inserted  through  an  opening  made  in  the  skin 
over  the  lower  part  of  the  axilla.  Drainage  along  the  line  of  the 
incision  is  unsatisfactory,  and  often  interferes  with  the  healing  of 
the  wound.  The  tube  should  be  secured  by  a  silkworm-gut  suture. 

Some  surgeons  recommend  that  drainage  should  not  be  used,  but 
my  own  experience  is  decidedly  in  its  favour.  When  the  muscles 
have  been  extensively  divided,  there  is  certain  to  be  a  considerable 
amount  of  oozing ;  well-applied  pressure  will  prevent  this  under  the 
thoracic  portion  of  the  wound,  but  it  is  almost  impossible  to  apply 
sufficient  pressure  to  prevent  it  in  the  axilla.  I  have  seen  several 
cases  in  which  extensive  collections  of  blood  and  serum  have  formed 
under,  the  skin  in  cases  in  which  no  drainage  has  been  employed. 

Suture  of  the  Woiuul. — In  some  cases  it  is  quite  impossible  to 
bring  the  skin  edges  into  apposition ;  in  most  cases  there  will  be 
some  difficulty,  which  can  usually  be  overcome  by  the  use  of 
tension  sutures. 

If  direct  suture  of  the  wound  is  impossible,  the  gap  may  be  left 
to  granulate,  or  it  may  be  covered  with  skin-grafts,  or  some  plastic 
operation  may  be  employed.  Before  the  sutures  are  inserted,  the 
arm  should  be  released  and  brought  nearer  to  the  side ;  this 
facilitates  approximation  of  the  skin  edges. 


972          Malignant  Disease  of  the  Breast. 

Dressings. — Thick  layers  of  dressings  are  applied,  especially  over 
the  axilla ;  sterilised  wool  should  be  packed  freely  over  and  behind 
the  drainage  tube  ;  a  layer  is  also  placed  over  the  sound  breast. 
The  dressings  are  firmly  fixed  with  bandages;  elastic-cotton 
bandaging  is  especially  useful  for  getting  firm,  even  pressure. 

Removal  of  loth  Pectoral  Muscles  is,  I  believe,  an  absolutely 
essential  part  of  the  complete  operation  for  mammary  cancer.  In 
the  first  place,  it  is  the  only  satisfactory  way  of  thoroughly  exposing 
the  upper  part  of  the  axilla  ;  and  in  the  second  place,  removal  of  the 
muscles  means  removal  of  portions  of  fascia  and  of  small  glands, 
which  are  readily  overlooked  in  the  less  extensive  operations.  It  is 
often  recommended  that,  instead  of  this  step  being  taken,  the 
superficial  portion  of  the  pectoralis  major  should  be  dissected  off 
with  the  pectoral  fascia ;  but  anyone  who  has  watched  this  proceed- 
ing will  know  what  an  unsatisfactory  one  it  is,  especially  when  it  is 
remembered  that  many  lymphatic  vessels  pass  into  the  muscle 
through  the  fascia,  and  that  lobules  of  the  mammary  gland  itself 
may  exist  in  the  superficial  parts  of  the  muscle. 

As  far  as  I  know,  there  are  no  arguments  of  any  importance 
against  removal  of  both  muscles.  It  is  true  that  this  step  adds 
somewhat  to  the  severity  of  the  operation ;  but  in  the  vast  majority 
of  cases  it  does  not  involve  any  additional  danger,  which  would  be 
a  small  matter  compared  with  the  importance  of  complete  removal 
of  the  disease.  The  movements  of  the  arm  are  scarcely  in  any  way 
impaired  after  the  removal  of  both  muscles,  if  the  correct  after- 
treatment  is  carried  out. 

The  Axillary  Glands  should  be  removed  in  every  case  icitJtout 
exception.  Glands  which  were  not  palpable  before  operation  again 
and  again  are  found  to  contain  small  deposits  of  growth  when 
examined  after  removal ;  in  stout  patients,  greatly  enlarged  glands 
may  be  discovered  which  were  not  demonstrable  before  operation. 
Moreover,  it  sometimes  happens  that  the  lower  axillary  glands 
escape,  whilst  those  in  the  apex  of  the  axilla  are  infected,  and  these 
glands  are  only  discoverable  after  removal  of  the  pectoral  muscles. 
The  essential  point  to  remember  is  that  there  may  be  an  infection 
of  the  glands  which  can  only  be  detected  by  the  microscope. 

1>  it  rat  ion  of  Operation. — In  most  cases  the  complete  operation 
may  be  performed  in  fifty  to  sixty  minutes.  The  operator  should  aim 
at  speed  and  avoid  haste.  Particularly  should  there  be  no  haste 
in  the  clearance  of  the  axilla,  for  if  one  particle  of  disease  is  over- 
looked, the  whole  operation  is  rendered  futile. 

After-tri'dtincnt. — As  soon  as  the  patient  has  recovered  from  the 
anaesthetic,  she  should  be  set  up  in  bed  with 'the  arm  of  the  affected 


Malignant  Disease  of  the  Breast.          973 

side  fixed  on  pillows  at  a  right  angle  to  her  body.  Should  there  be 
much  pain,  an  injection  of  morphia  may  be  given  in  the  evening, 
and  be  repeated  during  the  night  if  necessary. 

A  variable  degree  of  "  shock  "  follows  the  operation.  There  is  no 
doubt  that  much  of  the  so-called  "  shock  "  is  dependent  upon  blood 
lost  during  and  after  operation  ;  for  this  reason,  as  has  been 
pointed  out  above,  the  loss  of  blood  must  be  kept  to  a  minimum  by 
securing  vessels  before  they  are  divided,  and  by  carefully  ligaturing 
all  bleeding  points  before  the  wound  is  closed. 

Owing  to  the  amount  of  muscular  tissue  divided,  some  oozing 
must  be  expected  after  operation :  shock  is  conservative,  in  that  it 
greatly  diminishes  the  amount  of  oozing.  Blood  and  serum  may 
soak  through  the  dressing  within  four  or  five  hours  ;  the  soiled  area 
on  the  surface  of  the  dressing  should  be  well  dabbed  with  the  2  per 
cent,  solution  of  iodine  in  rectified  spirit,  and  fresh  sterilised  wool 
firmly  bandaged  over  it. 

The  drainage  tube  is  removed  in  twenty-four  to  thirty-six  hours 
after  operation,  the  dressing  over  the  main  wound  not  being 
disturbed.  Stitches  are  removed  between  the  tenth  and  the  four- 
teenth days,  by  which  time  healing  is  usually  sound,  if  complete 
approximation  of  the  skin  edges  has  been  possible. 

For  seven  days  after  the  operation  the  patient  is  kept  in  bed  and 
the  arm  maintained  at  a  right  angle  to  the  trunk.  After  the  third 
or  fourth  day  gentle  movements  of  the  arm  are  commenced,  and  after 
a  fortnight  massage  and  regular  movement  of  the  shoulder-joint 
are  ordered.  This  treatment  should  be  carried  out  for  at  least  two 
months  after  operation,  and  thus  painful  adhesions  about  the 
axilla  and  shoulder  are  avoided. 

A  course  of  X-rays  should  always  be  given,  when  possible,  as  soon 
as  the  wound  is  firmly  healed.  It  seems  highly  probable  that  this 
proceeding  checks  or  prevents  local  recurrences,  and  in  any  case  it 
usually  has  the  definite  effect  of  making  the  scar  more  pliable  and 
painless.  Mr.  H.  M.  Rigby  and  Dr.  J.  H.  Sequeira  recommend  six 
applications,  given  twice  a  week  over  a  period  of  three  weeks, 
a  full  dose  being  given  for  about  ten  minutes  on  the  average : 
especial  care  is  taken  to  avoid  dermatitis  by  the  use  of  aluminium 
filters. 

The  patient  should  be  seen  at  regular  intervals,  at  first  every  six 
weeks,  and  after  the  first  year  every  three  months,  so  that  any 
recurrence  may  be  detected  early  and  promptly  dealt  with.  This 
should  be  insisted  upon,  for  it  is  quite  useless  to  rely  on  the  watch- 
fulness of  the  patient,  her  husband,  or  other  relatives. 

Palliative    Operations. — When     the    extent    of     the     disease 


974          Malignant  Disease  of  the  Breast. 

precludes  any  attempt  at  radical  operation,  it  is  often  possible  to 
prolong  life  and  to  prevent  pain  by  operative  means. 

Excision  of  the  breast  is  sometimes  indicated  as  a  palliative 
proceeding  when  there  is  no  hope  of  being  able  to  cure  the  patient. 
This  operation  is  especially  called  for  in  eases  of  rapidly  growing 
tumours,  which  are  likely  to  fungate  and  to  cause  much  pain  and 
discomfort  from  constant  discharge ;  it  is  often  advisable  in  cases 
in  which  the  growth  is  already  fungating,  and  in  which  it  is  possible 
to  remove  the  fungating  area  and  the  main  mass  of  the  breast. 

The  extent  of  the  operation  must  depend  on  circumstances. 
Generally  speaking,  it  should  approach  the  radical  operation  as  far 
as  possible  ;  the  axillary  dissection  should  especially  be  thorough  if 
the  patient's  general  condition  allows  it,  for  this  may  do  much  to 
prevent  or  postpone  the  pressure  symptoms  which  are  so  distressing 
in  advanced  cancer. 

A  point  of  especial  importance  in  these  cases  is  that  the  skin 
flaps  should  be  so  cut  that  they  can  be  easily  brought  into  appo- 
sition ;  if  the  skin  is  so  affected  that  this  is  impossible,  the  operation 
may  not  be  worth  doing,  for  recurrence  is  apt  to  show  itself  before 
the  granulating  wound  has  healed,  and  the  object  of  the  operation 
is  then  defeated. 

Treatment  of  "  Recurrent"  Growths. — Fresh  manifestations 
of  the  disease  after  operation  are  inaccurately  described  as  "  recur- 
rences." They  represent  continued  growth  in  deposits  which  have 
escaped  removal  by  the  operation. 

Whenever  possible  they  should  be  at  once  excised,  unless  there  is 
evidence  that  other  deposits  render  the  case  hopeless.  Superficial 
deposits  in  the  neighbourhood  of  the  scar  are  usually  multiple,  but 
may  often  be  removed  successfully :  for  small  isolated  nodules,  local 
anaesthesia  is  sufficient.  Deeper  deposits  adherent  to  the  sternum 
or  ribs  are  usually  irremovable,  and  no  good  can  be  done  by 
attacking  them. 

Recurrences  in  the  axilla  should  be  dealt  with  at  once.  A  large 
incision  is  necessary,  and  the  parts  should  be  carefully  exposed. 
The  axillary  vein  may  be  involved  in  scar  tissue,  and  is  easily 
opened :  part  of  it  may  have  to  be  excised  if  the  glands  are 
adherent  to  it. 

If  for  any  reason  excision  of  the  nodules  is  impracticable,  treat- 
ment by  X-rays  or  radium  may  be  tried. 

Recurrence  in  the  Supra-clavicular  Glands. — Operation  may  be 
indicated  for  recurrence  in  this  region,  especially  when  there  is  no 
evidence  of  disease  elsewhere,  and  when  moderate  size  and  mobility 
of  the  glands  offers  a  reasonable  hope  that  they  are  removable : 


Malignant  Disease  of  the  Breast.          975 

a  thorough  examination  of  the  chest  should  always  be  made. 
A  flap  of  skin  should  be  turned  up,  by  incisions  along  the  outer 
border  of  the  sterno-mastoid  muscle  and  the  clavicle.  The  internal 
jugular  vein  is  first  exposed,  and  the  lymphatic  tissues  and  fat  of 
the  supra-clavicular  triangle  are  then  removed  in  one  piece  :  special 
care  is  taken  to  avoid  damage  to  important  structures  lying  in  this 
space. 

Other  palliative  operations  and  non-operative  methods  of  treat- 
ment of  irremovable  cancer  are  fully  discussed  in  the  section  on 
Tumours  (Vol.  I.). 

SARCOMA  OF  THE    BREAST. 

About  5  per  cent,  of  breast  tumours  are  sarcornatous.  These 
tumours  in  their  early  stages  are  apt  to  be  mistaken  for  fibro- 
adenomata. 

Sarcoma  of  the  breast  should  be  treated  exactly  as  carcinoma. 
A  searching  examination  must  be  made  for  secondary  deposits  in 
the  viscera,  bones  and  elsewhere,  and  in  the  absence  of  any 
centra-indication,  the  complete  radical  operation  should  be  per- 
formed. There  is  no  justification  for  less  complete  operations,  for 
the  patient's  only  chance  lies  in  early  and  thorough  removal. 

In  certain  cases  there  is  a  strong  tendency  to  local  recurrences ; 
these  should  be  dealt  with  as  early  as  possible. 


T.  CRISP  ENGLISH. 


EEFERENCES. 


Kelly,  H.  A.,  and  Noble,  C.  P.,  "Gynaecological  and  Abdominal  Surgery," 
1908,  Vol.  II. 
Rigby,  H.  M.,  Practitioner,  1911,  LXXXVL,  p.  34S. 


9/6 


NEURALGIA    OF    THE    BREAST. 

CASES  are  met  with  in  which  neuralgic  pain  in  the  breast  is  the 
leading  feature,  and  local  signs  are  absent  or  slight. 

For  successful  treatment  of  the  pain  it  is  essential  to  form  an 
opinion  as  to  its  cause ;  the  pain  is  usually  associated  with  one  or 
more  of  the  following  conditions :  (1)  A  small  local  lesion,  such  as 
a  small  fibro-adenoma  or  patch  of  mastitis,  or  a  congested  area ; 

(2)  pelvic    trouble,     especially     irregularities    in    menstruation ; 

(3)  general  ill-health,  such  as  ansemia  or  neurasthenia. 

The  cause  should  be  treated  first.  Small  fibro-adenomata  should 
be  removed ;  patches  of  mastitis  should  be  dealt  with  by  the 
application  of  mercurial  ointment,  by  X-rays,  or  by  excision. 
Pelvic  trouble  should  be  inquired  into,  and  any  defect  in  the 
general  health  should  be  dealt  with  by  appropriate  treatment. 

Locally,  if  no  definite  lesion  is  discoverable,  the  pain  may  be 
relieved  by  the  application  of  a  large  belladonna  plaster,  with  a  hole 
cut  in  its  centre  for  the  nipple,  or  by  the  application  of  mercurial 
ointment ;  the  breast  should  be  firmly  bandaged,  and  care  should 
be  taken  to  see  that  the  corsets  do  not  cause  irritation.  In  obstinate 
cases,  galvanism  often  proves  effectual. 

As  regards  general  treatment,  the  following  measures  are  of 
importance :  Fresh  air,  especially  seaside  air,  plenty  of  good  food, 
tonics  such  as  iron  and  quinine,  and  carefully  regulated  exercise. 

It  is  important  to  remember  that  patients  with  neuralgic  pains 
in  the  breast  usually  consult  their  medical  man  because  they  fear 
that  the  pain  is  a  symptom  of  cancer ;  in  fact,  they  come  to  find 
out  whether  they  have  cancer.  Eeassurance  upon  this  point,  when 
it  can  honestly  be  given,  will  do  much  to  cure  the  neuralgia. 

T.  CRISP  ENGLISH. 


977 


AFFECTIONS    OF    THE    NIPPLES. 

Cracks  and  Fissures  of  the  Nipples  are  especially  apt  to  form 
during  lactation  after  the  first  pregnancy ;  retraction  and  imperfect 
development  of  the  nipples  are  the  chief  predisposing  causes.  These 
lesions  and  their  common  sequel,  mammary  abscess,  are  far  less 
common  now  that  the  importance  of  care  of  the  nipples  during 
pregnancy  and  lactation  is  recognised. 

Prophylaxis. — Careful  attention  should  be  devoted  to  the  condition 
of  the  nipples  during  the  latter  months  of  pregnancy.  Dried 
secretion  should  be  regularly  washed  off  with  boric  lotion,  and  the 
nipples  should  be  dusted  with  an  antiseptic  powder ;  if  they  are 
tender,  they  may  be  smeared  with  lanolin  or  "  cold  cream  "  each 
morning  and  evening. 

Retraction  should  be  treated  by  gentle  manipulation,  the  nipples 
being  drawn  forwards  until  they  project  normally.  If  there  is 
difficulty  in  effecting  this,  the  wearing  of  a  nipple-shield  may  prove 
efficacious,  or  the  use  of  the  breast-pump  may  be  necessary. 

During  lactation  the  nipples  should  be  bathed  with  boric  lotion 
and  carefully  dried  before  and  after  suckling,  and  at  the  same  times 
the  infant's  mouth  should  be  swabbed  out  with  boric  lotion. 
Ineffectual  or  unsatisfactory  suckling  is  the  usual  cause  of  cracked 
nipples,  and  it  is  the  nurse's  duty  to  see  that  the  difficulty  is 
overcome. 

Treatment.'  When  fissures  have  formed,  they  should  be  treated 
promptly,  for  otherwise  they  frequently  lead  to  mammary  abscess. 
Glycerinum  Boracis  [U.S.P.  Sodium  Borate,  20  grm. ;  Glycerin, 
120  c.c.]  should  be  applied  every  two  or  three  hours,  or  in  more 
severe  cases,  a  solution  of  1  in  2,000  biniodide  of  mercury, 
or  equal  parts  of  glycerinum  acidi  tannici  and  1  in  40  carbolic 
acid.  The  nipple  should  be  well  washed  with  warm  water  each 
time  before  the  breast  is  used  for  suckling,  and  for  the  first  day  or 
two  a  shield  should  be  applied. 

Obstinate  fissures  should  be  dealt  with  by  the  application  of  pure 
carbolic  acid  on  a  probe,  or  by  a  solution  of  silver  nitrate  or  copper 
sulphate. 

Simple  Eczema  should  be  treated  as  eczema  elsewhere. 
Abscess  of  the  Areola  occurs  chiefly  in  young  girls,  and  is  to 
be  treated  by  simple  incision. 

S.T. — VOL.  ii.  62 


978  Affections  of  the  Nipples. 

"Paget's  Disease  of  the  Nipple. " — This  affection  is  almost 
invariably  associated  with  carcinoma  of  the  underlying  breast ;  in 
fact,  most  authorities  consider  that  the  mammary  tumour  is  the 
primary  lesion,  and  that  the  skin  affection  is  a  secondary  infiltration. 

The  treatment,  therefore,  is  that  of  carcinoma  of  the  breast,  the 
full  radical  operation  being  performed  unless  there  is  some  definite 
centra-indication .  In  early  cases  the  prospects  of  permanent  cure 
are  good,  whereas  local  treatment  affords  little  or  no  chance  of  cure, 
for  even  if  the  superficial  lesion  is  destroyed,  the  progress  of  the 
underlying  carcinoma  is  unaffected. 

T.  CRISP  ENGLISH. 


979 


OPERATIVE  DIAGNOSIS    OF    DOUBTFUL    TUMOURS 
OF  THE  BREAST. 

IN  many  cases  the  surgeon  will  be  in  doubt  as  to  whether  a 
mammary  tumour  is  malignant  or  not,  even  after  the  most  careful 
examination.  In  such  cases  the  doubt  must  be  cleared  up  at  once 
by  the  operative  examination  of  the  swelling.  There  can  be  no 
possible  justification  for  delay,  or  for  trying  the  effect  of  local 
applications  and  drugs  ;  those  who  adopt  this  course  are  undertaking 
a  grave  responsibility  for  which  there  is  no  excuse.  Doubtful 
tumours  usually  prove  to  be  malignant,  and  should  therefore  be 
investigated  at  once. 

Patients  with  mammary  swellings  are  particularly  amenable  to 
reason  when  matters  are  carefully  and  gently  explained  to  them. 
Tell  the  patient  plainly  that  she  has  a  swelling  in  the  breast,  of 
the  nature  of  which  it  is  impossible  to  be  certain,  and  that  it  is 
wisest  to  clear  the  matter  up  at  once  whilst  the  trouble  is  still 
early,  and  not  to  run  the  risk  of  allowing  a  serious  trouble  to 
become  more  advanced  by  delay.  There  is  no  need  to  make  use  of 
the  word  "  cancer  "  when  speaking  to  the  patient. 

The  operative  diagnosis  of  mammary  tumours  may  be  made  in 
one  of  the  following  ways  : 

(1)  Incision  into  or  on  to  the  tumour. 

(2)  Excision  of  the  tumour,  and  macroscopical  examination  of  the 
cut  surface. 

(3)  Excision   of  the  tumour,    or  a   piece  of  it,  and  immediate 
microscopical  examination,  whilst  the  surgeon  waits ;  the  tissue  is 
handed,  as  soon  as  it  has  been  removed,  to    a  pathologist,   who 
makes   fresh    sections    and  gives    a   report   in    from   five   to   ten 
minutes.     If  the  tumour  proves  malignant,  the  operator  proceeds  to 
the  full  radical  operation. 

(4)  Excision  of  part  or  whole  of  the  tumour  and  microscopical 
examination  of  hardened  sections  ;  in  this  case  three  to  six  days 
elapse  before  a  report  is  made. 

(5)  Removal  of  a  portion  of  the  tumour  under  local  anaesthesia 
for   microscopical    examination  a  few  days  before   the    proposed 
operation. 

In  practice  one  finds  that  the  choice  of  method  must  depend  upon 
the  circumstances  of  the  case.  Personally,  I  place  great  reliance  in 

62—2 


980     Operative  Diagnosis  of  Doubtful  Tumours. 

the  older  method  of  limited  incision  into  the  tumour,  as  being  less 
liable  to  cause  dissemination  of  cancer  cells  than  more  extensive 
proceedings.  In  at  least  90  per  cent,  of  the  cases  a  positive 
diagnosis  may  be  made  by  examination  of  the  cut  surface  with 
the  naked  eye  and  the  finger,  and  in  many  cases  it  is  quite 
sufficient  to  carry  the  incision  only  as  far  as  the  edge  of  the  tumour 
and  not  into  it. 

In  the  10  per  cent,  of  cases  where  doubt  still  exists,  the  diseased 
area  should  be  excised  for  microscopical  examination.  This  examina- 
tion may  be  made  immediately,  before  the  operation  is  continued, 
if  an  experienced  pathologist  is  available.  The  method  of  preparing 
frozen  sections  of  the  fresh  tissues  has  been  fully  described  by  Mr. 
Ernest  H.  Shaw.1  There  are  certain  cases  in  which  it  is  very 
important  that  arrangements  for  this  proceeding  should  be  made ; 
for  instance,  cases  in  which  the  patient  would  not  consent  to  a 
second  operation.  If,  however,  an  experienced  pathologist  is  not 
available,  this  method  should  not  be  attempted,  for  it  may  be 
impossible  to  decide  between  chronic  mastitis  and  early  carcinoma 
by  examination  of  fresh  sections  only ;  in  fact,  many  pathologists 
are  reluctant  to  make  these  immediate  examinations  under  any 
circumstances. 

T.  CRISP  ENGLISH. 
EEFEEENCE. 

1  Shaw,  Ernest  H.,  "  The  Immediate  Microscopic  Diagnosis  of  Tumours  at 
the  Time  of  Operation,"  Lancet,  1910,  II.,  p.  939. 


98 1 


TUBERCULOSIS    OF    THE    BREAST. 

THIS  is  an  uncommon  disease.  Clinically  it  presents  itself  in 
many  forms,  such  as  chronic  ahscess,  multiple  sinuses,  or  as  solid 
masses  with  caseating  centres.  The  axillary  glands  are  usually 
also  affected,  and  sometimes  they  are  apparently  the  primary  focus. 
Tuberculosis  is  often  found  in  other  parts  of  the  body. 

There  is  no  doubt  that  in  the  majority  of  cases  excision  of  the 
affected  breast  and  axillary  glands  is  the  wisest  course.  Investiga- 
tion of  the  subsequent  history  of  cases  treated  by  less  complete 
operations  shows  that  re-appearance  of  the  disease  is  very  common, 
and  that  many  of  the  patients  ultimately  die  of  some  form  of 
tuberculosis. 

The  chest  should  be  carefully  examined  before  operation  is  decided 
upon.  A  slight  degree  of  pulmonary  tuberculosis  would  indicate 
especial  care  in  the  administration  of  the  anaesthetic.  More  advanced 
disease  would  probably  centra-indicate  operation. 

In  excision  of  the  breast  all  unhealthy  skin  should  be  freely 
removed,  and  the  incisions  are  planned  to  include  any  sinuses  which 
may  be  present.  Infected  axillary  glands  are  removed,  together  with 
the  breast.  It  is  unnecessary  to  excise  any  portion  of  the  pectoral 
muscle  unless  it  is  infiltrated  with  the  disease,  but  sometimes 
division  of  part  of"  the  muscle  is  required  for  the  proper  clearance 
of  the  axilla.  If  amputation  is  contra-indicated,  less  extensive 
procedures  may  be  tried.  The  diseased  segment  of  the  breast  may 
be  excised,  or  sinuses  and  localised  collections  of  pus  may  be  freely 
laid  open,  scraped  and  stuffed  with  iodoform  ribbon  gauze. 

General  treatment  is  of  great  importance  in  all  cases,  and 
should  be  conducted  on  the  lines  of  Sanatorium  Treatment  (see 
Vol.  I.).  Tuberculin  may  be  used  when  healing  is  slow  after 
incomplete  operations,  and  also  after  the  radical  operation  to 
diminish  the  risk  of  recurrence  (see  Vaccine  Therapy,  Vol.  III.). 

T.  CRISP  ENGLISH. 


982 


DISEASES    OF    THE    NERVOUS    SYSTEM. 

AFFECTIONS  OF  OBSCURE  ORIGIN. 

COMA. 

THE  treatment  of  coma  is  largely  that  of  the  causal  condition 
underlying  its  production.  In  order  to  determine  this  in  any  given 
case  a  routine  examination  should  be  made.  The  previous  health 
and  mental  condition  of  the  patient  should  be  inquired  into, 
especially  as  to  the  occurrence  of  fits,  headache  or  vomiting. 
Where  possible,  the  mode  of  onset  of  the  coma,  whether  gradual  or 
sudden,  and  whether  attended  by  any  premonitory  symptoms, 
should  be  ascertained.  Evidence  of  poisoning,  the  odour  of  the 
breath  or  any  signs  of  injury  should  be  noted.  The  urine  should 
be  examined  for  indications  of  acute  or  chronic  renal  disease  or  of 
diabetes.  Having  examined  the  patient's  general  state,  the  nervous 
system  must  then  be  investigated.  The  state  of  the  pupils  as 
regards  size,  equality,  outline  and  reaction  to  light  must  be  noted. 
Evidence  of  paralysis  should  be  sought  for  in  asymmetry  of  the 
face,  squint,  deviation  of  the  head  and  eyes  to  one  side,  or  in  a 
greater  degree  of  flaccidity  of  the  muscles  on  one  side. 

All  the  reflexes  must  be  examined,  the  tendon  reflexes,  the  plantar 
reflexes  and  superficial  abdominal  and  epigastric  reflexes  and  every 
abnormality  noted,  and  in  addition  to  this  a  careful  comparison 
should  be  made  of  the  corresponding  reflexes  of  the  two  sides  of  the 
body. 

Where  the  paralysis  appears  to  be  bi-lateral  the  temperature 
should  be  taken  on  both  sides.  This  may  be  of  assistance,  as  in  an 
acute  cerebral  lesion  the  temperature  on  the  side  opposite  the  lesion 
is  usually  raised  one  or  two  degrees  above  that  of  the  other.  In  all 
cases  the  fundus  should  be  examined  for  optic  neuritis  or  renal  or 
diabetic  changes.  In  cases  of  toxsemic  coma  the  symptoms  are 
bi-lateral,  and  evidence  of  gross  intra-cranial  lesions  is  absent.  On 
the  other  hand,  in  cases  due  to  intra-cranial  lesion,  evidence  of  gross 
affection  of  the  central  nervous  system  will  be  obtained. 

Uraemic  Coma.— Treatment  is  directed  to  the  elimination  of  the 
toxic  substances  and  to  the  reduction  of  the  increased  intra-cranial 
pressure  which  is  present  in  these  cases.  The  bowels  should  be 
freely  opened  by  means  of  croton  oil :  1  or  2  rnin.  of  the  oil 
should  be  added  to  a  little  olive  oil,  and  then  placed  on  the  back  of  the 


Coma.  983 

tongue.  Diaphoresis  must  be  encouraged  by  placing  the  patient  in 
a  hot-air  bath  or  hot  pack,  and  the  action  of  the  heat  upon  the  skin 
may  be  assisted  by  giving  a  hypodermic  injection  of  ^  gr.  of  pilo- 
carpine  nitrate.  If,  however,  the  heart  is  weak,  or  there  is  any 
grave  danger  from  hypostatic  congestion  of  the  lungs,  it  is  wiser 
to  withhold  the  pilocarpine. 

Should  sweating  not  take  place  or  prove  ineffectual,  venesection 
should  be  performed,  and  10  to  15  oz.  of  blood  withdrawn  from  the 
arm.  The  loss  of  fluid  attendant  upon  diaphoresis  or  venesection 
should  be  compensated  for  by  intra-veuous  or  subcutaneous  injection 
of  a  warm  '85  per  cent,  solution  of  sodium  chloride. 

Inhalations  of  oxygen  have  been  recommended  to  diminish  the 
uraemic  intoxication,  but  in  practice  their  action  is  not  very 
obvious. 

In  all  cases  lumbar  puncture  should  be  performed  and  20  cubic 
centimetres  of  cerebro-spinal  fluid  withdrawn.  This  procedure  is 
almost  invariably  followed  by  a  rapid  and  striking  improvement  in 
the  patient's  condition. 

Diabetic  Coma. — The  advent  of  diabetic  coma  can  usually  be 
predicted  by  the  investigation  of  the  urine  and  the  faeces.  Purga- 
tion and  alkaline  treatment,  if  employed  in  time,  may  ward  off  an 
attack.  If  the  patient  is  suffering  from  diabetic  coma  the  most 
energetic  treatment  is  required.  He  should  be  infused  immediately 
with  2^  pints  of  a  '85  per  cent,  solution  of  sodium  chloride,  to  which 
8  drachms  of  sodium  bicarbonate  has  been  added.  This  infusion  may 
be  repeated  in  the  course  of  twenty-four  hours.  If  the  patient 
recovers  consciousness,  he  should  be  given  20  gr.  to  40  gr.  of  sodium 
bicarbonate  every  two  hours,  by  mouth.  If  constipation  exists,  free 
purgation  is  necessary,  and  when  it  is  practicable  inhalations  of 
oxygen  may  be  tried,  as  they  are  sometimes  of  benefit. 

In  cases  where  there  is  evidence  of  cerebral  compression,  such  as 
loss  of  the  superficial  abdominal  and  epigastric  reflexes,  lumbar 
puncture  should  be  performed,  and  20  cubic  centimetres  of  cerebro- 
spinal  fluid  withdrawn. 

Epileptic  Coma. — Coma  may  supervene  upon  an  epileptic  attack. 
If  this  occurs  after  a  single  fit,  the  patient  should  be  left  quiet  as  he 
will  soon  come  round ;  if,  on  the  other  hand,  he  is  having  repeated 
fits  and  not  recovering  consciousness  between  the  attacks,  he  is 
suffering  from  status  epilepticus,  a  most  dangerous  condition. 
Attempts  must  be  made  to  stop  the  fits  by  means  of  chloroform 
inhalations  and  the  administration  of  large  doses  of  potassium 
bromide  and  chloral  by  rectal  injection.  If  cardiac  failure  is 
present,  venesection  and  stimulation  must  be  carried  out. 


984  Coma. 

Coma  associated  with  Intra-cranial  Tumour  or  Abscess. 
—The  coma  which  occurs  in  cases  of  intra-cranial  tumour  or  abscess 
is  due  to  an  excessive  rise  of  intra-cranial  pressure.  Treatment, 
therefore,  should  be  primarily  directed  to  relieving  the  excessive 
intra-cranial  tension  ;  this  can  be  effected  radically  only  by  operation. 
If  the  tumour  or  abscess  has  been  localised  accurately,  a  consider- 
able area  of  bone  should  be  removed  over  the  site  of  the  lesion  and 
the  dura  freely  incised.  In  the  absence  of  any  precise  localising 
symptoms  the  operation  should  be  performed  bi-laterally  on  the  infra - 
tentorial  level.  If  immediate  operation  is  impossible,  the  patient 
should  be  given  1  or  2  min.  of  croton  oil  mixed  with  a  little  olive 
oil  and  placed  on  the  back  of  the  tongue,  and  lumbar  puncture 
should  be  performed,  20  cubic  centimetres  of  cerebro-spinal  fluid 
being  withdrawn.  These  measures  will  often  restore  the  patient  to 
consciousness,  and  may  further  enable  a  correct  diagnosis  of  the 
site  of  the  tumour  to  be  made,  as  the  relief  of  pressure  removes  all 
symptoms  of  compression  which  may  be  giving  rise  to  false  localising 
signs.  In  cases  where  abscess  is  suspected,  any  known  local  source 
of  infection  should  be  opened  at  once. 

Coma  in  Cerebral  Haemorrhage. — For  the  treatment  of  this 
condition  see  Cerebral  Haemorrhage  (p.  1168). 

Alcoholic  Coma. — In  alcoholic  coma  the  patient  can  generally 
be  aroused.  The  face  is  usually  flushed,  but  may  be  cyanotic.  The 
pulse  is  strong  and  full,  respiration  deep  and  slow,  and  the  pupils 
dilated.  The  temperature  maybe  subnormal.  The  breath  and  stomach 
contents  smell  of  alcohol ;  but  the  mere  fact  of  the  breath  smelling 
must  not  be  taken  as  evidence  of  alcohol  poisoning,  as  most  patients 
falling  into  a  comatose  state  are  given  alcohol  by  their  friends. 

When  possible  the  stomach  should  be  washed  out,  but  if  no  tube 
is  at  hand  and  the  patient  cannot  swallow,  vomiting  can  be  induced 
by  giving  a  hypodermic  injection  of  ^  gr.  of  apomorphine  hydro- 
chloride.  If  the  patient  can  swallow,  an  emetic  should  be  given, 
such  as  warm  mustard  water  (2  drachms  to  8  oz.  of  water)  or  a  large 
dose  of  zinc  sulphate. 

In  cases  where  the  patient  has  collapsed  hot  cloths  should  be 
applied,  and  he  should  be  given  hot  coffee  or  aromatic  spirits  of 
ammonia,  and,  if  necessary,  hypodermic  injections  of  strychnine. 

Coma  following  Morphia  Poisoning. — In  these  cases  the 
respiration  is  slow,  the  skin  cold  and  clammy,  the  pulse  small 
and  the  pupils  pin-point  in  size.  Where  the  patient  has 
swallowed  opium  the  stomach  must  be  washed  out,  or,  when  that  is 
impossible,  vomiting  must  be  induced  by  the  hypodermic  injection 
of  ^  gr.  of  apomorphine  hydrochloride,  or  by  the  administration  of 


Coma.  985 

any  emetic  which  can  he  obtained  at  once.  When  possible  8  gr.  of 
potassium  permanganate  in  half  a  tumbler  of  warm  water  should  be 
given  at  once,  and  after  a  short  interval,  the  stomach  should  be 
washed  out  with  a  warm  solution  of  potassium  permanganate. 
This  lavage  may  be  repeated  several  times  with  advantage. 
The  patient  must  not  be  allowed  to  sink  into  a  state  of  pro- 
found coma  ;  he  should  be  stimulated  by  flipping  him  with  wet 
towels,  administering  hot  coffee  by  rectum  or  stomach  tube,  and 
by  the  hypodermic  injection  of  ether  or  atropine  (gr.  £$).  If  respira- 
tion is  failing,  artificial  respiration  must  be  started,  and  strychnine 
and  atropine  should  be  injected  hypodermically.  Once  the  patient 
has  been  roused  from  the  coma  he  should  be  walked  about  until  the 
effect  of  the  poison  has  passed  off. 

Malarial  Coma.  —  In  one  form  of  pernicious  malaria,  coma  is  the 
most,  striking  manifestation.  The  patient  should  be  treated  at  once 
by  large  doses  of  quinine,  either  by  hypodermic  or  intra-venous 
injection.  The  following  solution  should  be  employed:  H.  Quininae 
II  ydrochloridi  Acidi,  gr.  15  ;  Sodii  Chloridi,  gr.  1  ;  Aquae  Destillatse, 


Further  treatment  depends  upon  the  condition  of  the  patient  in 
each  individual  case. 

Coma  in  Heat  Stroke.  —  In  this  condition  there  may  be  a 
sudden  onset  of  coma  with  hyperpyrexia.  The  patient  should  be 
placed  in  a  cold  bath  to  which  ice  is  added  ;  if  a  bath  is  not  avail- 
able, he  should  be  wrapped  in  a  cold  pack,  rubbed  with  ice  and 
have  ice  applied  to  his  head.  The  rectal  temperature  should  be 
tiiken  repeatedly,  and  when  it  has  definitely  begun  to  fall,  the 
patient  should  be  removed  from  the  pack,  as  dangerous  collapse  is 
liable  to  occur.  In  some  cases  stimulants  may  be  necessary. 

T.  GRAINGER  STEWART. 


986 


INFANTILE  CONVULSIONS, 

AT  birth  the  brain  is  far  from  fully  developed,  the  latest  part  to 
mature  being  the  cortex  of  the  cerebral  hemispheres.     The  lower 
centres  are  under  the  control  of  the  cortex,  and  in  the  absence  of 
control  are   easily  excited,  and  in  response  to  excitation  produce 
violent   muscular   movement.     Stimulation    of  the  brain  may  be 
effected  either  directly  or  through  the  afferent  nerves,  and   over- 
stimulation  of  any  part  of  the  cerebral  hemispheres  leads  to  general 
convulsions.     Thus  an  irritation,  too  slight  to  produce  an  effect 
on  an   adult,  may  lead  in  a  baby  to  muscular  twitching  or  to  a 
generalised  convulsion,  with  unconsciousness.    Infants  vary  in  their 
cerebral  excitability,  and  some  become  convulsed  with  very  slight 
causes,  while  the  majority  are  not  disturbed  by  stimuli  which  are 
comparatively  strong.     Thus   there   is  a  special  susceptibility  in 
certain  individuals  which  may  be  acquired  after  birth  or  be  inborn, 
and  is  often  found  to  be  hereditary  or  to  run  in  families.     Some 
writers  even  speak  of  a  "  spasmophile  diathesis,"  characterised  by 
increased  irritability  of  the  muscles  and  nerves  to  mechanical  and 
electrical  stimulation,  and  often  accompanied  by  spasmodic  neuroses, 
such  as  tetany,  laryngismus  or  convulsions.     Cerebral  irritability 
is  also  increased  in  certain  disorders,  of  which  rickets  is  the  most 
striking ;  and  it  is  possible  that  the  absorption  of  toxins  from  the 
intestinal   canal   may   also   lead   to   its   augmentation.     Anything 
which  interferes  with  the  flow  of  well-oxygenated  blood  through  the 
cerebral  vessels  may  bring  about  convulsive  attacks  and  uncon- 
sciousness, so  that  in  children  convulsions  are  a  common  terminal 
phenomena   in   diarrhoea   where   there   is   cerebral    anaemia,    and 
in  broncho -pneumonia  where  the  blood  is  insufficiently  oxygenated. 
A  sudden  rise  of  temperature  may  excite  convulsions  in  a  pre- 
disposed child,  so  that  a  fit  may  usher  in  an  acute  specific  disorder, 
such  as  pneumonia  or  scarlatina.     Lastly,  inflammatory  affections 
of  the  brain  or  meninges  and  tumours  or  other  gross  defects  of  the 
brain  are  usually  accompanied  by  convulsive  attacks. 

The  foregoing  points  have  to  be  remembered  when  the  appro- 
priate treatment  of  the  patient  is  under  consideration.  A  single 
convulsion  passes  away,  leaving  no  defect  except  a  liability  to 
recurrence,  and  is  in  itself  of  no  danger ;  but  repeated  attacks  of 
convulsions  may  be  followed  by  marked  mental  impairment  and 


Infantile  Convulsions.  987 

even  imbecility,  while  numerous  convulsive  fits  occurring  one 
directly  after  the  other  cause  a  condition  like  the  status  epilepticus, 
in  which  there  is  peril  of  immediate  death.  Death  may  also  result 
from  laryngismus  in  the  cases  with  marked  increase  of  muscular 
and  nervous  irritability.  Apart  from  these  urgent  cases  treatment 
has  to  be  directed  not  so  much  to  the  individual  fit  as  to  the  pre- 
vention of  recurrence.  The  parents  may  be  advised  in  case  an 
attack  supervenes  to  make  use  of  the  traditional  hot  mustard-bath, 
which  is  harmless,  and  may  be  of  some  slight  benefit.  The  other 
traditional  treatment  of  cold  applications  to  the  head  should  be 
avoided.  For  the  prevention  of  further  attacks  attention  has  to  be 
directed  to  two  points :  firstly,  to  the  removal  of  any  source  of 
irritation ;  and,  secondly,  to  the  lessening,  if  possible,  of  the  over- 
excitability  of  the  central  nervous  system.  The  irritants  that  have 
been  regarded  as  responsible  for  the  causation  of  convulsions  are 
very  numerous,  the  most  frequent  being  teething,  middle-ear 
disease,  phimosis  and  the  presence  of  undigested  food  or  ascarides 
in  the  intestines ;  but  it  is  probable  that  the  influence  of  most  of 
these  has  been  much  exaggerated.  Still,  if  there  is  a  source  of 
irritation  it  should  be  attended  to,  and,  if  necessary,  the  membrana 
tympani  punctured  or  a  circumcision  performed.  The  presence  of 
unsuitable  and  undigested  food  in  the  intestines  has  been  regarded 
as  causing  convulsions  in  another  way  than  by  acting  as  a  reflex 
irritant ;  such  food  ferments  in  the  intestinal  canal  and  toxins  are 
supposed  to  be  absorbed,  which  cause  the  fits  by  their  direct  action 
on  the  brain.  Thus  the  diet  requires  careful  regulation.  Usually 
it  is  necessary  to  give  the  milk  more  dilute  or  to  reduce  the 
quantity  of  proteid  in  the  feeding  mixture,  and  several  observers 
claim  to  have  stopped  convulsive  fits  solely  by  such  an  alteration 
of  diet.  If  there  is  reason  to  suppose  that  intestinal  fermentation 
has  any  part  in  causing  the  convulsions,  a  mixture  containing 
ol.  ricin.  (i»t5),  pot.  bicarb,  (gr.  2),  vin.  ipecac.  (iri2),  aq.  carui 
(ad  5J)  may  be  prescribed,  to  which  111^  of  tinct.  opii  should  be 
added  if  the  motions  are  frequent ;  or  small  quantities  of  calomel 
(gr.  ^)  frequently  repeated  are  very  useful  as  an  intestinal  anti- 
septic. To  this  must  be  added  attention  to  general  hygiene.  The 
child  should  get  plenty  of  fresh  air  both  in  and  out  of  doors ;  it 
should  be  warmly  clad,  special  care  being  taken  to  clothe  the 
abdomen  and  to  keep  the  extremities  warm.  If  the  feet  are 
chronically  cold,  it  is  well  to  have  the  legs  rubbed  from  below 
upwards  for  five  to  ten  minutes  night  and  morning.  Constipation 
is  commoner  than  diarrhoea,  and  may  require  a  purgative  to  get 
the  bowels  to  act  regularly  and  freely. 


988  Infantile  Convulsions. 

With  improvement  in  the  child's  general  condition  it  is  often 
found  that  the  over-excitability  of  the  brain  diminishes,  and  this  is 
specially  the  case  in  rickets.  Where  there  is  any  evidence  of  this 
disorder  its  treatment  should  be  carefully  carried  out  as  regards 
diet,  fresh  air,  and  the  management  of  the  chronic  intestinal 
catarrh  which  is  so  frequently  present.  The  advocates  of  the 
"  spasmophile  diathesis "  state  that  the  nervous  and  muscular 
excitability  is  increased  by  a  diet  of  cow's  milk  or  even  whey,  but 
decreased  by  human  milk.  The  withdrawal  of  cow's  milk  is  a 
serious  step  to  take  with  a  child  under  the  age  of  twelve  months,  and 
should  not  be  continued  longer  than  two  or  three  days.  If  a  wet 
nurse  is  available  the  difficulties  are  less,  and  the  occurrence  of 
convulsions  in  the  infant  may  be  regarded  as  an  additional 
argument  in  favour  of  her  employment.  The  over-excitability  can 
also  be  reduced  by  certain  drugs,  of  which  potassium  bromide 
(1  to  3  gr.  for  a  child  of  twelve  months)  is  the  best  for  continued 
treatment.  Phenazone  (1  to  2  gr.)  may  be  combined  with  the 
bromide,  or  may  be  substituted  where  the  bromide  does  not  seem 
to  suit  the  child.  Chloral  (£  to  2  gr.)  is  not  so  suitable  for 
continued  administration,  as  it  tends  to  irritate  the  gastro-inteslinal 
tract.  Under  this  regime,  which  should  be  continued  for  at  least 
two  months  after  the  last  fit,  the  improvement  can  in  some  cases  be 
measured  not  only  by  the  lessening  or  cessation  of  the  fits,  but  also 
by  the  steady  diminution  of  the  nervous  and  muscular  irritability  to 
mechanical  stimulation. 

Rapidly  Repeated  Convulsions,  which  produce  a  continued 
unconsciousness  and  often  a  marked  degree  of  fever,  require  active 
and  immediate  treatment,  since  life  is  in  imminent  danger.  As  a 
rule,  the  most  rapid  and  convenient  method  is  the  inhalation  of 
chloroform.  As  soon  as  the  patient  is  under  the  influence  of  the 
drug  the  rectum  should  be  cleared  out  with  a  soap-and-water  enema, 
which  usually  brings  away  a  quantity  of  very  foul-smelling  faeces. 
Then  1  to  4  gr.  of  chloral,  with  double  the  quantity  of  potassium 
bromide  in  an  enema  of  mucilage,  should  be  injected  high  up  into 
the  bowel :  when  this  begins  to  act  the  chloroform  may  be  dis- 
continued. In  bad  cases  it  may  be  necessary  to  repeat  the  rectal 
injection,  or  to  give  half  the  quantity  of  the  chloral  and  bromide  by 
the  mouth  every  two  to  three  hours.  Other  measures  which  may 
be  tried  are  inhalation  of  amyl  nitrite  or  the  hypodermic  injection 
of  morphia  (^  to  ^  gr.),  remembering  that  the  latter  must  be 
used  very  cautiously  in  infants  under  the  age  of  six  months.  Still 
recommends  urethane  in  2-gr.  doses  where  bromides  and  chloral 
seem  to  fail.  After  the  fits  have  ceased  the  general  treatment  must 


Infantile  Convulsions.  989 

be  carried  out  with  great  strictness,  and  it  will  probably  be  necessary 
to  continue  the  administration  of  bromides  over  several  months.  A 
child  that  has  been  brought  to  death's  door  by  repeated  convulsions 
is  liable  for  a  long  time  afterwards  to  similar 'attacks. 


ALFRED  M.  GOSSAGE. 


REFERENCE. 


Thiemich,  M.,'Pfaundler,  M.,  and  Schlossmann,  A.,  "Diseases  of  Children," 
Phila.,  1908,  Vol.  III.,  p.  285. 


990 


EPILEPSY. 

Introduction. — Before  giving  a  detailed  account  of  the  treatment 
of  epilepsy  it  is  necessary  to  define  what  is  meant  by  that  term 
and  to  mention  the  clinical  forms  in  which  it  may  reveal  itself. 

Idiopathic  or  genuine  epilepsy  is  a  chronic  disease  characterised 
clinically  by  the  recurrence  of  seizures,  in  which  interference  with 
consciousness  is  an  essential  feature,  associated  either  with  spasm, 
convulsions  or  transient  psychical  symptoms,  occurring  usually  in 
persons  with  an  hereditary  neuropathic  predisposition,  and  in  many 
cases  leading  to  more  or  less  permanent  mental  impairment.  The 
sole  feature  necessary  to  establish  the  diagnosis  of  epilepsy  is 
sudden,  brief  loss  or  impairment  of  consciousness. 

The  following  symptoms  may  be  observed  as  the  clinical 
expressions  of  the  disease  :  (1)  Transient  jerks,  jumps  or  partial 
falls  (  petit  mal  moteur),  often  unattended  by  loss  of  consciousness  ; 

(2)  aura  sensations,  with  or  without  impairment  of  consciousness ; 

(3)  incomplete  fits  (minor   epilepsy,    or  petit    mal};  (4)  complete 
fits  (major    epilepsy,  or  grand  mal ) ;    (5)  psychical    epilepsy,   or 
epileptic  automatism  ;  (6)  psychical  epileptic  equivalents. 

Epilepsy  may  be  the  clinical  expression  of  a  number  of  cerebral 
diseases,  which  may  be  to  a  large  extent  separated  from  each 
other. 

(1)  Organic  cerebral  disorders  may  give  rise  to  epilepsy  in  no  wray 
distinguishable  from  the  genuine  or  idiopathic  disease.     Such  are  : 
(a)  Traumatic  lesions  of  the  skull,  brain  or  membranes ;  (&)  focal 
organic  disease  of  the  brain,  such  as  tumour  and  thrombosis;  (c)  in- 
fantile   cerebral    hemiplegia ;     (d)    degenerative     cardio- vascular 
disease  ;  (e)  general  paralysis  of  the  insane. 

(2)  Other   forms   of    epilepsy   are   found    in   association   with  : 
(a)  Intoxications,  such  as  arise  from  alcohol,  absinthe,  tobacco  and 
lead   poisoning ;    (b)  eclamptic   conditions,    such    as    uraemia   and 
puerperal  eclampsia. 

(3)  A  variety  of    epilepsy   chiefly   characterised    by   the   great 
degree  of  mental  impairment,  amounting  in  most  cases  to  imbecility 
and  in  some  to  idiocy,  is  found  in  infancy  and  early  childhood. 
This  type  of  the  disease  is  difficult  to  distinguish  from  idiopathic 
epilepsy,  of  which  it  merely  forms  a  variety. 

(4)  Idiopathic   epilepsy.     There   would  appear   to    be    several 


Epilepsy.  991 

characteristic  types  of  the  idiopathic  disease.  There  is  a  form  of 
epilepsy  in  which  the  whole  course  of  the  disease  is  shown  by  the 
occurrence  of  a  few  fits  over  a  limited  period  of  time.  As  this  type 
undergoes  spontaneous  cure  it  is  probable  that  some  case's  of 
arrested  epilepsy  are  instances  of  this  variety.  There  is  also  a 
variety  of  epilepsy  whose  symptoms  consist  of  infrequent  occurrence 
of  fits  associated  with  little  or  no  mental  impairment.  This  con- 
stitutes a  favourable  and  in  many  cases  a  curable  form  when 
treated  over  long  periods  of  time.  The  majority  of  cases  of  epilepsy, 
however,  are  of  a  kind  in  which,  along  with  some  degree  of  mental 
impairment,  there  is  a  greater  or  less  frequency  of  seizures  of 
variable  types,  either  major  or  minor  fits  (alone  or  in  combina- 
tion) psychical  attacks  (purely  psychical  or  psychomotor)  or  fits 
occurring  in  series. 

The  treatment  of  so  multiform  and  persistent  a  disease  as  epilepsy 
requires  description  under  several  headings,  but  it  is  essential  to 
bear  in  mind  at  the  outset  that  it  is  necessary  to  treat  in  every 
instance  the  individual  and  not  solely  the  disease.  The  prescribing 
of  therapeutic  and  general  measures  must  therefore  depend  upon 
the  individual  peculiarities  and  temperament. 

TREATMENT  OF  ASSOCIATED  CONDITIONS. 
Reflex  Epilepsy. — Many  cases  of  epilepsy  are  to  some  extent 
influenced  by,  and  by  some  writers  ascribed  to,  local  irrita- 
tion of  peripheral  structures,  more  especially  the  nose,  eyes,  ears, 
teeth  and  generative  organs,  although  no  part  or  organ  of  the 
body  is  necessarily  exempt.  It  is  therefore  desirable  to  examine 
these  organs  individually  in  all  cases  of  the  disease. 

1.  The  nose  ought  to  be  examined  for  polypi,  adenoid  growths 
and  foreign  bodies,  the  last  two  being  not  uncommon  accompani- 
ments of  fits,  especially  in  children.     The  removal  of  such  causes 
of  nasal  irritation  and  obstruction  is  not  infrequently  followed  by 
temporary,  or  in  some  cases  permanent,  arrest  of    the   seizures. 
In   all  cases,    however,   treatment    by   the    bromides    should   be 
prescribed  and  continued. 

2.  The  eyes  ought  to  be  investigated  for  errors  of  refraction, 
which  are  very  common  in  epileptics.     In  every  case  the  existing 
error  should  be  corrected.     There  is,  however,  considerable  differ- 
ence of  opinion  as  to  their  influence  upon  the  disease.      At  the 
best  the   correction  of    a   refractive   error   will   only   temporarily 
mitigate  the  seizures,   and   all   cases    require   treatment    by  the 
bromides. 

3.  The  ears  ought  to  be  examined  for  disease  of  the  external 


992  Epilepsy. 

and  middle  ear ;  less  commonly  the  labyrinth.  The  relation  of 
chronic  otorrhoea  to  epilepsy  is  uncertain.  Appropriate  local 
as  well  as  general  treatment  should  be  carried  out  in  all  cases. 

4.  The  teeth  ought  to  be  examined  for  caries,  which  is  notoriously 
frequent   in   epileptics.      This   requires   the    necessary    attention. 
Improvement  in  the  number  and  severity  of  fits  is  not  uncommon 
after  adjustment  of  suitable  artificial  means  of  mastication. 

5.  The   stomach    and   intestines :   Constipation    and  dyspeptic 
disorders  are  frequent  in  epilepsy,  and  require  constant  attention. 
In  children  the  presence  of  worms  should  be  especially  enquired 
into.     It  is,  however,  not  uncommon  to  find   that  the  fits  persist 
after  the  worms  have  been  removed. 

6.  The  genital  organs  ought  to  be  examined  (a)  for  the  presence 
of  a  tight  prepuce  in  boys,  which  is  a  well-recognised  accompani- 
ment of  fits  ;  in  these  cases  circumcision  is  frequently  followed  by 
great   improvement;    (6)  for   abnormal   conditions   of    the   pelvic 
organs  in  females.     These  require  the  necessary  attention.     The 
old  procedure  of  removing  the  ovaries  or  other  parts  of  the  female 
generative  organs  was  based  on  an  entirely  mistaken  view  of  the 
nature  of  epilepsy. 

7.  Self-abuse  is  an  ascribed  cause  of  epilepsy,  but  it  would  seem 
to  be  less  a  contributory  cause  of  this  disease  than  of  some  of  the 
neuroses  which  appear  in  later  life.     As  an  associated  symptom,  it 
is  of  frequent  occurrence.     It  may  be  continued  as  a  habit  long 
after  the  disease  has   become  confirmed.      Stress  should  be  laid 
upon  its  dangers  and  any  local  source  of  irritation  relieved. 

In  all  cases  of  epilepsy  associated  with  the  above-mentioned 
abnormal  conditions  of  the  peripheral  organs  suitable  medicinal 
treatment  ought  to  be  carried  on  even  after  the  correction  or 
removal  of  the  local  disorders. 

Epilepsy  of  Infective  Origin. — The  common  infective  causes 
of  epilepsy  are  scarlet  fever,  measles,  influenza,  diphtheria, 
pneumonia  and  typhoid  fever.  Epilepsy  ascribed  to  one  or  other  of 
these  diseases  arises  either  during  the  course  of  the  fever  or  during 
convalescence. 

The  treatment  of  epilepsy  of  infective  origin  will  be  described 
under  the  treatment  of  recent  epilepsy  (p.  993),  as  it  in  no  way 
differs  from  the  idiopathic  disease.  Complications,  however,  of 
the  infective  disorder,  such  as  otorrhosa  or  album inuria,  should 
receive  appropriate  attention.  Another  aspect  of  the  relation 
between  epilepsy  and  the  acute  specific  disorders  is  a  tendency  to 
remission  of  the  fits,  which  may  be  temporarily  or  even  per- 
manently brought  about.  Several  cases  have  been  observed  in 


Epilepsy.  993 

which  scarlet,  typhoid  and  malarial  fevers  have  brought  about  a 
temporary  respite  from  epileptic  attacks. 

Epilepsy  of  Toxic  Origin. — Auto-intoxication. — Toxic  influences 
arising  in  connection  with  the  gastro-intestinal  tract  have 
within  recent  years  received  considerable  attention  as  possible 
causes  of  epilepsy.  There  is,  however,  little  evidence  as  to  what 
they  are  or  how  they  act.  Treatment  directed  towards  intestinal 
antisepsis  has  not  led  to  any  material  improvement.  In  some 
cases  the  onset  of  the  fit  or  fits  is  preceded  by  an  increase  of 
constipation  with  some  furring  of  the  tongue.  In  these  cases  a 
8  or  5  gr.  dose  of  calomel  at  bedtime,  followed  by  a  dose  of  salts  in 
the  morning,  is  desirable  and  often  efficacious.  In  all  cases  of 
epilepsy,  owing  to  the  tendency  to  constipation  and  to  gastro- 
intestinal disturbance,  whatever  the  nature  of  the  medicinal 
treatment  employed,  an  occasional  dose  of  calomel  is  of  advantage. 

Alcoholic  Intoxication,  more  especially  in  persons  predisposed  to 
fits,  induces  epilepsy,  sometimes  in  the  form  of  status  epilepticus 
associated  with  delirium  tremens.  This  form  of  epilepsy — the 
'true  alcoholic  epilepsy — is  rarely  followed  by  the  usual  chronic 
type  of  the  disease,  the  convulsions  passing  away  when  alcohol  is 
no  longer  given. 

The  potent  influence  of  alcohol  upon  the  brains  of  epileptics 
may  be  referred  to  here.  Alcoholic  intoxication  may  produce  serious 
and  severe  relapses  of  epileptic  fits,  and  sometimes  acute  maniacal 
outbui-sts  in  these  persons.  In  all  cases  of  epilepsy,  therefore, 
alcohol  should  be  forbidden  except  under  conditions  of  collapse, 
which  will  be  referred  to  later. 

Tobacco  Intoxication,  as  an  exciting  cause  of  epilepsy,  is  only 
of  rare  occurrence ;  but  in  an  epileptic  excessive  smoking  will 
occasionally  aggravate  the  disease  and  lead  to  frequent  and  severe 
fits.  Tobacco  smoking  need  not  be  prohibited  in  epilepsy,  but  the 
quantity  smoked  should  be  restricted. 

EPILEPSY  OF  RECENT    ORIGIN* 

The  Bromides. — There  is  no  single  specific  remedy  in  the  treat- 
ment of  epilepsy,  although  the  alkaline  salts  of  bromine  come 
nearest  to  this  definition.  Moreover,  the  influence  of  the  bromides 
upon  epileptic  convulsions  is  variable  and  uncertain. 

In  the  first  place,  bromide  medication  may  arrest  the  seizures 
immediately  or  within  a  short  period  of  its  administration, 
temporarily  or  permanently.  In  this  division  most  of  the  curable 
types  of  epilepsy  are  found,  cases  characterised  by  the  absence  of 
mental  impairment  and  with  fits  recurring  only  at  long  intervals. 

S.T. — VOL.  n.  63 


994  Epilepsy. 

If  any  given  case  is  capable  of  arrest  a  satisfactory  response  will  be 
apparent  within  a  comparatively  short  period,  usually  twelve  months, 
from  the  commencement  of  the  bromide  treatment. 

Secondly,  the  bromides  may  induce  a  lessening  in  the  severity 
and  frequency  of  the  seizures.  This  is  the  common  temporary 
result  of  bromide  treatment,  and  is  what  may  be  confidently  expected 
in  the  majority  of  cases  in  the  early  stages  of  the  disease.  Some- 
times the  change  is  effected  by  the  arrest  of  the  major  seizures,  the 
minor  continuing  ;  or  the  bromide  may  change  the  time-incidence 
of  fits,  from  the  waking  to  the  sleeping  hours,  or  vice  versa. 

Thirdly,  the  bromides  may  exert  no  influence  at  all  upon  the 
disease,  or  may  even  augment  the  frequency,  or  severity,  of  the 
seizures. 

These  observations  are  in  general  harmony  with  those  of  other 
writers  on  the  subject.  They  point  to  the  fact,  admitted  by  those 
who  have  had  much  personal  experience  of  the  treatment  of  epilepsy, 
that  a  large  percentage  of  epileptics  derive  no  benefit  from  the  use 
of  bromides.  Only  about  50  per  cent,  of  all  cases  of  epilepsy  would 
seem  to  be  benefited  by  their  use.  Notwithstanding  the  unfavour- 
able results  of  treatment  in  many  cases,  it  is  advisable  that  all  cases 
of  recent  epilepsy  should  be  given  the  benefit  of  these  drugs  for  a 
time. 

The  physiological  action  of  the  bromide  salts  consists  in  lessening 
the  irritability  of  the  central  nervous  system  and  in  exerting  a 
subduing  effect  upon  reflex  activity  and  cerebral  function.  The 
potash  salts  of  bromine  also  induce  a  slowing  of  the  pulse  and  of  the 
action  of  the  heart.  In  medium  doses  (10  to  30  gr.)  the  bromides 
produce  muscular  fatigue,  a  slowing  of  the  mental  processes,  dulling 
of  the  sexual  function  and  of  the  skin  sensibility. 

In  large  doses  (150  to  225  gr.)  the  speech  becomes  slurred,  there 
is  abolition  of  the  palatal  and  pharyngeal  reflexes,  while  frontal 
headaches  and  a  limitation  of  the  power  of  thought  soon  ensue. 
Salivation,  lowering  of  the  body  temperature  and  of  the  pulse  rate, 
catarrh  of  the  stomach  and  of  the  respiratory  mucous  membranes, 
are  general  bodily  symptoms,  resulting  from  continual  use  of 
large  doses  of  the  bromides.  It  is  therefore  obvious  that  the 
prolonged  and  injudicious  use  of  the  bromides  may  give  rise  to  toxic 
symptoms. 

Bromifitn. — This  condition  is  characterised  by  a  blunting  of  the 
intellectual  faculties,  impairment  of  the  memory,  and  a  dull  and 
apathetic  state.  The  speech  is  slow,  the  tongue  tremulous,  the  saliva 
may  flow  from  the  mouth,  the  gait  is  staggering,  and  the  movements 
of  the  limbs  feeble  and  infirm.  The  mucous  membranes  suffer  so  that 


Epilepsy.  995 

the  palatal  sensibility  may  be  abolished,  and  nausea,  flatulence  and 
diarrhoea  supervene.  The  action  of  the  heart  is  slow  and  feeble, 
the  respiration  shallow  and  imperfect,  arid  the  extremities  blue  and 
cold.  An  eruption  of  acne  frequently  covers  the  skin  of  the  face, 
neck  and  back. 

Dosage. — Bromide  treatment  should  be  commenced  at  the 
earliest  possible  time  after  the  onset  of  the  fits,  as  there  is  greater 
prospect  of  arrest  or  improvement  during  the  early  stages  of 
the  disease,  although  arrest  of  the  seizures  may  occur  after  a 
duration  of  twenty  years.  The  administration  of  the  bromides 
should  be  continued  for  a  period  the  duration  of  which  is  to  be 
determined  by  the  study  of  each  case  separately,  but  should  not  be 
less  than  two  years.  The  dose  usually  given  is  too  large.  If  benefit 
does  not  follow  a  daily  dose  of  from  45  to  60  gr.  of  one,  or  a 
combination  of  the  bromide  salts,  some  other  remedy  or  method  of 
treatment  should  be  sought  for  and  applied.  Clouston  showed  that 
no  appreciable  diminution  in  the  number  of  fits  took  place  when  the 
dose  of  bromide  exceeded  75  gr.  in  twenty-four  hours. 

The  large  doses  sometimes  prescribed,  from  100  to  150  gr.  daily, 
although  no  doubt  suppressing  the  seizures  for  a  time,  induce  other 
and  more  serious  phenomena,  namely,  those  of  bromism  already 
described.  Moreover,  the  bromides  have  an  accumulative  action. 
Laudenheimer  has  shown  that  an  epileptic  taking  10  grammes 
(150  gr.)  of  bromide  salt  daily  for  eight  days  only  excreted  a  total 
of  35  gr.,  or  less  than  half  the  quantity  ingested  during  that  period. 
He  also  showed  that  no  result  followed  its  administration  until  an 
equilibrium  was  established  between  the  intake  and  the  output;  this 
occurs  on  saturation  of  the  body  and  requires  about  30  gr.  of 
bromide  to  be  given  daily  for  three  or  four  weeks.  It  is  also  largely 
dependent  upon  the  amount  of  sodium  chloride  taken  in  food ;  the 
deletion  of  table  salt  from  the  dietary  being  an  important  modifica- 
tion in  the  treatment  of  epilepsy. 

Most  physicians  have  their  own  methods  of  prescribing  the 
bromides  in  epilepsy.  As  already  mentioned,  large  doses  are  not 
necessary,  nor  are  they  effectual  in  their  results,  both  the  amount 
of  the  dose  and  the  time  of  administration  being  gauged  by  the 
study  of  individual  cases. 

The  potassium,  sodium,  strontium  and  ammonium  salts  are  the 
most  usually  administered.  Each  is  of  value,  but  the  sodium  salt 
is  the  most  efficacious.  If  the  bromides  are  prescribed  in  combination, 
the  dose  should  not  exceed  60  gr.  in  the  twenty-four  hours.  The 
bromide  of  strontium  is  less  useful,  but  may  be  given  in  10  gr. 
doses  in  combination  with  the  other  salts. 

63—2 


996  Epilepsy. 

Should  the  seizures  be  only  nocturnal  or  occur  in  the  early 
morning,  one  dose  of  30  or  40  gr.  of  the  potassium  or  sodium  salt 
may  be  taken  in  a  small  tumbler  of  water  at  bedtime. 

Should  the  attacks  occur  at  or  about  the  time  of  rising,  which  is  a 
very  common  time,  a  full  dose  may  be  given  at  bedtime  and  a  half 
dose  (15  gr.)  before  the  patient  rises  from  bed.  This  may  be 
prescribed  along  with  a  cup  of  weak  tea. 

Should  the  attacks  occur  at  irregular  hours  in  the  day  the  medicine 
may  be  given  after  each  meal,  in  such  a  way  that  45  or  even  60  gr. 
may  be  given  per  diem.  The  larger  dose  is  preferably  given  at 
bedtime.  The  omission  of  the  bromides  for  one  day  per  week  is 
cften  satisfactory. 

Combinations  of  the  Bromides  with  other  Remedies. — A 
combination  of  the  bromides  and  digitalis  has  been  found  very 
satisfactory  in  cases  of  low  arterial  tension,  irregular  action  of  the 
heart,  or  failing  compensation  with  valvular  disease.  In  similar 
cases  Bechterew  recommends  adonis  r emails  in  conjunction  with 
the  bromides.  It  may  be  prescribed  in  15  min.  doses  of  the  tincture 
adonis  vernalis. 

Chloral  hydrate,  in  the  form  of  brornidia,  may  be  given  with  great 
advantage  in  cases  of  prolonged  serial  epilepsy  or  of  the  status 
eplleptieus. 

The  bromides  and  the  glycerophosphates  form  a  valuable  com- 
bination in  weak  or  debilitated  cases,  more  especially  in  young  women 
with  anaemia  or  neurasthenic  symptoms. 

A  combination  of  the  bromides  and  borax  has  been  of  service 
where  the  bromides  or  borax,  separately,  have  been  of  little  use. 

A  combination  of  the  bromides  and  bicarbonate  of  soda  has  been 
recommended  on  the  theory  that  it  is  a  more  efficacious  means  of 
maintaining  the  blood  alkalinity  than  the  bromide  salts  alone. 

Of  the  combinations  of  the  bromides  with  other  remedies,  I  have 
found  GelineaiCs  formula  the  most  useful  and  satisfactory.  It  is 
prescribed  in  the  form  of  drawees  containing  1  gramme  of  pot.  brom., 
%  milligramme  of  picrotoxin,  and  ^  milligramme  of  the  arseniate 
of  antimony. 

In  large  doses  picrotoxin  is  a  producer  of  convulsions,  leading 
to  spasms  of  a  tetanic  character  with  death  in  coma.  In  small  doses 
it  is  theoretically  supposed  to  lessen  the  tendency  to  cerebral  vaso- 
constriction,  which  is  believed  by  some  authors  to  be  a  fundamental 
factor  in  the  causation  of  epileptic  fits.  The  arseniate  of  antimony 
would  appear  to  be  a  more  satisfactory  remedy  than  arsenious 
acid. 

The  method  of  prescribing  the  drage.es  is  simple  :     One  dnitjee  is 


Epilepsy.  997 

taken  either  during  or  immediately  after  a  meal,  thrice  daily  for  a 
week,  an  additional  dragee  being  added  weekly  until  the  patient  is 
taking  four,  five  or  six  per  diem.  Four  dr ogees  daily  are  usually 
sufficient  to  hold  the  fits  in  check,  although,  according  to  Gelineau, 
as  many  as  ten  or  twelve  daily  may  be  taken. 

The  bromides  may  be  prescribed  alone  or  in  conjunction  with 
arsenic,  nux  vomica  or  gentian.  Their  taste  may  be  partially 
obscured  by  camphor,  chloroform  or  peppermint  water,  or  the 
syrup  of  Virginian  prune  may  be  added  as  a  pleasant  medium  for 
their  administration,  especially  for  children. 

The  treatment  of  bromide  acne  requires  a  few  words.  As  long  as 
the  bromides  are  being  taken  it  is  likely  to  resist  treatment.  The 
bromides  of  strontium  and  sodium  tend  less  to  its  production  than 
the  potassium  salt.  Arsenic,  as  Fowler's  solution,  may  be  given 
with  the  bromide  solution  or  separately  in  pill  form.  Locally, 
sulphur  ointment,  or  mercury  in  the  form  of  ung.  hydrarg. 
ammoniat.,  has  been  found  useful. 

New  Preparations  of  Bromine. — Many  new  remedies  con- 
taining bromine  have  been  recommended  with  a  view  to  eliminate 
the  toxic  effects  of  the  bromine  salts.  The  chief  of  these  is  bromalin 
(bromine  and  formaldehyde  derivatives),  which  may  be  given  in  doses 
of  from  10  to  30  gr.  ;  broinipin  (bromine  and  sesame  oil)  is  pre- 
scribed in  doses  of  from  15  to  60  gr.,  and  bromocarpine  (bromine 
and  pilocarpine)  prescribed  in  £  oz.  doses  of  the  syrup.  I  have 
not  found  these  remedies  in  any  way  preferable  to  the  ordinary 
bromide  salts.  Bromipin  is  difficult  to  dispense,  but  bromalin  is 
stated  to  cause  no  skin  eruption. 

Treatment  by  Drugs  other  than  the  Bromides. — Before  the 
introduction  of  the  salts  of  bromine  in  the  treatment  of  epilepsy 
many  remedies  were  used,  sometimes  with  marked  success,  as  may 
be  seen  from  the  satisfactory  results  obtained  by  Herpin,  Eeynolds 
and  others.  On  account  of  the  not  infrequent  failure  of  the 
bromides  to  arrest  or  even  to  ameliorate  epileptic  attacks,  it  will  be 
found  necessary  to  prescribe  some  other  medicinal  remedy,  and 
a  large  number  have  been  from  time  to  time  advocated  and 
employed.  Perhaps  the  drug  most  frequently  used  as  a  substitute 
for,  or  as  an  adjuvant  to,  the  bromides,  more  particularly  in 
England,  is  borax  (sodium  biborate).  Introduced  by  Gowers  many 
years  ago  as  an  antispasmodic,  it  has  met  with  considerable  favour 
in  cases  where  the  bromides  have  been  of  little  service.  It  would 
seem  to  be  of  most  use  in  combination  with  a  salt  of  bromine.  It 
may  be  given  in  doses  of  from  10  to  20  gr.,  thrice  daily,  but  is  apt 
to  induce  troublesome  gastro-intestinal  symptoms.  If  continued 


998  Epilepsy. 

over  long  periods  it  may  lead  to  cutaneous  eruptions  of  a  psoriasis- 
like  character. 

Belladonna  was  the  chief  anti-epileptic  remedy  of  the  pre-bromide 
days,  and  is  still  used  in  some  cases  with  marked  benefit  when  the 
bromides  or  other  remedies  have  proved  unsuccessful.  It  formed 
the  chief  remedy  of  Trousseau,  Huf eland,  Herpin,  Reynolds  and 
others,  and  in  the  hands  of  the  first  named  was  mainly  used  in  those 
cases  complicated  with  nocturnal  incontinence  of  urine.  A  com- 
bination of  bromide  and  belladonna  may  be  found  useful  in  cases 
of  otherwise  intractable  combined  seizure  types.  It  is  by  preference 
prescribed  as  the  tincture  in  doses  of  5  or  10  min.  [U.S. P.,  7  or 
14  min.]. 

The  zinc  salts  (valerianate,  1 — 3  gr.,  and  lactate,  10 — 15  gr.)  are 
old  established,  and  were  occasionally  successful  remedies  in  the 
hands  of  the  French  physicians. 

Opium  is  now  only  used  in  the  opium  bromide  method  recom- 
mended by  Flechsig.  My  experience  of  the  treatment  has  not 
been  such  as  to  encourage  further  trial. 

Strychnine  has  been  recommended  from  time  to  time  and  used  with 
considerable  success  by  some  physicians.  In  doses  of  ^  to  j^  gr. 
daily,  it  may  be  continued  over  considerable  periods.  Its  -modus 
operandi  is  probably  that  of  a  nerve  tonic,  although  it  may  have 
some  influence  in  strengthening  the  tone  of  the  vasomotor  centres. 
Strychnine  finds  its  most  useful  application*  in  the  treatment  of 
nocturnal  epilepsy,  especially  when  there  is  reason  to  suppose  that 
the  blood  pressure  is  materially  lowered. 

Solatium  Caiolinense,  or  horse  nettle,  is  recommended  by  American 
physicians  as  of  use  in  some  cases.  It  may  be  prescribed  in 
1  drachm  doses  of  the  liquid  extract. 

Duration  of  Treatment. — The  question  as  to  how  long  bromide 
or  any  other  form  of  medicinal  treatment  should  be  kept  up  is  not 
one  upon  which  any  rigid  statement  can  be  made.  Some  autho- 
rities maintain  that  treatment  should  be  continuous  for  a  period 
of  at  least  two  years  after  the  last  seizure.  In  my  opinion,  the 
bromides  should  not  be  stopped  under  a  period  of  five  years  in 
those  whose  fits  are  arrested.  On  the  other  hand,  many  persons 
in  whom  the  disease  has  been  arrested  after  a  year  or  two  of 
bromide  treatment  remain  free  from  attacks  without  the  aid  of  any 
medicinal  remedy.  The  important  practical  point  in  this  connec- 
tion is,  that  those  patients  who  take  bromide  well,  and  in  whom  the 
fits  are  thereby  kept  in  subjection,  ought  to  persevere  with  the 
remedy  and  not  to  stop  it.  It  is  just  when  the  fits  have  been  satis- 
factorily controlled  that  further  treatment  is  of  most  use.  The 


Epilepsy.  999 

withdrawal  of  medicinal  treatment  in  those  in  whom  the  fits  have 
been  arrested  should  be  carried  out  gradually.  Under  no  cir- 
cumstances should  bromides  be  withdrawn  suddenly,  after  their 
prolonged  use,  owing  to  the  tendency  towards  the  onset  of  status 
(.'pilepticus. 

Miscellaneous  Methods  of  Treatment. — It  may  be  useful  to 
refer  to  other  methods  in  this  place,  as  a  case  which  has  resisted 
one  form  of  treatment  may  react,  for  a  time,  satisfactorily  to 
another.  It  should,  on  the  other  hand,  not  be  forgotten,  what  is 
a  well-recognised  axiom  in  the  management  of  epilepsy,  that  cases 
of  this  disease  may  respond  favourably  for  a  time  to  each  and  every 
change  of  treatment,  medicinal  or  other,  and  even  when  active 
treatment  is  stopped.  As  the  disease  is  characterised  by  spon- 
taneous remissions  in  the  frequency  and  severity  of  the  seizures, 
a  favourable  result  may  occur,  not  on  account  of,  but  in  spite  of, 
therapeutic  or  other  measures. 

Of  all  the  recent  systems,  that  which  seemed  likely  to  be  of  most 
use  was  the  introduction  of  the  organic  extracts  in  the  treatment  of 
this  disease ;  but  further  experience  with  these  preparations  has 
been,  on  the  whole,  disappointing. 

Organotherapy. — The  administration  of  extract  of  the  thyroid 
gland,  or  of  iodothyrin,  was  at  one  time  strongly  advocated,  more 
with  a  view  to  counteract  the  co-existent  mental  deterioration  than 
as  a  subduer  of  convulsions.  In  a  number  of  cases  of  confirmed 
epilepsy,  in  which  preparations  of  the  thyroid  gland  were  given 
over  considerable  periods,  no  appreciable  diminution  was  detected 
in  the  frequency  of  the  seizures,  and  in  only  a  limited  number  of 
cases  and  for  brief  periods  was  there  any  lessening  of  the  co-existent 
dementia.  My  experience  is  that  thyroid  medication  tends  rather 
to  increase  the  number  of  fits  and  to  produce  at  times  irritability 
and  want  of  control. 

Preparations  of  the  thymus  gland  act  injuriously  in  epileptics  by 
increasing  the  number  of  the  seizures.  Cerebrin  has  not  been 
found  to  be  of  any  value. 

Xfrotiu'm})!/. — The  treatment  of  epilepsy  by  the  injections  of 
blood  serum,  either  from  another  epileptic  or  by  re-injection  of  the 
blood  serum  into  the  same  epileptic,  as  introduced  some  years  ago  by 
Ceni,  has  not  been  sufficiently  satisfactory  to  make  its  application 
general.  Later  investigators  have  failed  to  confirm  the  earlier 
results  or  to  establish  any  benefit  at  all  from  such  injections  into 
those  subject  to  fits. 

Diet  in  Epilepsy. — In  all  cases  of  recent  epilepsy  some  modi- 
fication of  the  diet  from  that  suitable  to  health  is  desirable.  The 


iooo  Epilepsy. 

primary  object  of  the  treatment  of  this  disease  is  to  subdue  the  fits 
and  keep  them  in  abeyance  by  as  small  a  dose  of  the  bromide  salts 
as  possible,  as  a  prolonged  course  of  treatment  is  usually  necessary, 
owing  to  the  persistent  character  of  the  malady.  Two  hypotheses 
may  be  mentioned  as  underlying  the  dietetic  treatment  of  epilepsy. 
The  first  is  that  nervous  energy  has  its  source  chiefly  in  the 
albuminous  and  nitrogenised  principles  of  foodstuffs.  The  second 
is  that,  owing  to  the  striking  homology  in  the  properties,  both 
chemical  and  physical,  of  the  bromide  and  chloride  salts,  deletion 
of  the  chlorides  from  the  food  may  assist  the  action  of  the  bromides 
in  the  treatment  of  this  disease. 

All  forms  of  dietetic  variations  have  been  tried  in  the  treatment 
of  epilepsy,  and  the  general  conclusions  which  have  been  formed 
from  these  observations  are  that  a  diet  without  meat  is  the  most 
satisfactory,  and  that  neither  a  milk  diet  alone  nor  a  vegetable  diet 
is  as  beneficial  as  their  combination.  The  deletion  of  table  salt 
from  the  diet  of  epileptics  was  recommended  by  Toulouse  and 
Bichet.  They  prescribed  a  diet  in  which  the  total  quantity  of 
sodium  chloride  per  diem  was  limited  to  1  or  2  grammes.  It 
was  thought  that  by  diminishing  the  quantity  of  the  ingested 
chlorides,  mainly  in  the  form  of  sodium  chloride  or  common  salt, 
the  bromides  might  be  administered  in  smaller  doses  and  the  risks 
of  bromism  thereby  lessened. 

Hoppe  has  shown  that  one-third  of  the  chlorine  of  the  blood 
serum  has  to  be  replaced  by  an  equivalent  amount  of  bromine 
before  any  therapeutic  result  is  obtained.  When  more  than  this  is 
replaced  bromide  intoxication  may  occur.  When  less  chloride  is 
ingested  saturation  takes  place  sooner.  It  has  been  shown  that 
with  a  diet  free  from  salt  saturation  takes  place  in  from  three  to 
four  days.  This  method  of  "  salt  starvation  "  in  the  treatment  of 
epilepsy  has  been  extensively  tested,  with  varying  results. 

In  some  cases  "salt  starvation"  has  proved  a  useful  adjuvant 
to  bromide  medication,  while  in  others  little  benefit  has  resulted. 
Other  observers  have  shown  the  dietary  to  be  of  especial  value  in 
cases  requiring  large  doses  of  the  bromides  and  in  those  which 
show  a  ready  tendency  to  bromiie  intoxication.  My  own  experi- 
ence of  the  method  has  been  such  that,  when  used  in  combination 
with  a  purin-free  dietary  in  cases  of  recent  epilepsy,  very  substantial 
benefit  is  derived,  and  relatively  small  doses  of  the  bromide  may  be 
prescribed. 

Purin-free  Dietary. — A  "  purin-free  "  diet  is  made  up  of  those 
foodstuffs  in  which  the  "  purin  "  or  alloxur  bodies  are  absent,  or 
present  only  in  such  quantities  as  to  be  negligible. 


Epilepsy.  1001 

Purin  bodies  exist  in  all  forms  of  meat  extract,  in  both  the  white 
and  red  meats,  commonly  used  as  food.  They  are  present  in  large 
quantities  in  such  substances  as  sweetbread,  liver  and  beefsteak. 
They  are  not  present  in  milk,  eggs,  bread,  butter,  cheese,  the 
farinacea,  most  fruits,  some  vegetables,  and  honey.  They  exist  to 
only  a  moderate  degree  in  most  forms  of  fish,  peas,  beans,  lentils, 
tea,  coffee  and  oatmeal.  The  following  list  of  purin-poor  or  purin- 
free  foodstuffs  will  be  found  of  use  to  those  desirous  of  giving  the 
treatment  a  trial :  Milk  (fresh,  soured,  buttermilk,  or  whey)  ;  eggs 
(boiled,  poached,  scrambled  or  raw) ;  white  bread  and  butter, 
cheese,  macaroni,  rice,  tapioca,  semolina,  vermicelli ;  suet  puddings 
with  currants,  jam  and  treacle,  apple  dumplings ;  pastries,  pan- 
cakes, jellies,  tea-cakes ;  all  vegetables  (except  peas,  beans,  lentils) ; 
of  beverages,  weak  infusion  of  China  tea  is  the  best. 

I  have  used  this  diet,  or  a  modification  of  it,  containing,  according 
to  the  need  of  individual  cases,  a  small  portion  of  fish,  either  once 
daily  or  three  times  a  week,  for  several  years  in  conjunction  with 
the  bromides  or  Gelineau's  dragces.  The  results  have  been  such 
that  I  am  led  to  advise  it  in  all  cases  of  recent  epilepsy.  In  cases 
in  which  the  bromides  alone  have  been  of  little  or  no  use,  the 
adoption  of  the  purin-free  saltless  diet  has  at  once  led  to  material 
improvement.  By  its  aid  the  dose  of  the  bromides  has  been 
largely  reduced  ;  as  it  is  in  cases  refractory  to  relief  by  bromides  that 
some  physicians  increase  the  salts  to  such  an  extent  that  bromism  is 
brought  about  and  maintained.  If  properly  supervised,  symptoms 
of  bromism  need  never  appear.  If  the  patient  shows  any  signs  of 
loss  of  weight  the  addition  of  cream  or  cod-liver  oil  is  usually 
sufficient.  If  not  sufficient  it  is  advisable  to  permit  fish  or  even 
a  little  lamb  or  mutton. 

Hygienic  Treatment. — In  conjunction  with  medicinal  remedies 
and  dietetic  modifications,  general  measures  of  a  hygienic  kind  are 
of  value  in  the  treatment  of  epilepsy,  and  require  to  be  mentioned. 
In  a  disease  so  difficult  to  handle  and  so  prone  to  mental  deteriora- 
tion assistance  from  all  sides  should  be  given,  for  no  greater  mistake 
can  be  made  than  to  rely  solely  on  medicinal  remedies,  which  so 
often  fail  in  the  treatment  of  epilepsy. 

There  are  many  cases  of  epilepsy  in  which  treatment  in  an 
institution  may  be  undertaken  with  great  satisfaction.  On  the 
other  hand,  should  this  be  impossible  or  inadvisable,  the  patient 
ought  to  be  placed  under  the  care  of  a  well-trained  nurse  attendant. 
This  instruction  is  usually  necessary  for  the  efficient  treatment  of 
this  disease  in  young  people. 

As  epileptics  suffer  from  lowered  vitality  and  sluggish  circulation, 


ioo2  Epilepsy. 

warm  baths,  spinal  douches  and  massage  are  desirable.  A  certain 
amount  of  exercise  in  the  open-air  is  also  necessary,  but  such 
exercises  as  bicycling,  rowing  and  swimming  should  be  avoided, 
owing  to  their  danger. 

The  out-of-door  life  is  usually  regarded  as  the  most  suitable  for 
epileptics,  hence  farming  or  market  gardening  are  frequently 
recommended  for  epileptics  of  a  robust  constitution.  Many  epi- 
leptics, however,  are  quite  able  to  carry  on  their  professional  work 
or  business  without  difficulty. 

It  is  preferable  that  those  who  are  subject  to  even  infrequent 
epileptic  seizures  should  be  educated  apart  from  healthy  boys  and 
girls.  In  all  cases  private  tuition  is  to  be  recommended.  In  cases 
with  marked  mental  impairment  appropriate  methods  of  teaching 
should  be  adopted.  No  greater  mistake  can  be  made  than  with- 
holding from  young  epileptics  the  advantages  of  education  under 
special  supervision  and  direction.  It  is  of  primary  importance 
that  the  teacher  and  the  physician  should  work  together  in  this 
connection. 

If  epilepsy  develops  during  a  period  of  mental  stress  or  strain, 
when  working  for  an  examination  or  under  like  circumstances, 
complete  abstinence  from  work  for  the  time  ought  to  be  enforced, 
but  when  the  type  of  the  disease  has  revealed  itself  education 
should  be  resumed  on  the  ordinary  lines. 

The  marriage  of  epileptics  ought  to  be  discouraged.  The  popular 
belief  that  if  an  epileptic  girl  is  married  the  disease  will  be  cured, 
does  not  often  come  true.  Isolated  instances  of  this  may  be 
observed,  but  in  the  majority  of  cases  the  risks  attendant  on  child- 
bearing  are  considerable,  and  the  probability  of  giving  birth  to 
epileptic  children  is  great. 

TREATMENT    OF    THE    FITS    AND    COMPLICATIONS. 

Prodromata. — The  recognition  of  the  prodromal  symptoms 
which  sometimes  usher  in  a  seizure  is  of  value,  as  active  and 
energetic  treatment  at  this  stage  may  prevent  the  occurrence  of  an 
attack.  These  symptoms  are  of  many  kinds,  motor  in  the  forms  of 
jumps  or  jerks,  sensory  in  the  form  of  segmental  anaesthesias 
(Muskens),  vasomotor,  and  psychical  or  temperamental. 

When  such  symptoms  arise  an  extra  dose  of  the  bromide  salt 
should  be  given  at  once  and  continued  daily  until  the  period  for 
the  seizure  is  safely  passed  ;  secondly,  the  patient  should  be  placed 
in  bed  and  kept  at  rest,  and  thirdly,  a  calomel  purge  ought  in  all 
cases  to  be  administered,  whether  constipation  is  present  or  not. 
On  the  other  hand,  in  many  cases  of  epilepsy  no  prodromal 


Epilepsy.  1003 

symptoms  are  present,  the  seizure  developing  suddenly  when  the 
patient  is  feeling  particularly  well. 

To  Arrest  the  Fit. — The  next  consideration  may  be  given  to 
the  question  whether  it  is  possible  to  arrest  an  attack  once  the 
warning  has  commenced.  Many  methods  have  been  suggested  for 
this  purpose,  some  of  which  are  of  old  standing  and  date  from  the 
time  of  Galen. 

The  attacks  in  which  abortive  measures  are  likely  to  be  successful 
are  those  commencing  with  a  peripheral  aura.  The  common  method 
of  encircling  the  wrist,  for  example,  with  a  ligature  or  tape,  and 
making  traction  upon  it  as  soon  as  the  aura  is  felt  in  the  hand,  is 
well  known.  As  great  force  is  sometimes  required  to  arrest  the 
attack,  a  strap  is  preferable  to  a  tape  or  ligature.  Sometimes  the 
patient  alone  is  unable  to  produce  sufficient  compression  and 
requires  the  assistance  of  a  second  person.  A  circular  blister  was 
suggested  by  Buzzard,  in  order  to  induce  a  more  permanent  effect, 
sometimes  with  advantage. 

Forced  extension  or  movement  in  the  direction  opposite  to  the 
warning  sensation  may  be  efficacious,  when  compression  alone 
is  unsatisfactory.  According  to  Herpin,  the  most  effectual  means 
of  arresting  such  attacks  is  a  combination  of  circular  compression 
and  forced  movement  in  the  opposite  direction.  Friction,  or 
rubbing  the  extremity  of  the  limb  where  the  sensation  starts,  has 
also  been  of  use,  and  I  have  known  a  patient  to  bite  the  finger 
in  which  the  aura  commenced  sometimes  with  a  successful 
issue. 

Abortive  means  are  less  satisfactory  in  cases  with  a  visceral 
aura.  Strong  pressure  by  the  hands  over  the  epigastrium  is 
resorted  to  by  some  epileptics,  while  others  prefer  to  drink  cold 
water  ;  swallowing  a  few  drops  of  ether  has  also  occasionally 
resulted  in  arresting  an  attack.  Inhalations  of  ammonia  have  been 
used  successfully.  The  insertion  of  a  seton  over  the  epigastrium 
has  been  employed  with  advantage  in  diminishing  the  frequency 
of  the  attacks.  Other  patients  refer  to  a  method  of  auto-suggestion, 
bringing  to  bear  a  strong  determination  to  overcome  the  attack, 
a  method  which  undoubtedly  has  been  followed  by  success  in 
some  cases. 

The  inhalation  of  nitrite  of  arnyl  is  a  method  of  arrest,  more 
especially  valuable  in  fits  with  cephalic  warning.  It  may  be 
administered  by  the  patient,  who  carries  about  with  him  capsules 
containing  the  drug,  one  of  which  he  breaks  into  his  handkerchief 
the  moment  the  warning  is  detected. 

During  the  Seizure. — All  that  is  necessary  is  to  lay  the  patient 


1004  Epilepsy, 

on  the  floor  so  as  to  obviate  danger  of  falling.  The  collar  or  any 
constriction  round  the  neck  should  be  undone.  Tongue  biting  may 
be  prevented  by  placing  a  cork  or  indiarubber  ring  between  the 
teeth.  In  fits  occurring  during  sleep  the  chief  danger  to  the  patient 
lies  in  rolling  on  to  his  face  and  inducing  suffocation.  This  can 
only  be  prevented  by  attending  carefully  to  the  patient  until  the  fit 
is  over.  The  post-convulsive  sleep  should  be  encouraged  and  the 
patient  not  awakened  until  he  does  so  spontaneously.  Placing  the 
patient  upon  the  left  side  at  the  onset  of  a  seizure  has  been 
recommended  as  a  satisfactory  measure  to  minimise  the  intensity 
of  the  fit. 

Status  Epilepticus. — The  chief  complication  of  epilepsy  is  the 
acute  stage  known  as  status  epilcpticus.  This  may  be  the  first 
symptom  of  the  disease,  particularly  in  those  forms  which  arise  in 
puerperal  and  ursemic  conditions.  It  may  also  occur  as  an  inter- 
current  symptom  in  any  case  of  epilepsy  ;  but  more  especially  it 
may  be  artificially  induced  by  the  sudden  stoppage  of  the  bromides 
in  cases  in  which  they  have  been  given  for  a  long  time. 

Status  commences  by  a  gradually  increasing  number  of  fits. 
With  this  warning  the  dose  of  bromide  ought  to  be  increased  to 
double  what  is  usually  given,  and  chloral  hydrate  (10  to  15  gr.) 
added,  this  mixture  being  repeated  every  four  hours. 

Should  the  fits  be  recurring  with  great  frequency  and  severity, 
no  remedy  is  of  greater  benefit  than  the  inhalation  of  chloroform, 
given  up  to  the  stage  of  complete  anassthesia.  On  the  other 
hand,  in  less  severe  types  of  status,  or  in  serial  epilepsy,  a  com- 
bination of  the  bromide  salts  (20  gr.)  and  chloral  hydrate  (10  gr.) 
may  be  repeated  frequently  (about  every  two  or  three  hours)  for 
a  time  especially  in  the  latter  condition.  The  liquor  morph.  in  10 
to  30  min.  [U.S.P.,  morphinae  hydrochlor.,  T\y  to  ^  gr.]  doses  may 
be  added  to  the  mixture,  or  morphia  may  be  administered  hypo- 
dermically  in  doses  of  2  to  5  mins.  of  the  injectio  morph.  tartratis 
(B.P.)  [U.S.P.,  morph.  tart,  -fo  to  J  gr.]  or  ^  to  J  gr.  given  in 
tabloid  form. 

The  bromides  given  alone  are  of  little  avail ;  but  within  recent 
years  their  hypodermic  administration  in  sterile  solutions  of  not 
more  than  10  per  cent.  (Clark)  has  been  recommended ;  these  may 
be  repeated  until  60  or  100  gr.  have  been  injected. 

Lumbar  puncture  with  or  without  the  injection  of  the  bromides 
has  also  been  advised.  The  latter  may  be  given  in  sterile  solution 
of  30  gr.  to  the  ounce,  10  or  15  cubic  centimetres  of  the  cerebro- 
spinal  being  withdrawn  before  10  cubic  centimetres  of  the  bromide 
solution  are  injected. 


Epilepsy.  1005 

The  hydrobromide  of  Iryoscine  has  also  been  used  occasionally 
with  success  (~V  to  T^o  gr.  hypodermically). 

Acute  Exhaustion. — During  the  after-stage  of  exhaustion 
following  upon  ordinary  seizures  no  special  treatment  is  necessary, 
as  the  stage  passes  into  that  of  sleep,  from  which  the  patient 
spontaneously  recovers. 

In  the  acute  exhaustion  following  serial  or  status  outbursts,  on 
the  other  hand,  great  care  and  attention  are  required,  the  patient 
having  to  be  nursed  as  one  suffering  from  acute  illness.  It  is 
during  this  stage  that  death  may  occur,  a  circumstance  which  is 
as  frequentl}7  attributable  to  want  of  attention  as  to  the  clinical  con- 
dition. During  the  few  days  of  stupor,  abundant  and  nourishing 
liquid  diet,  in  the  form  of  milk,  eggs  and  custards,  should  be 
frequently  given.  If  the  patient  is  unable  to  swallow,  nourishment 
should  be  administered  in  the  form  of  nutrient  enemata.  Hypo- 
dermic injections  of  strychnine  (liq.  strych.  5  mins..  [U.S.P., 
strychnina-  hydrochloridi,  ^  gr.  ;  Aquae,  111 5]  or  strych.  sulph. 
;.',,  gr.)  may  require  to  be  frequently  administered. 

If  necessary,  alcohol  may  be  given  in  considerable  doses,  and 
the  action  of  the  heart  steadied  and  maintained  by  digitalis  and 
strophanthus.  Later  on,  during  the  delusional  stage,  general 
attention  and  care  is  all  that  is  usually  needed,  while  later  tonics 
may.be  prescribed  with  advantage. 

Acute  Mania.— This  form  of  excitement,  whether  occurring 
as  a  post-paroxysmal  phenomenon  or  as  a  psychical  equivalent,  is 
characterised  by  the  suddenness  of  its  onset,  the  intensity  and 
violence  of  its  manifestations  and  the  shortness  of  its  duration, 
extending  usually  over  a  few  hours.  All  that  is,  therefore,  required 
lies  in  protecting  the  patient,  and  those  attending  him,  from  the 
effects  of  the  violence  and  excitement.  For  this  purpose  resort 
may  be  had  to  the  services  of  attendants,  or,  if  a  drug  is  con- 
sidered advisable,  none  is  more  safe  to  administer,  or  more 
speedy,  certain  and  satisfactory  in  its  action,  than  the  hydro- 
bromide  of  hyoscine  in  doses  of  T^o  to  ^  gr.,  injected  hypo- 
dermically. One  injection  is  usually  sufficient  to  induce  quiet  and 
repose  for  a  period  of  several  hours. 

Automatism. — This  requires  no  special  treatment.  If  genuinely 
epileptic  the  attacks  are  usually  short  and  resolve  naturally,  all  that 
is  required  being  the  protection  of  the  patient  and  the  prevention 
of  undressing  and  exposure,  which  are  not  uncommon  in  this  state. 

If  automatism  is  of  an  hysterical  character  resort  may  be  had  to 
the  affusion  of  cold  water  to  the  face  and  back  or  the  application 
of  a  strong  faradic  current  by  a  wire  brush  to  the  limbs. 


ioo6  Epilepsy. 

CONFIRMED    EPILEPSY. 

Confirmed  epilepsy  is  of  two  kinds.  One  variety  is  accompanied 
by  little  or  no  mental  change,  although  fits  may  have  persisted  for 
twenty  or  more  years.  The  second  variety  shows  a  tendency 
towards  an  increase  in  the  number  of  the  seizures  with  associated 
mental  deterioration. 

In  the  first  type  of  case  the  bromides,  either  alone  or  in  combina- 
tion, as  already  described,  are  often  of  great  use  in  subduing  the 
seizures,  especially  when  of  the  major  type. 

In  the  second  type  medicinal  treatment  is  of  little  or  no  value. 

In  most  cases  of  confirmed  epilepsy  with  dementia  the  bromides 
are  only  of  use  when  the  doses  are  so  large  as  to  produce  toxic 
effects. 

It  has  long  been  known  that  any  change  of  treatment  may 
temporarily  be  beneficial  in  epilepsy,  as,  for  instance,  placing 
epileptics  under  favourable  hygienic  surroundings  in  a  hospital, 
home  or  institution.  This  will  often  bring  about  temporary 
improvement  without  the  aid  of  any  medicinal  remedies.  In  like 
fashion,  modifications  in  diet  whereby  salt  is  eliminated  from  the 
dietary  along  with  highly  purin  foodstuffs  are  of  but  little  use. 
Most  confirmed  epileptics  feel  better  when  on  a  purin-free  diet, 
but  there  is  no  marked  improvement  in  the  frequency  or  severity 
of  the  seizures.  It  would  seem,  however,  as  if  the  attacks  of  serial 
epilepsy  or  status  epilepticus  may  be  more  readily  controlled 
under  this  regimen. 

Cases  of  confirmed  epilepsy,  in  which  the  disease  has  become 
established  upon  an  organic  foundation,  are  preferably  lodged  in 
an  institution  for  epileptics,  where  they  may  be  prescribed 
(1)  regular  and  congenial  employment,  (2)  judicious  alternations 
of  work  and  play,  (3)  suitable  and  simple  mode  of  living,  and 
(4)  avoidance  of  excitement  and  abstinence  from  alcoholic  drinks. 

FEATURES  OF  EPILEPSY   FAVOURABLE    AND  UNFAVOURABLE 
FOR    TREATMENT. 

(1)  The  following  features  constitute  a  favourable  type  of 
epilepsy  :  (a)  The  onset  of  the  disease  between  the  ages  of  sixteen 
and  twenty  years  and  after  forty-five  years  of  age  ;  (b)  attacks  of 
infrequent  occurrence,  and  of  the  major  type ;  (c)  the  absence  of 
any  obvious  or  pronounced  mental  impairment;  (d)  neither  the 
presence  of  a  hereditary  predisposition  nor  the  duration  of  the 
disease  over  many  years  are  unfavourable  features,  provided  that 
the  other  symptoms  of  the  disease  in  any  particular  case  are 
favourable. 


Epilepsy.  1007 

(2)  Among  the  chief  unfavourable  features  may  be  mentioned  : 
(a)  The  early  commencement  of  the  disease,  more  especially  when 
under  five  years  of  age ;  (b)  the  presence  of  marked  mental  impair- 
ment, stigmata  of  degeneration  and  fades  epileptica ,•  (c)  great 
frequency  of  seizures,  especially  when  there  is  a  combination  of 
minor  and  major  attacks  ;  (</)  psychical  types  of  seizure,  psychical 
epileptic  equivalents  and  post-paroxysmal  psychoses ;  (e)  the 
occasional  occurrence  of  serial  outbursts,  and  of  the  status 
epilepticus. 

For  the  Mental  Aspects  of  Epilepsy,  see  p.  1310. 

WILLIAM  ALDREN  TURNER. 


THE  SURGICAL  TREATMENT  OF  EPILEPSY. 

ALTHOUGH  many  operations  have  been  devised  for  the  relief  of 
idiopathic  epilepsy,  it  is  practically  certain  that  this  condition  is  not 
amenable  to  surgical  treatment.  When,  however,  epilepsy  follows 
some  definite  head  injury  and  the  convulsions  remain  localised, 
relief  may  sometimes  be  obtained  by  surgical  interference.  The 
skull  should  be  trephined  over  the  site  of  injury  and  any  local 
lesion,  such  as  depressed  fragment  of  bone,  thickened  or  adherent 
meninges,  suitably  dealt  with. 

C.    H.    S.    FRANKAU. 


ioo8 


HYSTERIA. 

HYSTERIA  is  essentially  a  psychical  disorder  which  may  or 
may  not  be  accompanied  by  somatic  manifestations,  and  the 
ultimate  object  of  all  methods  of  treatment  should  be  to  correct 
the  abnormalities  of  the  mind  on  which  the  disordered  functions  of 
the  different  organs  of  the  body  depend. 

One  attribute  of  hysterical  patients  is  their  great  susceptibility 
to  suggestion.  It  is  often  enough  to  prophesy  the  probability  of 
the  presence  of  a  new  symptom  to  ensure  its  appearance,  and  the 
types  of  a  large  proportion  of  the  somatic  symptoms,  such  as  con- 
tractures  and  paralyses,  are  undoubtedly  frequently  determined 
by  memories  of  previous  experiences  of  similar  disabilities  in 
others,  or  even  suggested  during  examination  by  the  physician. 
Another  peculiarity  of  hysterical  patients  is  their  craving  for 
sympathy,  and  it  is  common  knowledge  that  once  the  bodily  and 
mental  symptoms  have  appeared,  their  hold  on  the  patients  is 
immeasurably  strengthened  by  injudicious  attention  and  pity,  such 
as  they  frequently  receive  from  relatives  and  friends. 

By  reason  of  their  susceptibility  to  suggestion  and  their 
inordinate  desire  for  sympathy  it  seldom  happens  that  patients 
suffering  from  hysteria  of  a  pronounced  character  can  be  success- 
fully treated  in  their  own  surroundings,  and  it  is  generally  desirable 
to  insist  upon  their  removal  to  a  home  or  hospital,  as  the  case 
may  be. 

There  one  has  command  to  a  large  extent  over  the  nature 
of  the  impulses  which  are  allowed  to  reach  them,  and  by  closing 
the  door  to  visitors,  forbidding  letters  and  "news,"  the  nervous 
system  can  be  isolated  and  guarded  against  all  sense  impressions 
which  would  be  likely  by  suggestion  to  strengthen  some  symptoms 
or  to  start  others. 

Thus  shut  off  from  the  world,  the  patient  is  in  the  best  position 
to  profit  by  any  treatment  of  body  and  mind  which  the  physician 
in  charge  considers  suitable.  The  patient  should  be  kept  at  rest 
in  bed.  So  far  as  treatment  of  the  body  is  concerned,  in  most 
cases  the  aim  is  to  increase  nutrition  and  to  induce  the  patient  to 
put  on  weight.  This  is  to  be  done  by  judicious  feeding,  especially, 
where  possible,  by  milk,  the  amount  of  which  can  be  gradually 
increased  in  quantity,  until  often  the  patient  can  take  as  much  as 


Hysteria.  1009 

4  or  6  pints  in  the  twenty-four  hours.  •  The  precise  way  in  which  the 
milk  is  given  is  a  detail  that  must  necessarily  be  determined  for 
every  patient  individually.  Some  take  it  best  in  quantities  of  a 
few  ounces  every  hour  or  two,  while  others,  again,  will  get  through 
it  more  easily  in  larger  quantities  at  longer  intervals.  The  amount 
that  can  be  usually  taken  varies  between  2  and  6  pints  in  the  day. 

The  quantity  of  other  kinds  of  food  must  be  regulated  in  pro- 
portion to  the  amount  of  milk  taken  and  according  to  the 
susceptibilities  of  the  individual. 

As  an  adjunct  to  the  rest  and  full  feeding,  massage  is  usually 
necessary.  It  promotes  the  lymphatic  and  hsemic  circulations,  and 
in  a  sense  takes  the  place  of  exercise  by  enabling  the  patient  to 
digest  his  food,  and  by  preventing  excessive  deposit  of  fat.  Thus 
far,  then,  the  treatment  is  on  the  Weir-Mitchell  lines,  and  in  cases 
of  slight  intensity  this  combination  of  increasing  the  nutrition  of 
the  body  and  isolating  the  nervous  system  from  outside  influences 
may  of  itself  be  sufficient  to  effect  a  cure. 

It  cannot,  however,  be  too  strongly  insisted  upon  that  the  mere 
fact  of  putting  patients  to  bed  and  isolating  them  in  a  "  rest 
cure  "  is  in  the  majority  of  cases  insufficient.  If  success  is  to  be 
obtained  there  is  needed  the  addition  of  some  form  of  psychical 
treatment  practised  in  a  systematic  manner. 

Of  the  various  methods  that  are  in  vogue  that  of  simple 
"  suggestion  "  is  the  most  commonly  practised,  and  mention  has 
already  been  made  of  the  proneness  of  hysterical  patients  to  react 
to  this  stimulus.  Suggestion  is  indeed  practised  consciously  or 
unconsciously  in  some  degree  or  other  by  nearly  all  medical  men, 
and  is  contained  in  the  manner  and  personality,  which  cause 
patients  to  have  faith  in  them.  Like  most  personal  attributes,  it 
can  generally  be  cultivated  to  some  extent  with  care  and  patience, 
and  can  often  be  used  to  great  advantage.  It  is  a  difficult  attribute 
to  define,  but  it  consists  essentially  of  the  power  of  putting  patients 
into  an  optimistic  mood ;  of  causing  them  to  feel  that  their 
physician  sympathises  with  and  understands  them,  and  of  giving 
them  the  feeling  that  he  is  a  real  help  to  them  in  combating  their 
symptoms. 

The  practice  of  "  suggestion  "  is  allied  to  and  can  generally  be 
usefully  combined  with  that  of  "  persuasion,"  which  latter  method 
has  been  elaborated  particularly  by  Dubois.  It  consists  in  the 
main,  as  its  name  implies,  of  talking  out  the  matter  with  the 
patient,  explaining  minutely  where  his  reasoning  has  erred,  and  so 
making  him,  what  in  ordinary  daily  life  is  known  as,  "  to  see 
things  in  a  different  light." 

S.T. — VOL.  ii.  64 


ioio  Hysteria. 

Another  method,  and  one  which  is  giving  much  food  for  thought 
among  psychologists  and  psychiatrists  of  to-day,  is  that  known  as 
Psycho-analysis. 

This  method,  of  which  only  the  briefest  outline  can  be  given 
here,  originated  from  a  physician  in  Vienna,  named  Breuer,  with 
whom  Freud  was  closely  associated.  It  is  owing  to  the  extensive 
researches  of  the  latter  that  the  method  has  gained  the  important 
position  it  occupies  in  the  psychological  world  of  to-day. 

The  basis  of  this  method,  in  so  far  as  it  applies  to  the  treatment 
of  hysteria,  rests  on  the  hypothesis  that  the  symptoms  of  this  disease 
are  due  to  a  "  mental  trauma,"  that  is,  to  some  mental  experience 
unpleasant  to  the  patient,  the  unpleasant  memory  of  which  has 
become  dissociated  from  the  conscious  mind  and  repressed  into 
that  of  the  subconscious.  But  though  kept  under  and  outside 
the  consciousness  of  the  patient,  the  memory  is  still  there 
and  in  certain  circumstances  is  capable  of  activity  and  of 
influencing  the  feelings  and  actions  of  the  patient  without  his 
recognition.  In  other  words,  as  Freud  says,  hysterical  patient* 
suffer  from  reminiscences.  In  ordinary  life  the  tendency  in  the 
average  individual  is  for  such  emotional  experiences  to  be  neutralised 
and  so  rendered  harmless  and  incapable  of  forming  a  dissociated 
reminiscence.  An  insulted  person,  for  instance,  may  work  off  his 
feelings  by  angry  words,  grief  may  be  made  harmless  by  crying, 
while  in  other  cases  length  of  time  dims  the  memories  of  hurtful 
experiences  so  that  they  either  fade  away  or  come  to  occupy  their 
rightful  perspective  in  association  with  other  ideas.  Now  and  then, 
however,  either  through  some  abnormality  of  the  individual  or 
through  some  peculiarity  of  the  stimulus,  it  happens  that  the  sensory 
effect  is  not  neutralised  by  any  suitable  reaction,  and  it  is  then  that 
there  is  the  danger  of  the  memory  being  buried  and  yet  able  to 
harass  the  patient  in  the  way  that  has  been  mentioned  above. 
Groups  of  ideas  which  have  a  common  emotional  basis  are  designated 
as  "  complexes,"  and  it  is  towards  unmasking  these  buried  complexes 
which  unknown  to  the  patient  are  influencing  him  that  Freud's 
method  of  psycho-analysis  is  directed. 

The  technique  consists  in  the  main  in  encouraging  the  patient  to 
communicate  his  ideas  with  absolute  freedom  as  they  occur  to  him, 
withholding  any  self-criticism,  no  matter  how  disconnected  or  un- 
pleasant his  thoughts  may  appear  to  him  to  be.  By  this  free 
association  of  ideas  the  physician  picks  out  the  salient  points  and, 
weaving  them  together,  gradually  arrives  at  the  "  complexes,"  which 
have  hitherto  been  hidden  away  in  the  patient's  mind.  These 
"complexes,"  thus  brought  out,  then  become  part  of  the  patient's 


Hysteria.  ion 

conscious  mind;  they  are  associated  normally  with  other  thoughts, 
and  cease  to  exist  and  to  trouble  him  as  "  foreign  bodies."  The 
difficulty  of  attaining  this  object  lies  in  the  fact  that  the  patient  is 
not  himself  necessarily  conscious  of  the  ideas  which  have  to  be 
searched  for,  indeed  they  are  generally  definitely  repressed  or 
"  censored  "  from  his  ordinary  thoughts,  and  it  is  foreign  to  his 
nature,  so  to  speak,  to  reproduce  them.  Consequently  a  resistance 
has  to  be  broken  down  before  they  can  be  reached  and  brought  to 
light.  In  the  earlier  part  of  his  researches  Freud  made  use  of 
hypnotic  suggestion  in  order  to  get  behind  this  resistance,  but  later 
on  he  discarded  this  as  unsound  and  now  relies  mainly  on  persua- 
sion and  observation  as  the  technique  by  which  to  reach  the  desired 
goal. 

Valuable  assistance  in  arriving  at  the  buried  complexes  may 
further  be  obtained  by  the  Association  Method  which  has  been 
especially  elaborated  by  Jung,  and  by  following  Freud's  instructions 
on  the  analysis  of  dreams. 

The  association  method  consists  in  reading  out  a  selected  list  of 
words  to  the  patient,  requesting  him  to  respond  as  quickly  as 
possible  to  each  word  he  hears  by  saying  the  first  word  that  comes 
into  his  mind  and  noting  the  time  (i.e.,  the  reaction  time)  taken  to 
make  the  association  with  every  word  as  it  is  called  out.  By 
studying  large  numbers  of  cases  in  this  way  it  has  been  found  that 
when  the  stimulus  word  hits  off  an  association  with  one  of  the 
patient's  hidden  complexes,  the  time  taken  in  making  the  associa- 
tion is  lengthened  together  with  other  peculiarities  which  indicate 
that  there  has  been  some  unusual  stir  in  the  mental  process 
concerned  in  making  the  associations.  By  careful  comparison  it 
becomes  possible  in  this  way  to  form  an  opinion  as  to  along  what 
lines  the  patients'  minds  are  working. 

In  the  cases  of  dream  analysis  Freud  holds  that  dreams  represent 
in  their  essentials  the  fulfilment  of  some  ungratified  desire,  but  this 
essential  is  clothed  so  thickly  and  so  grotesquely  with  superadded 
material  that  it  is  often  a  matter  of  great  difficulty  to  arrive  at  the 
core  of  the  matter. 

By  the  combined  methods,  then,  of  psycho-analysis,  the  associa- 
tion method,  and  dream  analysis,  it  is  possible  in  favourable  cases 
to  penetrate  the  innermost  workings  of  the  patient's  mind  and  to 
bring  to  light  those  buried  painful  reminiscences  upon  which  the 
faulty  mental  superstructure  has  been  built.  By  restoring  these 
reminiscences  to  their  proportionate  place  in  the  mental  surround- 
ings they  cease  to  act  independently  and  to  be  a  source  of 
trouble. 

64—2 


ioi2  Hysteria. 

While  there  is  much  that  is  at  present  controversial  in  Freud's 
hypotheses  and  deductions,  every  one  must  admit  that  his  works 
have  opened  up  new  paths  in  psychology  and  that  his  methods  may 
frequently  be  used  with  great  benefit  to  the  patients  in  carefully 
selected  cases. 

Hypnotism  is  recommended  by  some,  and  is  no  doubt  occasionally 
suitable  in  selected  cases,  but  it  is  not  a  form  of  treatment  to  be  in 
any  way  systematically  advocated  in  this  disease.  Freud  made  use 
of  it  in  his  earlier  days  to  aid  him  in  unravelling  the  buried 
reminiscences,  but  found  it  undesirable  and  discarded  it  in  favour 
of  the  more  simple  method  of  "  free  association  "  detailed  above. 

As  already  mentioned,  Dubois  relies  largely  on  the  Method  of 
Persuasion,  which  consists  broadly  of  frequent  talks  in  which 
attempts  are  made  to  encourage  the  patient  to  direct  his  mental 
outlook  along  more  logical  lines  and  to  develop  a  sounder  philosophy 
on  which  to  base  his  mental  outlook. 

As  an  adjunct  to  psychical  treatment  Physical  Methods  are  of 
course  still  important,  and  the  most  consistent  success  will  be 
obtained  by  those  who  make  a  judicious  selection  of  the  different 
forms  of  treatment  according  to  the  requirements  of  their  particular 
patients. 

The  application  of  a  faradic  current,  for  instance,  may  be  instru- 
mental in  curing  anaesthesias,  paralyses  and  contractures,  though 
it  is  an  open  question  as  to  what  degree  the  stimulus  in  these  cases 
is  mental  rather  than  physical.  Massage,  baths,  douches  and 
other  means  calculated  to  increase  the  nutrition  and  improve  the 
tone  of  the  body,  all  find  a  place  in  certain  cases. 

Of  the  value  of  drugs  there  is  not  much  to  be  said  ;  iron,  arsenic, 
and  other  tonics  are  often  useful  in  a  general  way,  as  also  occasion- 
ally are  valerian  and  asatotida,  but  none  of  these  have  any  specific 
action  on  the  disease.  In  the  more  acute  cases  where  restlessness 
is  a  prominent  feature  the  bromides  may  be  useful  for  a  time,  and 
for  sleeplessness  it  may  be  necessary  to  prescribe  hypnotics,  such  as 
veronal  or  paraldehyde. 

Prophylactic  Treatment  is  of  the  greatest  importance,  and 
much  can  be  accomplished  in  preventing  hysteria  by  careful  educa- 
tion in  childhood  and  youth. 

Apart  from  the  general  moral  training  which  should  lead 
towards  regarding  events  in  a  reasonable  light  to  one  another 
and  towards  keeping  the  emotions  within  reasonable  bounds,  it 
is  most  important  to  exercise  the  motor  output  in  due  propor- 
tion to  the  sensory  intake.  Useful  and  steady  occupation  of 
one  kind  or  another  is  perhaps  the  greatest  safeguard  against 


Hysteria.  1013 

hysteria,  for  it  works  off  the  forces  which  might  otherwise  spend 
themselves  aimlessly  through  the  channels  of  emotion. 

Finally,  it  is  to  he  remembered  that  no  fixed  rules  can  be  laid 
down  for  the  treatment  of  hysteria.  Success  is  only  to  be  gained 
by  careful  attention  to  each  case  and  by  the  application  of  such 
system  or  combination  of  systems  of  treatment  as  the  individual 
patient  appears  to  require. 

H.  CAMPBELL  THOMSON. 


INSOMNIA. 

THE  etiology  of  insomnia  includes  the  consideration  of  a  large 
number  of  factors,  and  no  rational  treatment  can  be  instituted 
before  an  extensive  inquiry  concerning  them  has  been  accomplished. 
The  amount  of  sleep  required  by  individuals  varies  with  their  age, 
occupation  and  personal  idiosyncrasy.  Broadly  speaking,  children, 
juveniles  and  young  adults  require  much  more  sleep  than  do  the 
middle-aged,  while  the  middle-aged  require  more  than  do  the  old. 
Occupation  of  an  exhausting  character,  whether  of  work  or  of 
pleasure,  requires  more  subsequent  sleep  than  does  an  occupation 
which  needs  but  little  output  of  energy  or  sustained  attention. 
Some  persons,  often  of  great  intellectual  capacity,  can  live  healthily 
on  so  small  an  allowance  of  sleep  as  would  be  ruinous  to  most  ; 
while,  on  the  other  hand,  there  are  many  whose  sleep  is  so  light 
and  is  so  liable  to  be  disturbed  by  trivial  causes  that  they  need 
more  hours  of  sleep  than  do  those  whose  rest  is  profound.  Sleep 
is  also  largely  a  matter  of  habit,  and  those  whose  habits  are,  in  this 
respect,  irregular  and  who  have  no  set  time  for  going  to  bed  and  for 
getting  up,  are  prone  to  insomnia,  as  also  are  those  who,  practising 
a  regular  habit,  have  had,  for  one  reason  or  another,  to  break  it. 
Apart  from  interference  with  these  habits  and  these  idiosyncrasies, 
there  are  two  kinds  of  causes  of  insomnia,  the  nervous  and  the  toxic, 
and  it  will  become  plain,  as  we  proceed,  that  the  two  are  frequently 
conjoined. 

Sleep  may  either  be  defective  in  its  quantity  or  its  quality,  and 
it  is  important  for  the  physician  to  diagnose  accurately  the  true 
condition  before  beginning  his  treatment,  as  frequently  some  slight 
alteration  in  the  patient's  mode  of  living  is  sufficient  to  re-establish 
the  normal  conditions. 

Among  the  causes  which  we  may  classify  as  nervous,  pain  and 
other  paraesthesiae  hold  a  most  prominent  place,  and  successfully  to 
combat  these  symptoms  is  also  to  remove  the  sleeplessness  which 
results  from  their  presence.  Mental  anguish,  anxiety,  grief  and 
disappointment  must  also  be  remembered  in  this  connection.  The 
worry  of  long  duration,  rather  than  the  passing  tribulation,  is  the 
most  prone  to  induce  insomnia,  and  it  is  among  those  who  are 


Insomnia.  1015 

harassed  for  months  or  years  by  business  or  domestic  cares  that 
we  find  the  worst  and  most  obstinate  cases.  Moderate  and 
congenial  mental  occupation  predisposes  to  sleep,  but  excess  is  pre- 
judicial to  it,  and  this  is  as  true  of  emotional  disturbance  as  of  over- 
much intellectual  exertion,  while  in  all  cases  insomnia  is  aggravated 
if  the  particular  work  is  of  an  anxious  character.  Sleeplessness, 
apart  from  the  presence  of  pain,  is  often  a  symptom  of  such  affec- 
tions as  neurasthenia  and  other  functional  neuroses,  of  the  more 
acute  disorders  of  mind,  of  hysteria  and  of  organic  lesions  of  the 
brain. 

Among  the  toxic  causes  of  insomnia  perhaps  the  commonest  are 
deficient  aeration  of  the  blood  from  the  faulty  ventilation  of  the  bed- 
room, chronic  constipation  and  the  excessive  use  of  alcohol,  tea, 
coffee  and  tobacco.  Among  less  frequently  occurring  toxsemic 
states  may  be  mentioned  those  of  microbic  origin,  as,  for  instance, 
in  the  various  febrile  states ;  those  of  autogenetic  origin,  as  in 
gout,  renal  insufficiency,  arterio-sclerosis  and  dyspepsia  ;  and  those 
of  deficient  blood  aeration,  as  in  various  cardiac  and  respiratory 
disorders.  It  seems  not  improbable  that  fatigue  consists  essentially 
in  the  circulation  of  certain  poisons  in  the  blood,  and  it  may  well  be 
mentioned  at  this  point,  for  it  is  a  fruitful  cause  of  continued 
insomnia,  however  it  may  have  been  originally  induced. 

It  will  be  plain  from  the  above  that  the  physician  will,  as  a 
prelude  to  his  treatment  of  a  sleepless  patient,  have  a  large  field  to 
explore  in  the  domain  of  etiology.  In  some  cases  treatment 
becomes  simplicity  itself  when  once  the  cause  has  been  definitely 
discovered.  In  other  cases,  notwithstanding  a  careful  inquiry  into 
all  the  systems  of  the  patient,  into  his  habits  and  into  his  mental 
condition,  the  cause  remains  obscure,  while  in  others,  again,  though 
the  cause  may  be  discovered  and  removed  so  far  as  is  possible, 
certain  adjuvants  in  treatment  must  be  employed  before  the  proper 
amount  and  proper  quality  of  sleep  can  be  restored.  Of  these 
adjuvants  we  shall  now  give  an  account,  premising  the  necessity  of 
using,  in  the  first  instance,  the  simplest  and  such  as  cannot  be 
followed  by  nocuous  or  toxic  effects.  To  have  immediate  recourse 
to  hypnotics  is  always  unscientific  and  frequently  results  in  the 
establishment  of  a  habit  which  is  as  harmful  to  the  patient  as  was 
the  original  insomnia.  It  should  also  be  borne  in  mind  that  drugs 
tend  to  lose  their  efficacy,  and  that  it  therefore  becomes  necessary 
to  increase  the  amount  given.  In  small  doses  there  are  several 
satisfactory  drugs  whose  harmful  effects  are  only  likely  to  display 
themselves  in  certain  individuals  having  a  peculiar  susceptibility, 
but  with  the  increase  of  dose  it  becomes  more  and  more  probable 


ioi6  Insomnia. 

that  symptoms  will  arise  detrimental  to  health  and  perhaps 
endangering  life.  Sleep  induced  by  drugs  is  never  the  same  thing 
as  normal  physiological  sleep  and  is  rather  of  the  character  of  toxic 
sleep. 

General  Measures- — Premising  that,  so  far  as  is  possible,  the 
original  cause  of  the  insomnia  has  been  removed,  it  now  becomes 
necessary  to  regulate  the  conditions  of  the  patient's  rest.  It  should 
be  laid  down  that  the  patient's  work  should,  especially  if  it  is  of  an 
intellectual  variety,  cease  at  least  an  hour,  and  where  possible  two 
hours,  before  he  goes  to  bed,  though  it  should  not  be  forgotten  that 
a  due  amount  of  fatigue  towards  the  close  of  the  day  and  before 
bedtime  is  physiological  and  is  perhaps  productive  of  just  those 
fatigue  bodies  which  are  nature's  own  true  hypnotics.  The  last 
meal  should  be  neither  too  remote  from  nor  too  close  upon  bedtime. 
It  is  probable  that  an  interval  of  three  or  four  hours  between  that 
which  is  perhaps  the  heaviest  meal  of  the  day  and  bedtime  is  either 
too  great  or  too  little.  During  the  earliest  stages  of  digestion  there 
is  a  tendency,  widely  spread  in  the  animal  world,  to  fall  asleep,  and 
of  this  tendency  we  do  not  take  advantage,  but  when  the  body  is 
reaping  the  advantages  of  the  meal  and  when  its  fires  are  being  fed 
and  its  energies  revived  we  make  ready  for  sleep  rather  than  for 
further  activity.  It  will  be  found  in  some  persons  that  to  transfer 
the  heaviest  meal  to  the  middle  of  the  day  and  to  cause  the  last 
meal  to  be  of  quite  a  light  character  will  diminish  the  tendency  to 
insomnia,  but  it  is  difficult  to  be  precise  in  any  given  case  as  to  the 
amount  of  time  that  should  intervene  between  the  last  meal  and 
bedtime.  The  temperature  of  the  bedroom  should  be  regulated, 
and  above  all  the  stream  of  air  passing  through  it  should  be 
adequate.  The  window  should  be  open  and,  as  a  general  rule,  the 
wider  the  better.  The  room  of  the  sleepless  patient  should  be 
situated  in  a  quiet  part  of  the  house,  and  such  noises  as  those  of 
loudly  ticking  clocks  or  rattling  windows  should  be  prevented.  The 
mattress  and  pillows  should  be  neither  too  soft  nor  too  hard,  the 
bedclothes  should  be  sufficient  but  as  light  as  possible.  If  the 
patient's  circulation  is  poor  the  bed  should  be  warmed  with  hot 
bottles  or  a  warming-pan.  Having  inquired  into  and  regulated 
these  details,  it  will  be  as  well  to  order  a  glass  of  milk,  which  in 
some  cases  may  be  warmed,  to  be  taken  the  last  thing  before  settling 
for  sleep.  If  the  wakeful  period  occurs  in  the  middle  of  the  night 
and  after  some  amount  of  preliminary  sleep  light  food,  such  as  milk 
or  cocoa,  with  a  biscuit  or  two,  may  be  ordered  to  be  placed  at  the 
bedside  to  be  taken  when  the  patient  wakes.  Of  itself  this  often 
induces  sleep,  and  even  if  it  does  not,  tends  to  diminish  the  sense  of 


Insomnia.  1017 

weariness  which  supervenes  upon  a  night  without  sleep.  The 
question  of  the  administration  of  alcohol  may  here  be  raised. 
Given  in  sufficiently  large  quantities  alcohol  will,  of  course,  produce 
a  somnolent  condition  in  most  persons.  It  is,  however,  highly 
undesirable  that  the  physician  should  order  such  doses  of  a  drug 
which  besides  having  toxic  effects  is  liable  to  give  rise  to  a  habit  of 
most  serious  import.  In  moderate  doses  alcohol  in  its  various 
forms  has  different  effects  upon  different  individuals.  A  couple  of 
ounces  of  whisky  in  hot  water  with  a  slice  of  lemon  or  a  glass  of 
stout  taken  just  before  bedtime  will,  in  some  persons,  act  as  an 
admirable  hypnotic,  but,  on  the  other  hand,  may  in  others  result 
in  increased  wakefulness.  Alcohol  is  perhaps  most  useful  in 
febrile  states  accompanied  by  restlessness  and  agitation,  as,  for 
example,  in  catarrh  of  the  upper  respiratory  tract  or  influenza. 
It  may  also  be  used  with  advantage  when  the  patient  is  weakly  and 
anaemic  and  when  the  circulation  is  poor. 

Hydrotherapeutic  Measures  are  of  considerable  importance  in 
the  treatment  of  insomnia,  and  are  capable  of  producing  marked 
sedative  effects.  As  a  matter  of  general  hygiene  useful  for 
prophylactic  purposes  the  cold  morning  bath  is,  among  such  as 
enjoy  good  or  very  fair  physical  health,  excellent.  Cold  baths  and 
other  modes  of  application  of  cold  water  are  contra-indicated  during 
pregnancy,  lactation  and  menstruation,  as  also,  as  a  general  rule,  in 
those  who  suffer  from  rheumatism,  cardiac  disease,  arterio- 
sclerosis or  albuminuria,  and  some  forms  of  neurasthenia,  but 
amongst  others  it  may  be  laid  down  that  where  the  subsequent 
reaction  is  pleasant  to  the  patient  the  treatment  is  correct,  but  that 
where,  on  the  contrary,  the  patient  is  left  in  a  cold  and  depressed 
condition  the  treatment  is  undesirable.  In  such  individuals  the 
warm  bath  followed  by  a  cold  douche  of  short  duration  is  often 
better  borne.  Such  a  douche  may  be  satisfactorily  given  without 
any  special  appliance  by  the  contents  of  a  large  can  being  poured 
over  the  back  of  the  patient.  Whether  the  cold  bath  or  the  warm 
bath  followed  by  a  douche  is  given,  the  patient  should  subsequently 
be  well  rubbed  down  with  a  rough  towel.  The  cold  bath  of  short 
duration  may  also  be  found  useful  immediately  before  bedtime. 
The  succeeding  reaction  takes  place  in  bed,  and  during  it  the 
relatively  anaemic  condition  of  the  brain,  due  to  the  increased 
amount  of  blood  contained  in  the  peripheral  vessels,  tends  to 
produce  a  drowsiness  which  soon  passes  on  to  sleep.  Among  other 
patients  a  bath,  the  temperature  of  which  is  between  95°  and 
100°  F.,  has  a  better  effect.  The  cold  or  hot  foot  bath  very  often 
has  similarly  good  results  and  involves  somewhat  less  disturbance 


ioi8  Insomnia. 

to  the  patient.  Warm  and  cold  packs  are  of  the  greatest  service. 
The  patient  is  swathed  in  a  sheet  which  has  been  dipped  in  water, 
partially  wrung  out,  and  laid  upon  the  mattress  defended  by  a 
mackintosh  spread.  He  is  then  covered  with  a  sufficiency  of 
blankets,  and  in  a  few  minutes  will  commence  to  perspire  and  to 
feel  drowsy.  He  may  npw  be  taken  out  of  the  pack  or  left  in  it, 
and  in  either  case  the  treatment  will  probably  be  followed  by  some 
hours'  peaceful  sleep.  It  is  occasionally  only  necessary  to  apply 
a  local  pack,  which  is  then  usually  termed  a  compress.  For  instance, 
a  towel  damped  in  water  may  be  laid  over  the  abdomen  and 
covered  by  a  layer  of  some  waterproof  material,  or  the  lower 
extremities  may  be  enveloped  in  an  analogous  way.  Whatever 
procedure,  whether  that  of  the  bath  or  that  of  the  pack,  is  adopted, 
it  will  often  be  found  that  simultaneous  cold  compresses  wrapped 
round  the  head  will  be  of  material  assistance.  The  effect  of 
any  of  these  methods  may  be  further  enhanced  by  the  administration 
of  some  hot  drink. 

Special  Causes  of  Insomnia. — In  insomnia  associated  with  dis- 
or.der  of  some  system,  the  treatment  is  necessarily  directed  primarily 
to  the  treatment  of  that  system.  Constipation,  for  instance,  is  a  most 
fruitful  cause  of  insomnia,  and  the  treatment  of  the  latter  becomes 
the  treatment  of  the  former.  Forthwith  to  lead  off  with  hypnotics 
might  plainly  in  these  circumstances  aggravate  the  constipation,  and 
so  ultimately  the  insomnia,  and  it  must  be  further  remembered  that 
constipation  may  lead  to  a  dangerous  accumulation  of  the  drug  in  the 
alimentary  tract  and  the  consequent  development  of  most  serious 
toxic  symptoms.  It  should  be  borne  in  mind  that  many  persons  are 
constipated  without  knowing  it,  and  that  this  is  especially  the  case 
among  women.  The  answer  to  a  perfunctory  inquiry  as  to  the 
regularity  of  action  of  the  bowels  is  often  wholly  misleading,  and  it 
is  not  until  a  regular  examination  of  the  amount  of  faeces  passed  is 
instituted  that  it  is  discovered  that  a  grave  state  of  constipation 
exists.  It  is  not  necessary  here  to  enter  into  the  details  of  the  treat- 
ment of  constipation  ;  it  is  only  necessary  to  affirm  the  importance 
of  discovering  the  fact  of  its  existence,  and  to  point  out  that  those 
hygienic  measures  which  should  first  of  all  be  put  into  practice  in 
the  treatment  of  constipation  are  just  those  which  are  in  large 
measure  appropriate  in  the  treatment  of  insomnia. 

A  great  source  of  disturbance  of  sleep  is  to  be  found  in  perversion 
of  the  functions  of  the  viscera  in  general  and  of  the  aliincitttir// 
tract  in  particular.  In  the  stomach  and  intestines  the  food 
undergoes  manifold  changes  which,  under  normal  circumstances, 
are  produced  by  the  activities  of  various  agencies  which  pass 


Insomnia.  1019 

unnoticed.  In  disorder  of  the  alimentary  tract,  whether  by 
alteration  of  the  character  of  the  secretions,  by  a  process 
of  improper  fermentation,  by  an  undue  degree  of  peristalsis,  by 
a  congested  condition  of  the  portal  system,  or  by  the  absorption 
of  toxins,  there  are  obtruded  upon  consciousness  a  variety  of 
abnormal  sensations  which  are  inimical  to  sleep.  The  regulation 
of  the  period  which  should  elapse  between  the  last  meal  and  bed- 
time has  been  already  mentioned,  and  here  we  would  rather  refer 
to  the  occurrence  of  those  special  phenomena  which  denote 
dyspepsia,  such  as  feelings  of  fulness,  flatulence,  eructations, 
nausea,  and,  perhaps,  pain  and  vomiting.  Such  symptoms  are 
very  likely  to  rouse  the  patient  after  some  hours  of  troubled  sleep, 
and  to  prevent  his  going  to  sleep  again  for  two  or  three  hours, 
or  until  appropriate  remedies  have  been  administered.  These 
symptoms  are  usually  dependent  upon  hyperchlorhydria,  and  at 
least  may  temporarily  be  allayed  by  the  application  of  a  cold 
compress  and  the  administration  of  bicarbonate  of  soda.  For  the 
dietetic  and  other  measures  which  should  be  taken  we  must  refer 
the  reader  to  the  articles  proper  to  this  subject.  Insomnia  without 
abdominal  pain  or  any  very  marked  dyspeptic  phenomena  may 
occur  in  the  course  of  a  case  of  neurasthenia  of  which  a  con- 
tributing cause  has  been  functional  derangement  of  the  stomach. 
Hydrotherapy  in  the  form  of  warm  douches  and  cold  packs,  to- 
gether with  massage,  is  then  of  great  service.  In  such  cases  it  is 
important  to  remember  that  hypnotics  may,  very  readily,  still 
further  pervert  the  gastric  functions.  The  practice  of  giving 
purgatives  at  night  must  also  here  be  mentioned.  Such  drugs, 
especially  in  the  case  of  dyspeptics,  are  prone  to  irritate  the 
alimentary  tract,  and  it  may  be  desirable  to  administer  them,  where 
they  are  really  necessary,  at  some  other  time  when  they  will  not 
disturb  the  rest  of  the  patient. 

Insomnia  is  a  marked  symptom  in  many  cases  of  cartlio-vascular 
disease.  In  those  maladies  in  which  the  cardiac  cycle  is  not  fully 
and  completely  performed  there  may  occur,  from  loss  of  vascular 
tonus  in  the  vessels,  a  hyperaemia  of  the  brain.  In  such  cases  the 
feet  are  often  cold,  and  the  mere  application  of  a  hot  bottle  to  the 
extremities  may  suffice  to  produce  sleep.  The  same  effect  may  be 
produced  by  the  administration  of  hot  milk  or  other  drink,  by 
means  of  which  the  blood  is  diverted  from  the  brain  to  the 
abdominal  vessels.  A  more  active  hyperaemia  may  be  the  result  of 
ventricular  hypertrophy,  and  in  such  cases  the  bromides  and 
nitrites  may  be  useful.  In  cases  where  the  heart  is  failing 
sleeplessness  is  at  times  so  distressing  as  to  threaten  the  patient's 


IO2O  Insomnia. 

life  from  the  resulting  exhaustion.  Here,  in  addition  to  those  drugs 
and  other  measures  which  are  appropriate  to  the  nature  of  the 
lesion,  the  bromides,  paraldehyde,  and  morphia  are  of  much 
service.  The  hypodermic  injection  of  quite  small  doses  of  morphia 
not  only  relieves  the  distress  and  sleeplessness,  but  also  improves 
the  general  condition  by  the  induction  of  the  rest  which  is  the  first 
requirement  of  such  a  patient.  In  arterio-sclerosis  and  Bright's 
disease  sleeplessness  may  sometimes  be  at  once  relieved  by  putting 
the  patient  upon  a  milk  diet.  If  it  becomes  necessary  to  administer 
hypnotics,  the  bromides,  paraldehyde  and  amylene  hydrate  will  be 
found  to  be  efficacious  and  safer  than  other  hypnotics.  The  insomnia 
of  old  age,  in  part  probably  dependent  upon  arterial  degeneration, 
may  suitably  be  treated  by  dietetic  means,  and  to  place  the  patient 
upon  a  purin-free  dietary  and  to  regulate  his  meal  hours  will  often 
suffice.  If  drugs  become  necessary  the  bromides,  sulphonal, 
trional  or  veronal  will  be  found  useful.  In  those  suffering  from 
pulmonary  affections  and  amongst  whom  cough  is  troublesome  and 
interferes  with  sleep,  various  derivatives  of  opium  are  the  most 
serviceable.  Morphia,  dionine,  codeine  and  heroin  may  each  be 
tried,  but  it  is  important,  where  the  prospect  of  length  of  days  is 
good,  that  the  physician  should  exercise  strict  control  over  the 
amount  of  the  drug  administered.  Paraldehyde  is  contra-indicated 
in  hepatic  disorder,  in  bronchitis  and  in  emphysema,  since  it 
increases  the  difficulty  of  expectoration.  But  here  also  it  is 
important  that  the  cough  rather  than  the  insomnia  should  be 
treated  in  the  first  instance,  and  hypnotics  should  be  resorted  to 
when  other  means  have  failed.  In  sleeplessness  of  febrile  origin, 
as  for  instance  during  the  first  or  second  nights  of  a  nasal 
catarrh  or  of  an  influenza,  opium  is  of  great  service,  and  no 
more  modern  preparation  has  replaced  pulvis  ipecacuanhas 
compositus  [U.S.P.  pulvis  ipecacuanhas  et  opii]  given  the 
last  thing  at  night  with  a  hot  drink.  Quinine  is  similarly  of 
immense  service.  In  those  conditions  in  which,  as  in  typhoid  fever, 
the  febrile  period  is  likely  to  be  a  prolonged  one,  the  bath  and  pack 
become  of  prime  importance  in  the  treatment  of  insomnia.  Where 
pain  is  the  immediate  cause  of  insomnia,  opium  and  its  prepara- 
tions, antipyrin  and  acetanilide  are  indicated.  If  the  disease  is 
one  likely  to  last  for  a  long  time,  and  especially  where  it  is  unlikely 
to  have  a  speedily  fatal  issue,  extreme  caution  must  be  used  in  the 
administration  of  morphia,  and  the  physician  should  rigorously 
keep  the  use  of  the  syringe  in  his  own  hands.  At  the  commence- 
ment the  dose  given  should  be  a  minimum  one,  and  if  possible  the 
patient  should  not  know  the  name  of  the  drug  given. 


Insomnia.  1021 

Before  passing  to  the  hypnotic  drugs  the  practice  of  hypnotism 
must  be  alluded  to.  Suggestion  without  the  deeper  degrees  of 
hypnosis  may  well  he  practised  by  the  physician  as  an  accompani- 
ment to  other  methods  of  treatment,  and  it  may  occasionally  prove 
of  value  with  no  adjuvant.  It  is  not  to  be  regarded  as  replacing 
such  therapeutic  measures  as  may  be  suggested  by  a  discovery  of 
the  cause  of  the  malady.  Its  practical  application  requires  time 
and  often  more  time  than  the  patient  and  physician  can  well  afford, 
and  it  may  be  regarded  as  being  specially  indicated  where  the 
hypnotic  drugs  are  contra-indicated  either  by  the  patient's 
personal  idiosyncrasy  or  by  some  particular  feature  of  some 
organic  disease.  The  same  applies  to  hypnosis  of  deeper  degree,  a 
degree  often  very  difficult  to  produce  in  sleepless  persons,  while  it 
should  not  be  forgotten  that  even  as  the  most  harmless  of  drugs 
have  been  known  on  rare  occasions  to  produce  toxic  symptoms,  so 
also  may  hypnotism  in  certain  individuals  produce  nocuous  results. 
It  is,  perhaps,  hardly  here  necessary  to  emphasise  the  point  that 
hypnotism  should  on  no  account  be  practised  by  any  person  save  by 
a  qualified  practitioner.  In  the  hands  of  the  charlatan  this 
therapeutic  agency  becomes  fraught  with  intellectual  and  moral 
danger. 

We  now  turn  to  a  review  of  the  hypnotic  drugs.  Of  these  there 
is  a  large  number,  indeed,  almost  a  redundancy,  while  the  list 
enlarges  as  time  widens  the  scope  of  organic  chemistry.  Year  by 
year  new  drugs  characterised  by  long,  polysyllabic,  scientific  titles, 
and  by  short,  attractive  officinal  appellations,  are  introduced  and 
vaunted.  A  few  of  these  stand  the  test  of  time,  but  for  the  most 
part  they  disappear.  The  physician,  bearing  in  mind  that  the  best 
of  hypnotics  is  the  therapeutic  agent  which  removes  the  cause  of 
the  insomnia,  has  a  wide  choice  of  medicaments  which  were 
unknown  to  his  immediate  forebears  in  medicine.  He  will  find 
that  his  sleepless  patient  has  probably  also  a  wide  knowledge  of 
such  drugs,  and  it  may  happen  that  his  first  duty  will  be  to 
restrain  the  patient  from  dosing  himself  with  many  preparations, 
or  with  increasing  doses  of  some  one  preparation.  Generally 
speaking,  when  prescribing  a  hypnotic,  it  is  desirable  to  bear  in 
mind,  firstly,  the  age  of  the  patient  and  his  physical  condition  ; 
secondly,  the  fact  that  drugs  differ  as  to  the  amount  of  time  they 
take  to  produce  effects  ;  and,  thirdly,  that  some  are  depressing  and 
some  stimulating.  It  is  inadvisable  to  keep  a  patient  too  long  on 
any  one  drug,  as,  in  the  first  place,  drugs  are  apt  with  continuance 
to  lose  their  effects,  and  in  the  second  place  seemingly  to  become  so 
essential  to  the  patient  that  he  becomes  obsessed  with  the  idea 


IO22  Insomnia. 

that  he  cannot  do  without  them.  Hypnotics  are  often  continued 
for  a  much  longer  time  than  is  necessary,  and  the  physician 
should  make  frequent  essays  to  diminish  the  quantity  originally 
administered,  and  so  gradually  to  withdraw  the  drug  altogether. 
It  were  well  if  it  were  generally  feasible  to  provide  the  patient  with 
his  medicament  and  not  with  the  prescription  therefor,  and  an 
attempt  should  be  made  in  every  case  to  do  this.  Patients 
continue  to  make  use  of  prescriptions  long  after  their  legitimate 
use  has  ceased,  and,  which  is  even  worse,  hand  their  prescriptions 
on  to  friends  whom  they  may  hope  to  benefit.  Among  the  most 
commonly  used  drugs  is  veronal,  of  which  the  chemical  synonym  is 
diethyl-malonyl-urea.  It  may  be  given  in  doses  up  to  10  gr., 
but  quite  small  doses  of  2  or  4  gr.  are  often  efficacious.  It 
is  very  slightly  soluble  in  water,  and  is  best  given  in  a  little  warm 
milk  about  half  an  hour  before  bed-time.  In  the  case  of  this  drug, 
as  in  the  case  of  others,  the  time  which  elapses  between  ingestion 
and  effect  varies  with  different  individuals,  but  of  veronal  it  may, 
on  the  whole,  be  said  that  it  is  a  rapidly  acting  drug.  The 
monosodiuni  salt  of  this  substance  is  known  as  medinal  or 
sodium  veronal.  It  has  the  advantage  of  being  soluble,  and  should 
be  given  in  half  a  tumbler  of  warm  milk  or  water.  Being  a  urea 
compound,  veronal  should  be  administered  with  care  and  only 
under  the  direction  of  a  medical  man.  The  accidents  which  have 
happened  owing  to  its  use  have  usually  occurred  when  it  has  been 
given  in  the  form  of  a  tabloid  or  cachet,  and  where  no  doubt  the 
dose  has  been  repeated  before  the  original  one  has  become  dissolved. 
Among  the  earliest  toxic  symptoms  of  an  overdose  of  veronal  is 
a  tottering  gait,  which  is  suggestive  of  a  slight  degree  of  drunken- 
ness. Other  symptoms  of  not  infrequent  occurrence  are  headache 
and  cutaneous  rashes.  The  rash  has  been  described  by  some  as 
rubeoliform,  but  more  commonly  is  like  the  rash  of  typhoid  fever, 
though  the  elements  are  far  more  thickly  set  than  are  usually  the 
elements  of  the  typhoid  rash.  It  is  of  great  importance  in  the 
continued  administration  of  veronal  and  kindred  drugs  to  secure  a 
free  evacuation  of  the  bowels.  The  toxic  symptoms  which 
occasionally  develop  after  comparatively  small  doses  almost  always 
occur  in  those  who  are  constipated,  and  this  is  no  doubt  to  be 
attributed  to  the  collection  of  the  drug  in  the  intestinal  tract.  If 
this  collection  is  prevented  there  is  little  to  fear  from  the  adminis- 
tration of  medicinal  doses.  Somewhat  similar  drugs  are  bromural, 
hedonal,  trional  and  sulphonal.  The  first  of  these  may  be  given 
in  doses  of  5  to  10  gr.  in  cachets  or  made  up  as  tablets  ;  it  is  a 
mild  and  seemingly  safe  hypnotic  and  particularly  useful  in  cases 


Insomnia.  1023 

where  the  sleeplessness  is  due  to  some  undue  amount  of  excitement 
or  work.  Hedonal  may  be  given  in  doses  of  15  to  30  gr.  in 
cachet,  in  tablet,  or  suspended  in  milk,  and  the  effect  is  rapidly 
produced.  Sulphonal  is  very  widely  used.  Its  synthetic  name  is 
dimethyl-rnethane-diethylsulphon,  and  it  may  be  given  in  doses 
of  10  to  30  gr.  in  cachets,  capsules,  tablets  or  suspended  in 
mucilage  or  in  hot  milk.  The  drug  in  the  vast  majority  of  cases 
produces  its  effect  about  four  hours  after  it  has  been  taken,  and 
even  in  some  cases  not  until  the  following  day  or  night.  It  is  a 
medicament  which  should  not  be  continued  for  many  days  together, 
and  it  is  of  the  utmost  importance  that  while  it  is  being  given  the 
bowels  should  be  freely  opened  daily.  Among  the  most  usual  toxic 
symptoms  are  feelings  of  weakness,  inco-ordination  of  gait  and 
speech,  vomiting,  diarrhoea,  or  constipation  and  hrematopor- 
phyrinuria.  This  last  condition  is  of  the  most  serious  import,  and 
many  patients  exhibiting  it  die  after  a  week  or  ten  days.  Trional 
and  tetronal  are  similar  to  sulphonal,  but  are  less  reliable.  Trional 
may  be  given  with  paraldehyde,  suspended  in  oleum  amygdalae,  either 
by  the  mouth  or  by  the  rectum.  It  is  most  efficacious  in  simple 
sleeplessness  in  old  persons  and  in  some  types  of  neurasthenia. 
Paraldehyde  is  a  very  valuable  drug,  but  unfortunately  is  repulsive 
to  the  smell  and  taste,  and  as  it  continues  to  be  excreted  by  the 
lungs  and  perhaps  by  the  skin  for  many  hours  after  its  effect  has 
passed  off,  it  is  exceedingly  unpleasant  both  to  the  patient  and  to 
his  companions.  Its  dose  is  from  30  min.  to  '2  or  3  drachms,  or 
even  more,  and  it  may  be  given  in  capsules  or  with  lemon  juice  or 
other  flavouring  agents  or  emulsified  with  the  white  of  an  egg. 
It  is  not  wise  to  continue  the  use  of  this  drug  in  old  persons,  owing 
to  its  action  on  the  respiratory  tract. 

Amylene  hydrate  is  a  useful  hypnotic  which  may  be  given  in 
doses  from  30  min.  to  2  drachms.  It  may  be  administered  in 
capsules,  but  as  it  is  not  very  unpleasant  in  flavour  it  may  be  given 
with  water  only  or  with  some  mild  flavouring  agent.  Dormiol  is 
of  a  very  similar  composition  and  action,  but  is  more  uncertain  in 
producing  sleep.  Potassium  bromide  and  other  bromide  salts  are 
admirable  drugs  and  are  particularly  indicated  where  there  is  any 
suspicion  of  epilepsy  being  present.  Seven  to  30  gr.  given  at 
bedtime  will  often  produce  speedy  effects  and  the  sleep  is  of  a 
peaceful  character.  The  smaller  doses  of  bromide  frequently  act 
better  than  the  larger  doses.  It  may  be  given  with  chloral  hydrate, 
and  its  effect  seems  to  be  even  better  in  this  combination,  especially 
in  those  cases  in  which  the  insomnia  is  severe  and  of  long  standing 
and  in  which  the  bromide  salt  alone  is  of  little  avail.  Chloral  is  a 


IO24  Insomnia. 

very  sure  hypnotic  and  quickly  produces  sleep,  but  is  a  cardiac 
depressant,  and,  like  the  bromides,  in  large  quantities  may  produce 
gastro-intestinal  irritation.  It  should  therefore  be  given  with 
considerable  caution  in  diseases  of  the  heart,  lungs  and  alimentary 
tract.  Chloralamide  may  be  given  in  doses  from  15  to  45  gr.  It 
is  best  given  dissolved  in  a  small  quantity  of  brandy  and  taken 
with  water  at  bed-time.  Butyl-chloral  hydrate  and  chloretone 
are  similarly  mild  preparations,  and  are  useful  only  in  slight 
degrees  of  insomnia. 

MAURICE  CRAIG  and  E.   D.  MACNAMARA. 


1025 


LUMBAR    PUNCTURE. 

THE  spinal  cord  in  the  adult  terminates  at  the  level  of  the  lower 
part  of  the  first  lumbar  vertebra.  Below  this  level  the  arachnoidal 
sac  extends,  as  a  hollow  cavity,  as  far  as  the  second  sacral  vertebra. 
Thus,  between  the  second  lumbar  and  the  second  sacral  vertebrae,  we 
have  a  space  devoid  of  spinal  cord,  containing  only  the  roots  of  the 
cauda  equina  suspended  in  the  cerebro-spinal  fluid.  From  this 
region,  by  entering  the  arachnoidal  sac  from  behind,  the  fluid  can 
be  withdrawn  without  risk  of  injury  to  the  cord. 

The    two    widest    interlaminal    spaces    are    the    one    between 
the   third  and   the   fourth    lumbar,  and   the   other   between   the 
fourth   and   fifth  lumbar   vertebrae.     Of  these  two   the  lower  is 
slightly    wider    and    more    easily   accessible.      To    identify  these 
spaces  we  take  the  following  landmarks:— A  horizontal  line  drawn 
across  the  back  at  the  level  of  the  highest  part  of  the  iliac  crests 
intersects  the  vertebral  column  at   the  tip  of  the  fourth  lumbar 
spine.     We  make  our  puncture  immediately  below  this  spine.     A 
platino-iridium    needle    of    fairly  large  calibre  and  measuring  at 
least  8  cm.  in  length  is  used  for  performing  the  puncture.     The 
patient  should,  if   possible,  be  made  to  sit  on  a  low  seat,  stoop- 
ing well   forwards    with   the   knees    separated,  the  arms  hanging 
loose  and  the  hands  touching  the   ground.      In  this  posture  the 
laminae   are   separated   to   their  widest  extent.     If,  however,  the 
patient  is  bedridden,  or  comatose,  he  may  lie  in  the  left  lateral 
posture,  with  the  hips  close  to  the  edge  of  the  bed,  the  knees  and 
shoulders  being  closely  approximated.  We  carefully  sterilise  the  skin 
at  the  site  of  the  puncture,  and  unless  the  patient  is  already  uncon- 
scious, we  render  it  locally  anaesthetic  by  means  of  an  ethyl-chloride 
spray.     Placing  the  left  index  finger  on  the  fourth  lumbar  spine  as 
a  guide,  we  push  the  needle  in  with  the  right  hand,  about  ^  inch 
below  this  spot  and  slightly  to  the  right  of  the  middle  line,  directing 
the  point  of  the  needle  horizontally  forwards  and  slightly  inwards. 
Deep  in,  the  ligamentum  subflavum,  between  the  laminae,  is  en- 
countered as  a  somewhat  resistant  band,  but  pushing  firmly  on,  if 
no  bone  is  struck,  the  ligament  is  somewhat  suddenly  pierced,  and 
the  needle  penetrates  the  spinal  theca,  which  lies  close  against  the 
dorsal  aspect  of  the  spinal  canal.     If  we  happen  to  strike  a  lamina 
instead  of  a  ligament,  we  withdraw  the  needle  somewhat,  and  try 
again,  above  or  below.     In  a  normal  case  the  cerebro-spinal  fluid  at 
once  begins  to  escape  from   the  needle.     No   suction  should  be 
S.T. — VOL.  ii.  65 


IO26  Lumbar  Puncture. 

employed  to  start  the  flow.  If  the  fluid  does  not  run,  a  sterilised 
stilette  should  be  passed  along  the  needle  to  make  sure  that  its 
lumen  is  clear.  If  the  lumen  is  clear  and  still  no  fluid  comes,  it 
may  be  that  the  spinal  theca  has  been  displaced  forwards  instead  of 
penetrated  by  the  needle.  In  this  case,  it  is  best  to  start  afresh, 
making  another  puncture  at  the  interlaminal  space  above  or 
below. 

Examination  of  the  cerebro-spinal  fluid  thus  obtained  is  frequently 
of  the  utmost  diagnostic  value.  The  physical,  chemical,  cytological 
and  bacteriological  characters  of  the  fluid  may  be  of  supreme  value 
in  many  diseases  of  the  central  nervous  system.  With  these, 
diagnostic  points,  however,  we  are  not  directly  concerned.  For 
fuller  details,  the  reader  is  referred  to  text-books  on  the  subject.1 

As  a  therapeutic  measure  thecal  puncture  may  be  employed  in 
various  ways. 

(1)  Withdrawal  of  a  certain  quantity  of  cerebro-spinal  fluid  is 
often  beneficial    for  the  immediate  mechanical   relief  of  cases  of 
increased  intracranial  pressure,  e.g.,  in  meningitis  of  any  variety, 
in  uraemic  coma,  in  coma  due  to  fracture  of  the  base  of  the  skull, 
and  in  certain  intracranial   tumours.      Great    caution  should  be 
observed  in  cases  of   tumour  in   the  posterior  cranial  fossa,  lest 
sudden  withdrawal  of  the  cerebro-spinal  fluid  may  introduce  prolapse 
of  the  pons  and  medulla  towards  the  foramen  magnum,  with  conse- 
quent pressure  upon  the  vital  centres. 

(2)  Thecal  puncture  may  also  be  employed  therapeutically  for  the 
purpose  of  injecting  remedial  substances  into  the  cerebro-spinal 
cavity.     Thus,  for  example,  we  may  inject  antitoxic  sera  in  such 
diseases  as  epidemic  cerebro-spinal  meningitis,  tetanus,  etc. 

(3)  We  may  also   employ  thecal  puncture   for  the  purpose  of 
injecting  anaesthetic  drugs  to  produce  spiryal   anaesthesia  prior  to 
operation  on  the  lower  limbs  and  trunk.     Amongst  the  drugs  most 
commonly  used  for  this  purpose  we  may  mention  stovaine  (with  or 
without  strychnine),  and  novocaine.     Spinal  anaesthesia  is  specially 
valuable  in  cases  of  profound  shock,  in  acute  abdominal  conditions, 
in  patients  with  severe  cardiac  or  pulmonary  disease,  in  fact,  in 
many  cases  where  a  general  anaesthetic  is  particularly  hazardous. 
Spinal  anaesthesia,  however,  should  be  avoided  in  young  children, 
in  most  cases  of  hysteria  and  in  severe  scoliosis. 

PURVES  STEWART. 

REFERENCE. 
1  Purves  Stewart,  "  Diagnosis  of  Nervous  Diseases,"  2nd  ed.,  1908,  p.  385. 


IO2J 


MIGRAINE    AND    OTHER    FORMS  OF    PERIODIC 

HEADACHE. 

MIGRAINE. 

IT  is  convenient  to  consider  the  treatment  of  this  disease  as  con- 
sisting of  three  branches,  each  of  which  is  directed  towards  the 
attainment  of  a  distinct  object :  (1)  Treatment  directed  towards  the 
removal  or  mitigation  of  the  numerous  conditions  which- act  as  the 
immediate  exciting  causes  of  the  attacks ;  (2)  the  continuous 
administration  of  remedies  during  the  intervals  between  the  attacks 
with  the  object  of  rendering  the  attacks  less  frequent  and  less 
severe ;  and  (3)  the  treatment  of  the  patient  during  the  attack  with 
the  object  of  relieving  his  immediate  suffering. 

Treatment  Directed  to  the  Exciting  Causes  of  each  Attack. 
— By  far  the  most  frequent  individual  exciting  cause  of  an  attack  of 
migraine  IB  fatigue,  both  physical  and  mental,  and  careful  attention 
must  be  paid  to  any  conditions  which  tend  to  lower  the  nutritional 
condition  of  the  patient  or  which  make  too  great  demands  upon  his 
physical  resources.  The  hours  of  work,  recreation  and  rest  should 
be  judiciously  apportioned,  and  causes  for  mental  worry  and 
depression  as  far  as  possible  avoided.  The  hygienic  surroundings 
of  the  patient  should  be  good,  and  regular  exercise,  fresh  air  and 
sunlight  are  highly  desirable.  It  is  of  the  greatest  importance  that 
the  nutrition  of  the  patient  should  be  improved  and  then  kept  at 
as  high  a  standard  as  possible,  for  it  is  an  unvarying  rule  in  this 
disease  that  the  better  the  general  state  of  health  of  the  patient  is 
the  fewer  and  the  less  severe  his  attacks  become.  The  most  severe 
and  frequently  recurring  attacks  are  often  seen  in  patients  who, 
from  the  conviction  that  the  malady  is  owing  to  dyspeptic  troubles, 
have  come  to  restrict  their  diet  more  and  more,  with  the  result  that 
nutritional  failure  and  loss  of  weight  have  supervened.  In  such 
patients,  therefore,  who  are  thin  and  cachectic  it  is  often  of  signal 
advantage  to  commence  treatment  with  a  few  weeks'  complete  rest 
in  bed,  with  liberal  feeding  and  massage.  In  this  connection,  too, 
it  is  all-essential  to  rectify  any  unhealthy  condition  of  the 
alimentary  canal,  such  as  dyspepsia,  dilatation  of  the  stomach  and 
constipation,  to  improve  the  appetite  by  the  use  of  such  tonics  as 
iron,  strychnine,  arsenic,  the  hypophosphites  and  the  glycero- 
phosphates,  by  regular  and  compatible  exercise,  and  by  change  of 

65—2 


IO28  Migraine. 

air  and  scene,  and  to  allow  a  liberal  diet.  It  is  best  to  avoid  the 
use  of  alcohol  entirely  except  in  patients  who  have  passed  middle  life. 

Indiscretions  in  diet  and  dyspeptic  states  have  held  an  important 
position  both  with  the  medical  profession  and  with  the  laity  as 
exciting  causes  of  migraine,  and  it  is  easy  to  realise  that  from  the 
early  nausea  and  subsequent  vomiting  the  patient  may  be  readily 
convinced  that  his  "  bilious  headaches  "  are  of  gastric  origin.  But 
while  it  is  quite  true  that  in  a  few  patients  certain  articles  of 
diet  will  invariably  bring  on  an  attack  of  migraine,  yet  it  is 
probable  that  dyspeptic  conditions  play  little  or  no  part  in  the 
etiology  of  migraine  except  as  agents  in  the  production  of  a  poor 
nutritional  state,  and  that  any  improvement  which  careful  dieting 
and  treatment  of  dyspepsia  bring  to  the  migrainous  patient  is  the 
result  of  the  improvement  in  bodily  health  thus  brought  about. 
Provided  that  a  full  and  nutritious  diet  is  secured  for  the  patient, 
and  that  those  things  are  avoided  that  are  known  to  upset  his 
digestion  or  to  bring  on  his  headaches,  there  is  no  need  to  lay 
down  any  rules.  Since  there  seems  to  be  no  evidence  that  the 
gouty  diathesis  or  the  presence  of  actual  gout  is  a  causative  factor 
of  migraine,  though  the  two  conditions  not  unfrequently  co-exist, 
no  advantage  can  be  expected  from  the  exemption  of  meat  and 
other  purin-producing  substances  from  the  diet  nor  from  the 
employment  of  hydro therapic  and  such  other  measures  as  are 
commonly  employed  for  the  treatment  of  goutiness,  though  all  of 
these  have  been  largely  advocated  for  the  treatment  of  migraine. 

Errors  of  refraction,  diplopia  and  other  ocular  troubles  are  in 
some  patients  important  exciting  causes  of  migrainous  attacks. 
Two  very  striking  examples  of  this  have  been  observed  by  the  writer, 
for  in  both  of  these  cases  the  artificial  diplopia  produced  by  placing  a 
prism  in  front  of  one  eye  for  a  few  minutes  was  always  followed  by 
an  attack.  Quite  recently  the  old  conception  of  the  ophthalmic 
origin  of  migraine  has  been  revived,  and  some  ardent  advocates  of 
this  theory  have  gone  so  far  as  to  maintain  that  all  migraine  is 
the  result  of  eye-strain.  The  facts  that  no  ocular  defect  exists  in 
the  majority  of  severe  cases  of  migraine,  and  that  looked  at  from 
the  side  of  errors  of  refraction  migraine  is  a  remarkably  uncommon 
accompaniment,  at  once  remove  ocular  troubles  from  the  position 
of  essential  factors  of  migraine  into  a  true  perspective,  as  simply 
exciting  causes  of  the  attacks.  It  is,  therefore,  absolutely  essential 
that  the  eyes  shall  be  carefully  examined  by  a  competent  observer 
in  every  case  of  migraine,  and  that  any  defect  found  shall  be  care- 
fully corrected  and  repeatedly  re-corrected  as  time  goes  on.  In  a 
few  of  the  cases  where  some  ocular  defect  exists,  great  improve- 


Migraine.  1029 

ment  in  the  migraine  occurs  when  the  defect  is  corrected ;  but  in  the 
majority  of  cases  there  is  little  benefit  .in  such  correction  alone,  in 
the  absence  of  other  treatment. 

In  many  cases  such  events  as  a  long  railway  journey,  the  travelling 
in  a  closed  vehicle,  the  attentive  watching  of  a  brilliantly-lit  stage 
or  of  a  moving  crowd,  the  driving  against  a  cold  wind,  or  a  stay  in 
an  overheated  room  are  potent  exciting  causes  of  attacks.  The 
treatment  is,  011  the  one  hand,  to  avoid  as  far  as  possible  the  exciting 
cause,  and  on  the  other  to  fortify  the  patient  against  the  exciting 
cause  by  the  administration  of  certain  remedies,  which  should  be 
taken  an  hour  before  exposure.  The  most  useful  combination  is 
sodium  bromide  (10  to  15  gr.)  with  liq.  strychnin®  On.5)  [U.S.P., 
strychninae  hydrochloridi,  ^  gr.]  and  phenazone  (10  gr.).  A 
cachet  composed  of  aspirin  (10  gr.),  phenacetin  (10  gr.),  and 
caffeine  citrate  (2^  gr.)  is  sometimes  advantageous  in  place  of  the 
phenazone. 

Treatment  Between  the  Attacks. — In  the  foregoing  paragraphs 
enough  has  been  written  to  give  all  indications  for  the  general 
management  of  the  patient.  As  regards  regular  medicinal  treatment  it 
must  be  pointed  out  to  the  patient  that  the  remedies  will  only  avail 
him  if  taken  with  regularity  and  over  a  very  long  period,  and  that 
he  is  to  expect  a  slow  and  steady  improvement  both  in  the  severity 
and  in  the  frequency  of  the  attacks  rather  than  that  his  attacks  will 
cease  altogether,  although  the  complete  cessation  of  the  attacks 
under  treatment  is  by  no  means  beyond  the  bounds  of  likelihood. 
He  must  be  told  that  the  remedies  which  he  takes  between  the 
attacks  must  be  omitted  at  once  if  an  attack  occur,  for  if  not  they 
will  tend  to  make  the  headache  during  the  attack  unusually  severe, 
;uul  he  must  be  instructed  that  at  the  slightest  warning  of  an 
oncoming  attack  he  must  have  recourse  to  other  remedies,  which 
will  be  described  below  under  Treatment  of  the  Attack. 

There  seems  to  be  one  combination  of  drugs  the  value  of  which  far 
exceeds  that  of  all  others  in  the  inter-paroxysmal  treatment  of  mi- 
graine, and  it  is  made  up  of  nitro-glycerine,  strychnine,  gelsemium 
and  an  alkaline  bromide,  the  necessary  adjuvant  being  some 
stable  acid,  such  as  dilute  phosphoric  acid,  since  nitro-glycerine 
is  only  stable  in  an  acid  medium.  The  nitro-glycerine  should 
be  given  in  the  form  of  liq.  trinitrini  [U.S.P.,  spiritus  glycerylis 
nitratis]  in  doses  of  from  £  to  2  minims,  the  object  being 
to  give  as  large  a  dose  as  possible  short  of  producing  the 
least  discomfort  from  head-throbbing.  As  a  rule,  1  minim  is  well 
borne.  The  strychnine  should  be  given  in  full  doses  of  -£$  gr.  to  an 
adult  and  in  much  smaller  doses  to  children,  while  5  minims  of 


1030  Migraine. 

tr.  gelsemii  and  10  gr.    of   potassium   bromide  with    5    drops   of 
dilute  phosphoric  acid  complete  the  mixture,  which  should  be  given 
thrice  daily  after  food.     The  writer  has  not  had  the  experience  of 
any  case  of  migraine  which  was  not  considerably  improved  by  this 
treatment,  which  may  be  continued  with  increasing  advantage  for 
many  months.     The  recent  researches  of  Spitzer  have  led  him  to 
the  conclusion  that  in  cases  of  migraine  there  is  a  narrowing  of  one 
or  both  of  the  foramina  of  Munro,  which  allows  of  the  temporary 
blocking  of  the  foramen  by  the  choroid  plexus,  with  the  production' 
of  a  temporary  distension  of  one  or  both  of  the  lateral  ventricles 
with  cerebro-spinal  fluid,  and  that  the  symptoms  of  migraine  are 
the  phenomena  resulting  from  this  temporary    distension.     The 
distension,  and,  therefore,  the  symptoms,  are  relieved  by  the  fall  of 
blood-pressure  and  of  inter-cranial  tension  which  occurs  when  the 
stage  of  vomiting  and  partial  collapse  is  reached.     These  considera- 
tions have  suggested  a  line  of  treatment  which  may  be  used  with 
advantage  in  addition   to   the  foregoing,   and  especially  in  cases 
where  the  attacks  show  a  regular  periodicity  in  their'  recurrence, 
and  where  we  may  with  some  degree  of  certainty  anticipate  the 
advent  of  an  attack  by  the  administration  of  remedies.     This  line 
of  treatment  aims  at  keeping  the  blood-pressure  and    the    intra- 
cranial  tension  low,  and  so  hindering  the  tendency  to  the  blocking 
of  the  foramina  of  Munro,  if  such  indeed  occurs.     Now  it  is  quite 
certain  that  the  regular  exhibition  of  diuretics   tends  to  keep  the 
intra-cranial  tension  low  by   diminishing  the  output  of   cerebro- 
spinal  fluid,   and  those  remedies  which  tend  to   lower  the  blood- 
pressure,  and  keep  it  low,  tend  to  lower  the  intra-cranial  pressure, 
in  that  the    former   is  the  chief   causative    factor   of   the   latter. 
Therefore  the  administration  of  such  diuretics  as  theocin  sodium 
acetate  (in  5  gr.  doses),  combined   with   potassium  or  ammonium 
acetate   and   digitalis,    and    a    remedy   which   tends  to  lower  the 
blood-pressure,  such  as  sodium  benzoate  (in  10  to  20  gr.  doses)  given 
thrice   daily,   should   be   used   regularly   in   refractory  cases  and 
temporarily    in    cases    where    an  attack  can  be  anticipated    with 
any  degree  of  certainty.     If    we    hold  to  Spitzer's  theory  of  the 
production  of  migraine  we  explain  the  value  of  nitro-glycerine,  in 
that  it  is  a  remedy  which    is  likely    to    reduce    the  intra-cranial 
pressure  and  so  to  prevent  blocking  of  the  intra-cerebral  foramina. 
However  this  may   be,  it   seems  certain  that  nitro-glycerine   has 
more,  effect  in  benefiting  the  subjects  of  migraine   when  given  in 
the  liquid  than  in  the  tabloid  form,  and  in  the  writer's  experience 
it  is  more  useful  and  produces  fewer  disagreeable  effects  than  either 
sodium  nitrite  or  erythrol  tetra-nitrate. 


Migraine.  1031 

Many  other  remedies  have  been  strongly  advocated  for  the  relief 
of  migraine,  and  among  them  are  ergot,  belladonna,  hyoscyamus, 
cannabis  indica,  iron,  arsenic,  iodide  of  potassium  and  ammonium 
chloride.  Of  many  of  these  the  writer  has  had  no  experience. 
The  important  value  of  iron  and  arsenic  has  already  been  referred 
to  and  explained,  while  of  the  cases  reported  in  which  iodide  of 
potassium  has  been  of  signal  service  it  is  just  to  presume  that 
some  condition,  other  than  pure  migraine,  capable  of  being 
influenced  by  this  drug  may  have  existed. 

Ross  has  found  that  the  administration  of  the  salts  of  calcium 
is  of  much  benefit  in  certain  cases  of  migraine  where  the  attacks 
were  associated  with  the  occurrence  of  much  puffiness  beneath  the 
eyes,  and  it  seems  likely  that  this  treatment  may  be  of  service  also 
in  those  patients  in  whom  migraine  is  associated  with  albuminuria, 
and  in  those  cases  of  nephritis  in  which  paroxysmal  headaches 
approaching  to  the  type  of  migraine  occur. 

Surgical  Procedures  for  the  relief  of  migraine  have  been 
advocated  and  found  successful  by  Whitehead  and  others.  They 
consist  in  the  revival  of  an  ancient  method  of  treatment  by  counter- 
irritation  :  the  placing  of  a  seton  in  the  back  of  the  neck.  It  is 
a  well-known  fact  that  when  a  migrainous  patient  is  suffering 
from  any  infective  malady,  such,  for  example,  as  typhoid  fever, 
pneumonia  or  influenza,  the  attacks  do  not  occur,  and  it  is  quite 
likely  that  the  value  of  the  seton  lies  in  the  fact  that  it  induces  a 
chronic  septic  process  which  checks  the  occurrence  of  the 
migrainous  attacks. 

Treatment  of  the  Attacks. — When  an  attack  of  migraine  is 
well  developed  it  is  seldom  possible  to  cut  it  short  or  even  to  modify 
its  usual  course  to  any  useful  degree  by  any  kind  of  treatment.  All 
that  can  be  done  is  to  lessen  to  some  extent  the  sufferings  of  the 
patient.  But  in  the  early  stages  of  the  attack,  and  especially  when 
the  first  warnings  of  its  approach  appear,  it  is,  in  some  patients, 
very  amenable  to  treatment,  though  in  other  patients  quite 
rebellious.  The  best  remedy  is  a  single  full  dose  of  any  of  the 
coal-tar  group  of  analgesic  drugs,  combined  with  a  stimulant 
diuretic.  Antifebrin  (in  a  10  gr.  dose)  is  perhaps  the  most  useful, 
but  phenazone  (20  gr.),  phenacetin  (25  gr.),  ammonol  (10  gr.)  and 
aspirin  (20  gr.)  are  all  useful,  and  it  must  be  borne  in  mind  that  these 
drugs  are  by  no  means  identical  in  their  effect,  for  it  often  happens 
that  one  of  them  is  highly  successful  and  another  fails  altogether  in 
the  same  patient.  The  best  diuretic  to  use  with  one  of  the  above 
is  theocin  sodium  acetate  (in  a  dose  of  5  gr.).  If  these  remedies 
fail  to  check  the  onset  of  the  attack,  the  dose  should  not  be 


1032  Migraine. 

repeated,  but  recourse  should  be  had  to  palliative  measures  and  an 
attempt  made  to  cut  short  the  succeeding  attack  by  a  fresh  com- 
bination of  the  above-mentioned  remedies. 

During  attacks  of  any  severity  the  patient  should  rest  quietly  in 
bed  in  a  well-ventilated  and  preferably  darkened  room,  and  should 
be  kept  warm  by  hot-water  bottles.  The  application  of  warmth  to 
the  head,  and  especially  to  the  occiput  and  back  of  the  neck,  is  often 
very  grateful  to  the  patient,  and  for  this  purpose  electrically  heated 
pads,  which  can  be  kept  at  a  uniform  temperature  and  which  can 
be  run  off  an  ordinary  wall  plug  by  means  of  a  single  Tamp 
resistance,  are  very  convenient.  As  alternative  measures  hot 
fomentations,  poultices  or  sinapisms  may  be  used. 

It  is  desirable  to  engender  sleep  as  soon  as  possible,  and  for  this 
purpose  chloral  hydrate  (10  gr.),  butyl  chloral  (20  gr.),  or  veronal 
(5  gr.)  may  be  used,  and  of  these  remedies  veronal  is  in  my 
experience  the  most  efficacious.  It  is  obvious  that  these  remedies 
must  not  be  given  when  the  patient  is  vomiting,  but  they  may  be 
used  with  advantage  early  in  the  attack  or  after  the  vomiting  has 
ceased.  The  hypodermic  injection  of  morphine  affords  striking 
relief  in  some  cases,  but  it  is  more  often  useless,  and  sometimes 
increases  the  vomiting  and  lengthens  the  prostration  after  the 
attack  is  over.  For  these  reasons,  and  because  the  habitual  use  of 
morphine  may  be  set  up  in  those  patients  who  are  at  once  relieved 
by  this  drug,  it  is  better  avoided  altogether  in  the  treatment  of 
migraine.  The  application  of  the  constant  current  to  the  head,  the 
anode  being  applied  by  a  large  pad  electrode  to  the  region  of  the 
pain,  has  been  vaunted  as  giving  relief  during  the  attack,  but  in 
most  cases  it  is  quite  useless. 

Alcohol  is  certainly  beneficial  in  many  cases,  and  it  may  be 
expected  to  lessen  the  headache,  check  the  vomiting  and  induce 
sleep.  A  dose  of  \  oz.  of  brandy  may  be  given  early  in  the 
attack,  and  this  may  be  repeated  with  advantage  when  the  stage  of 
vomiting  is  reached. 

The  feeding  of  the  patient  during  the  attack  is  not  of  importance 
in  most  cases,  for  the  attacks  do  not  last  more  than  twenty-four 
hours,  and  from  the  nausea  and  anorexia  which  the  patient  suffers 
he  has  little  inclination  to  do  more  than  relieve  thirst.  But  when 
the  attacks  last  from  two  to  three  days,  or  when  shorter  attacks 
occur  at  frequent  intervals,  it  becomes  imperative  to  feed  the 
patient  during  the  attacks.  Small  and  easily  assimilable  meals  are 
indicated,  and  a  dry  diet  consisting  of  toast  and  underdone  meat  or 
chicken,  such  as  is  used  in  the  treatment  of  sea  sickness,  is  often  of 
great  advantage. 


Periodic  Headache.  IO33 

OPHTHALMOPLEGIC    MIGRAINE. 

No  special  treatment  is  indicated  .in  the  rare  cases  in  which 
paralysis  of  some  of  the  ocular  muscles,  usually  transient  but 
sometimes  permanent,  follows  an  attack  of  migraine  :  they  are 
amenable  to  the  same  procedures  as  are  cases  of  the  ordinary  type. 

OTHER    FORMS    OF    PERIODIC    HEADACHE. 

It  is  a  frequent  experience  to  meet  with  patients  in  whom 
periodic  headaches  occur,  which  differ  widely  in  type  from  those  of 
classical  migraine.  Thus  the  visual  phenomena  may  be  always 
absent,  the  headache  may  be  bi-lateral  and  general,  vomiting  may 
never  occur,  and  even  nausea  may  be  absent.  The  majority  of 
such  cases  are  essentially  cases  of  migraine,  and  are  to  be  treated 
as  such  with  success.  A  consideration  of  certain  facts  in  the 
history  of  the  patient  will  often  solve  any  doubt  as  to  the  nature 
of  the  headache.  In  the  first  place  if  the  headaches  have  dated 
from  childhood,  this  fact  is  strong  presumptive  evidence  of 
migraine.  Secondly,  careful  interrogation  will  often  bring  to  light 
the  fact  that  in  some  attack  or  other  definite  signs  of  migraine  have 
occurred.  A  patient  of  mine,  who  suffered  from  simple  recurring 
headaches,  when  questioned  upon  the  subject,  recalled  most  vividly 
that  twenty  years  before  he  had  an  attack  in  which  the  most 
characteristic  visual  phenomena  of  migraine  occurred.  This  was 
the  only  occasion  in  his  experience  on  which  definite  symptoms  of 
migraine  appeared,  and  curiously  enough  on  this  occasion  he  had 
no  headache.  Lastly,  a  history  of  migraine  occurring  in  other 
members  of  the  family  is  important  in  the  diagnosis,  since  this 
malady  is  so  often  hereditary  and  familial. 

There  remain  to  be  mentioned  certain  other  conditions  in  which 
recurring  headaches  occur,  the  treatment  of  which  must  not  be 
confused  with  that  of  migraine. 

Headache  resulting  from  Ocular  Conditions.  (Errors  of 
Refraction,  etc.). — These  are  not  truly  periodic  in  their 
occurrence,  and  are  apt  to  be  at  once  brought  on  by  eye-strain. 
Characteristic  symptoms  of  migraine  are  absent,  but  it  must  be 
borne  in  mind  that  eye-strain  may  precipitate  the  attack  in  a  case 
of  migraine.  A  competent  examination  of  the  eyes  in  every  case  of 
recurring  headache,  and  the  correction  of  any  defect  that  may  be 
present,  is  essential. 

Headaches  resulting  from  Disease  of  the  Nasal  Accessory 
Chambers,  Skull  Bones,  etc. — The  nature  of  the  pain  will  usually 
serve  to  distinguish  these  conditions.  It  is  a  fixed  pain  with 
irregular  exacerbations. 


1034  Periodic  Headache. 

Headaches  resulting  from  Gross  Intra-cranial  Disease, 
Intra-cranial  Tumour,  Cerebral  Syphilis,  and  Chronic  Hydro- 
cephalus. — In  the  early  stages  of  intra-cranial  tumour,  and  before 
the  more  obvious  signs  of  involvement  of  the  nervous  system 
appear,  periodic  attacks  of  headache  associated  with  vomiting  often 
occur,  and  may  closely  resemble  the  common  variety  of  migraine 
in  which  no  visual  phenomena  occur.  These  attacks  are  often 
referred  to  by  the  patient  as  "  bilious  attacks,"  a  term  which  is 
frequently  used  by  the  laity  for  attacks  of  migraine.  In  this 
connection  it  is  important  to  bear  in  mind  that  it  is  rare  to  meet 
with  vomiting  in  cases  of  brain  tumour  in  the  absence  of  optic 
neuritis,  and  that  ophthalmoscopic  examination  is  an  essential  step 
in  arriving  at  a  correct  diagnosis  in  every  case  of  recurring 
headache.  The  same  remedies  as  have  been  advocated  for  the 
relief  of  the  migrainous  attack  will  be  found  to  be  those  most 
successful  in  relieving  the  headache  and  vomiting  of  gross 
intra-cranial  disease. 

Headaches  associated  with  High  Arterial  Tension,  Renal 
Disease  and  Uraemia. — The  mechanism  of  the  production  of 
recurring  headaches  in  the  subjects  of  high  arterial  tension  is 
obscure.  Since  the  intra-cranial  pressure  varies  directly  with  the 
blood-pressure,  provided  that  the  walls  of  the  cerebral  arteries  are 
elastic  and  that  their  channels  are  not  obstructed  by  endarteritis, 
it  is  presumable  that  the  headache  may  be  the  direct  result  of  the 
high  intra-cranial  pressure,  and  that  measures  which  tend  to  lower 
the  general  blood-pressure  will  relieve  such  headache. 

This  seems  to  be  the  case  in  subjects  who  have  not  passed  middle 
age,  in  whom  the  arterial  tension  is  very  high,  and  who  do  not 
present  a  severe  degree  of  arterial  degeneration  as  determined  by 
the  examination  of  the  palpable  arteries  and  by  the  ophthalmoscopic 
examination  of  the  retinal  vessels,  and  in  these  patients  measures 
which  tend  to  reduce  the  arterial  tension  should  be  employed.  A 
carefully  regulated  diet,  with  a  reduction  in  the  quantity  of  meaty 
foods  taken,  the  securing  of  a  regular  free  action  of  the  bowels,  and 
the  administration  of  2  gr.  of  pil.  hydrarg  [U.S.P.,  massa  hydrargyri] 
on  alternate  nights  are  all-important,  while  the  blood-pressure  may 
be  further  reduced  by  the  regular  administration  of  sodium  benzoate 
(10  to  20  gr.)  or  sodium  nitrite  (3  to  5  gr.)  thrice  daily,  with  a 
diuretic  such  as  sodium  acetate.  The  value  of  aspirin  in  10  to 
20  gr.  doses  in  securing  immediate  relief  from  these  headaches  is 
considerable. 

On  the  other  hand,  where  arterial  degeneration  is  severe,  and 
especially  in  patients  who  have  passed  middle  life  and  in  whom 


Periodic  Headache.  1035 

narrowing  of  the  channels  of  the  cerebral  arteries  is  likely  to  exist, 
the  intra-cranial  pressure  is  not  raised  to  a  corresponding  extent 
when  the  arterial  pressure  is  high,  and  it  is  highly  probable  that 
headache  occurring  in  such  cases  is  due  to  a  relative  insufficiency 
in  the  amount  of  blood  passing  through  the  brain,  caused  by  the 
narrowing  of  the  arterial  channels  from  endarteritis,  and  experience 
tells  us  that  a  stimulant  method  of  treatment  as  opposed  to  the 
above-mentioned  depletive  method  of  treatment  is  often  highly 
successful.  To  this  end  strychnine  combined  with  bromide  of 
potash  should  be  given,  and  the  addition  of  digitalis  is  often  useful. 
Alcohol  and  an  increase  in  the  more  stimulating  portions  of  the  diet 
such  as  underdone  meat  are  often  indicated.  In  this  connection  it 
cannot  be  too  strongly  insisted  that  to  the  patient  with  advanced 
arterio-sclerosis  a  high  arterial  pressure  is  essential  to  his  life,  for 
otherwise  a  sufficient  circulation  of  blood  through  his  tissues  cannot 
be  maintained.  Further,  since  the  sclerosis  of  the  peripheral 
vessels  has  destroyed  their  motility,  the  peripheral  resistance 
cannot  be  altered,  and  the  only  means  at  our  disposal  by  which  the 
arterial  pressure  can  be  lowered  is  the  lowering  of  the  heart's  force, 
an  event  fraught  with  every  danger  to  the  patient  in  the  way  of 
heart  failure  and  thrombosis  in  the  peripheral  vessels. 

In  conditions  of  renal  disease  and  in  uraemia  headache  is 
doubtless  the  result  of  toxaemia,  and  when  small  white  kidney  or 
granular  kidney  is  present  cerebral  vascular  disease  may  be  adju- 
vant causes.  The  treatment  is  that  of  Uraemia  (sec  special  article, 
p.  837).  When  it  is  borne  in  mind  that  a  relative  failure  of 
the  heart's  force  is  the  precipitating  cause  of  the  appearance  of 
urieinic  symptoms,  the  importance  of  cardiac  stimulants  in  the 
treatment  of  this  condition  needs  no  comment.  Aspirin  is  a 
valuable  remedy  for  the  immediate  relief  of  the  headache. 


JAMES  COLLIER. 


EEFERENCES. 


Gowers,  Sir  W.  E.,  "Diseases  of  the  Nervous  System,"  2nd  edit.,  London, 
1893,  II.,  p.  984.  Liveing,  E.,  "  On  Megrim  and  Sick  Headache,"  London, 
IST.'J.  Spitzer,  A.,  Neurol.  Centrabl.,  Leipzig,  1901,  XX.,  p.  755. 


1036 


NIGHT  TERRORS. 

THE  differentiation  between  nightmare  and  night  terror  is  well 
marked  in  cases  at  either  end  of  the  scale,  but  there  are  many 
intervening  degrees  and  apparently  they  are  closely  allied  in  their 
mode  of  causation.  Nightmare  is  commonly  due  to  digestive 
disorder  or  mal-aeration  of  the  blood.  The  asphyxial  type  of  night 
terror  is  similar  in  origin  and  the  terror  is  subjective.  It  depends 
on  deficient  oxidation,  due  to  adenoids  or  enlarged  tonsils,  or  on 
gastric  disturbance,  perhaps  through  reflex  stimulation  of  the  vagus. 
The  primary  cerebral  or  idiopathic  type  occurs  in  neurotic  or 
neurasthenic  children  in  whom  no  asphyxial  or  alimentary  cause  is 
discoverable.  The  terror  is  objective  and  due  to  over-excitement  of 
the  cerebral  cortex.  Frequently  there  is  a  neurasthenic  basis  and 
an  alimentary  or  asphyxial  exciting  cause. 

During  the  attack  the  child  must  be  calmed,  petted  and  consoled, 
although  unconscious  of  his  surroundings  and  unable  to  recognise 
his  attendant.  It  lasts  for  a  few  minutes  to  an  hour,  and  is 
rarely  repeated  the  same  night.  The  child  frequently  falls  asleep 
without  recovering  consciousness.  Hypnotics  are  unnecessary.  A 
warm  foot  bath,  with  cold  affusion  to  the  head,  is  of  use  in  prolonged 
attacks. 

In  all  cases  an  aperient  should  be  given,  the  diet  and  digestion 
attended  to,  and  the  mode  of  life  regulated.  A  grey  powder  and 
a  mixture  of  rhubarb  and  soda  will  cure  many  patients.  Allow  no 
late  supper.  Insist  on  regular  meals  and  that  no  food  is  given  in 
the  intervals.  Alcohol,  meat  extracts,  tea,  coffee  and  cocoa  extracts 
should  be  prohibited,  and  the  amount  of  saccharine  and  starchy 
foods  limited,  if  there  is  intestinal  distension. 

The  child  must  sleep  on  a  hair  mattress,  with  no  heavy  bedclothes, 
and  a  low  firm  pillow.  A  bobbin  should  be  fixed  to  the  spine  to 
prevent  the  dorsal  decubitus.  The  sleeping  apartment  must  be 
ventilated  thoroughly.  A  nightlight  may  be  allowed  and  an 
attendant  should  sleep  in  an  adjoining  room  with  the  intervening 
door  open.  Firmness,  tact  and  sympathy  are  essential  in  the 
attendant,  and  a  stupid  or  neurotic  nurse  must  never  be  employed. 

Carious  teeth  and  disorders  of  dentition  must  be  treated.  If  the 
alimentary  tract  is  in  a  healthy  state,  any  cause  of  asphyxia,  such 
as  adenoids  and  enlarged  tonsils,  should  be  sought  for  and  removed. 


Night  Terrors.  1037 

Phimosis,  retained  smegma,  refractive  errors,  impacted  wax  in  the 
ears,  and  other  sources  of  local  irritation,  are  of  doubtful  import,  but 
should  receive  attention. 

In  the  primary  cerebral  or  idiopathic  type  the  usual  digestive  and 
asphyxial  causes  must  be  treated,  since  they  are  as  likely  to  be 
present  in  the  neurotic  as  in  other  children.  In  addition  it  may  be 
necessary  to  limit  the  school  work  to  the  morning  hours  or  even, 
in  the  worst  cases,  to  forbid  it  altogether  for  some  months.  Children 
subject  to  night  terrors  are  usually  clever  and  precocious,  and  will 
not  suffer  mentally  from  some  delay  in  their  education.  Examina- 
tions, exciting  and  competitive  games,  pantomimes,  parties  and  late 
hours  must  be  forbidden.  The  child  must  be  protected  from  excite- 
ment, threats,  ghost  stories  and  gruesome  tales,  unpleasant  sights 
and  shocks,  ugly  pictures  and  the  appalling  toys  wrongly  considered 
suitable  for  children,  especially  during  the  hours  before  bedtime. 

A  dose  of  bromide,  phenazone,  bromural,  or  bromide  and  chloral, 
can  be  given  at  bedtime  for  a  few  days  until  the  habit  is  broken. 
If  pavor  occurs  in  the  daytime  bromides  or  phenazone  can  be  given 
three  times  daily. 

Change  of  residence,  cold  bathing  and  sea  bathing  are  often  of 
remarkable  benefit.  The  general  health  is  best  assisted  by  iron 
and  arsenic  for  anaemia  and  by  cod-liver  oil  for  malnutrition, 
provided  always  that  alimentary  disorders  have  been  efficiently 
treated. 

EDMUND   CAUTLEY. 


io38 


NEURASTHENIA. 

IN  neurasthenia  the  symptoms  depend  essentially  upon  a  con- 
dition of  irritable  weakness  of  the  nervous  system,  and  their 
character  is  determined  by  the  part  of  the  nervous  system  which 
has  been  specially  exposed  to  strain  or  injury,  or  is  the  seat  of 
inherent  over-sensitiveness.  It  is  to  be  regarded  as  a  true  disease 
determined  by  derangement  of  function  unaccompanied  with  any 
gross  change  in  structure,  and  is  of  two  varieties. 

The  treatment  of  the  condition  of  neurasthenia  is  one  of  no 
little  difficulty,  requiring  insight  on  the  part  of  the  physician,  com- 
bined with  unlimited  tact  and  infinite  patience.  In  the  slighter 
varieties  the  patient  is  able  to  go  about  his  work  to  all  outward 
appearance  quite  well.  It  is  only  to  his  wife  or  to  his  physician 
that  he  unburdens  himself,  and  in  this  act  he  unconsciously 
exaggerates  his  symptoms.  Such  a  patient  is  to  be  encouraged  to 
continue  his  work,  which  he  usually  carries  out  efficiently  and 
successfully.  It  serves  as  a  distraction,  and  it  is  only  under  con- 
ditions which  offer  no  restraint  that  he  becomes  conscious  of  and 
communicative  about  his  discomforts. 

Sometimes  there  is  a  degree  of  excitability  which  calls  for  firm 
remonstrance  and  the  use  of  sedatives.  In  such  conditions  bromide 
is  of  inestimable  service,  and  where  it  has  to  be  given  it  should  be 
given  generously  in  doses  of  1  drachm,  or  even  more,  in  the  day. 
The  cold  or  tepid  spinal  douche,  as  a  daily  application,  is  also 
useful  in  such  cases,  frequent  rest  and  change  are  urgently  called 
for,  and  generous  feeding  is  a  necessity.  The  cephalic  sensations 
in  such  cases  are  not,  as  a  rule,  amenable  to  the  influence  of  drugs. 
Phenazone  or  phenacetin  with  caffein  or  some  similar  drug 
occasionally  gives  a  little  relief ;  a  mustard  leaf  at  the  back  of  the 
neck  is  much  more  useful,  and  spinal  pain  or  discomfort  is  best 
treated  by  means  of  the  cold  or  tepid  douche.  Cardiac  discomfort 
is  often  relieved  by  a  plaster,  belladonna  or  any  other  variety, 
over  the  heart  region,  and  a  flannel  belt  is  often  most  useful  in 
relieving  abdominal  discomfort,  especially  if  the  patients,  as  is  not 
infrequently  the  case,  are  the  subjects  of  enteroptosis. 

To  the  sleeplessness  which  is  so  common  in  neurasthenia  much 
attention  must  be  given.  Sometimes  it  is  found  to  be  associated 
with  flatulence  and  dyspepsia,  and  the  diet  must  be  modified  and 


Neurasthenia.  1039 

intestinal  disinfectants  or  sedatives,  like  salol  and  bismuth,  given 
with  care  and  discrimination.  When  the  sleeplessness  is  of  the 
intra-nocturnal  variety,  i.e.,  occurring' after  a  period  of  sound  sleep 
and  followed  by  a  period  of  broken  and  unrefreshing  sleep,  it  can 
often  be  overcome  by  getting  the  patient  to  have  a  small  meal  of 
biscuit  and  milk  when  he  wakes  from  his  first  sleep.  The  solid 
part  of  this  meal  is  essential,  as  milk  alone  is  often  ineffective.  In 
many  cases  a  little  gentle  rubbing,  especially  to  the  head  and  the 
back  of  neck,  will  suffice  to  procure  sleep,  and  this  is  especially  true 
of  the  cases  in  which  sleep  is  difficult  to  obtain  in  the  first  part  of 
the  night.  Often,  however,  it  is  necessary  to  resort  to  sedatives, 
and  in  my  experience  the  most  effective  by  far  is  bromide.  I  have 
never  known  bromide  do  harm  in  these  cases  given,  if  necessary,  in 
£  drachm  or  even  a  whole  drachm  dose  at  bedtime,  sometimes 
alone,  sometimes  with  bicarbonate  of  soda,  sometimes  with  bismuth, 
and  usually  in  hot  milk  as  a  vehicle.  I  believe  that  to  many 
neurasthenics  a  nightly  dose  of  bromide  is  not  only  harmless 
but  distinctly  helpful.  Trional  may  occasionally  be  given,  and  in 
cases  in  which  the  sleeplessness  is  very  obstinate  the  combination 
of  trional  with  bromide  is  nearly  always  effective.  Opium  in  any 
form  is  to  be  avoided. 

In  cases  in  which  the  condition  of  neurasthenia  is  very  pro- 
nounced it  is  only  to  be  relieved  by  much  more  radical  measures. 
The  active  professional  or  business  man  who  finds  that  the  strain 
is  becoming  intolerable  must  be  ordered  away  at  once.  A  sea 
voyage,  if  it  is  fancied,  is  often  of  inestimable  use  if  it  is  undertaken 
in  suitable  conditions  and  with  congenial  companionship ;  a  quiet 
month  or  two  in  the  country  in  bracing  mountain  air,  involving  a 
complete  change  of  interest  and  environment,  are  often  sufficient 
to  effect  a  complete  cure.  Similarly,  to  the  often  thin,  anaemic, 
sleepless  housewife,  so  long  as  the  nervous  signs  are  not  very 
active,  a  complete  change  to  a  bracing  climate  with  fresh  air  and 
simple  abundant  food  will  often  work  wonders  and  effect  much 
more  than  many  drugs,  and  even  more  than  can  be  got  from  more 
elaborate  treatment.  Mountain  or  moorland  country  is  better  as  a 
rule  for  such  cases  than  seaside. 

It  will  be  seen  at  once  that  the  treatment  of  a  case  of 
neurasthenia  is  by  no  means  simple.  Each  case  is  a  problem  in 
itself,  although  there  are  broad  general  principles  underlying  the 
treatment  of  all.  Any  local  condition  must,  of  course,  be  attended 
to.  Dyspeptic  symptoms,  a  dragging  feeling  resulting  from  a 
floating  kidney,  and  actual  mucous  colitis,  are  not  infrequently 
present  in  association  with  neurasthenia,  especially  in  women,  and 


1040  Neurasthenia. 

undue  attention  may  be  concentrated  on  these  symptoms.  Appro- 
priate treatment,  both  medicinal  and  mechanical,  must  of  course 
be  adopted  in  such  cases.  In  the  cases  of  sexual  neurasthenia 
there  is  often  present  an  exaggerated  idea  of  the  bad  effect  of 
youthful  indiscretions,  and  the  physician  must  set  himself  to  dispel 
the  patient's  morbid  remorse  over  such  matters.  And  so  with 
other  symptoms ;  a  strenuous  effort  must  be  made  by  his  adviser 
to  get  the  patient  to  see  matters  in  their  real  relationship,  and  to 
dispel  the  distorted  view  of  them  which  he  has  pictured  for 
himself. 

In  severe  cases  of  neurasthenia  these  general  measures  are  not, 
however,  sufficient,  and  the  condition  of  the  patient,  her  aches  and 
pains,  her  disagreeable  faint  feelings,  her   general  weakness   and 
want  of  energy,  make  any  treatment  in  which  she  has  to  assume  an 
active  part  almost  impossible.     It  is  necessary  to  get  such  patients 
into  good  condition.     This  can  only  be  done  by  copious  feeding, 
yet  copious  feeding  when  exercise  cannot  be  taken  can  only  lead  to 
discomfort    and    actual    dyspepsia.       The    substitute    for    active 
exercise  is  to  be  found  in  passive  exercise  or  massage,  and  in  the 
use  of  a  mild  faradic  current,  which  will  cause  contraction  in  the 
muscles   without   pain  or  fatigue  to  the  patient.     The  massage, 
rubbing,   pinching  and  kneading  of  muscles,   so  as  to  cause  the 
fibres  to  contract  and  to  force  blood  through  them,  acts  by  leading 
to  such  changes  in  their  metabolism  and  in  that  of  the  organs 
generally,  as  are  produced   by  active  exercise.     And  the  same  is 
true  of  the  contractions   produced  by  faradism.     It   is   necessary 
to  describe  in  some  detail  the  conduct  of  a  case  under  this,  the 
Weir  Mitchell  method  of  treatment,  a   method  which,  although 
most  useful  as  a  rule  in  the  case  of  female  patients,  is  often  called 
for  and  successfully  used  in  the  case  of  males. 

It  is,  of  course,  essential  that  the  patient  should  be  separated 
from  her  friends,  and  in  the  great  majority  of  cases,  it  is  desirable 
to  have  her  in  a  nursing  home.  In  any  case  she  must  be  in 
the  hands  of  a  well-trained  capable  nurse,  who  is  kind,  firm, 
sympathetic,  but  unemotional.  All  letters  are  stopped,  absolute 
rest  in  bed  is  essential,  and  the  patient  is  not  allowed  to  leave  it 
for  any  purpose.  In  bad  cases  the  adoption  of  the  recumbent 
posture  even  during  meals  is  necessary  for  the  first  few  days  at 
least  and  even  for  longer. 

For  the  first  three  days,  no  food  except  milk  and  rusks  is  given. 
The  milk  should  be  given  in  quantities  of  4  oz.  every  two  hours 
at  first,  but  the  total  quantity  in  twenty-four  hours  should  be 
increased  to  2  quarts  by  the  end  of  three  days.  The  patient 


Neurasthenia.  1041 

should  not  be  waked  at  night,  but  her  milk  should  be  placed  by 
her  bed  so  that  she  may  drink  it  if  she  wakes.  After  three  days 
of  this  simple  diet,  a  small  morning  meal  should  be  given,  a  little 
fish  with  bread  and  butter,  and  bread  and  butter  with  milk  in  the 
evening.  Then  two  days  later,  i.e.,  on  the  fifth  day  of  treatment, 
a  cutlet  may  be  given  in  the  middle  of  the  day,  and  in  two  or  three 
days  more  three  light  meals  should  be  given  in  addition  to  the 
2  quarts  of  milk.  The  actual  composition  of  the  meals  can  be  left 
to  the  nurse,  but  it  may  be  of  service  to  indicate  the  kind  of  meal 
desirable,  e.g.,  fat  bacon  and  an  egg  in  the  morning,  a  chop  or 
cutlet  with  stewed  fruit  and  cream  in  the  middle  of  the  day,  and 
fish  with  butter  sauce  in  the  evening. 

Meantime  massage  is  given  twice  daily.  At  first,  twenty 
minutes  at  a  time  is  as  much  as  is  tolerable,  and  this  is  gradually 
increased  until  an  hour  is  given  twice  daily  in  the  course  of  the 
fifth  day.  The  faradic  current  is  now  to  be  used  for  a  quarter  of 
an  hour  twice  a  day,  and  this  need  not  be  increased.  At  the  end 
of  ten  days  raw  meat  juice  is  to  be  given,  an  ounce  daily.  If  it 
is  very  unpalatable  it  may  be  given  in  milk,  or  the  meat  may  be 
quickly  cooked  on  the  outside  and  the  juice  squeezed  out  of  it. 
Such  juice  from  half -cooked  meat  is  more  easily  taken  by  the 
majority  of  patients  than  the  actually  raw  meat  juice. 

Trouble  with  the  bowels  frequently  arises.  At  the  end  of  the 
third  day,  a  dose  of  calomel  is  desirable,  but  after  this  it  is  usually 
easy  to  regulate  the  bowels  with  fruit  and  butter  and  cream.  If 
this  is  insufficient  a  small  nightly  dose  of  cascara  and  nux  vomica 
should  be  given.  It  must  be  remembered  that  abdominal  massage 
is  very  efficacious  in  overcoming  even  chronic  constipation. 

Such  are  the  details  of  the  Weir-Mitchell  treatment,  and  in 
many  neurasthenic  cases  its  effects  are  both  striking  and  gratifying. 
Difficulties  are  encountered  in  most  cases,  the  patient  having  to 
be  persuaded  to  continue  the  treatment,  little  but  unessential 
points  in  detail  being  conceded.  But  this  can  be  done  so  long  as 
the  mind  is  steadily  fixed  upon  the  end  in  view,  and  everything 
arranged  accordingly.  It  must  be  remembered  that  one  is  dealing 
with  a  patient  whose  nutrition  has  suffered,  who  is  depressed  and 
ill,  and  who  possibly  has  distorted  views  and  morbid  imaginings, 
and  that  the  measures  adopted  are  aimed  at  enabling  her  to 
assimilate  much  food  of  the  most  simple  and  nourishing  character, 
and  so  to  increase  her  bodily  vigour  and  to  improve  the  nutrition 
of  her  nervous  system  that  she  may  throw  off  all  her  symptoms 
and  return  to  a  natural  useful  life. 

An    interesting    and   important   variety    of    neurasthenia   was 

S.T. — VOL.  ii.  66 


1042  Neurasthenia. 

described  some  years  ago  by  the  late  Sir  William  Gull,  under  the 
name  of  Anorexia  Nervosa.  This  may  develop  in  consequence  of 
overstrain  from  nursing,  etc.,  but  in  many  instances  no  such  cause 
can  be  traced.  The  subjects  of  it  are  usually  girls  between  the  age 
of  seventeen  and  twenty-five  (although  it  sometimes  occurs  later), 
often  with  a  keen  interest  in  some  particular  kind  of  work,  an 
interest  which  absorbs  them,  even  leading  to  carelessness  about  food. 
As  a  consequence,  meals  become  irregular,  there  is  no  compelling 
appetite,  and  gradually  and  almost  imperceptibly  the  patient 
wastes.  The  loss  of  appetite  grows,  food  becomes  positively  dis- 
tasteful, and  profound  emaciation  ensues.  The  patient  becomes 
nothing  more  than  a  living  skeleton,  and  seems  to  be  in  the  last 
stage  of  pulmonary  tuberculosis.  But  there  is  no  cough  and 
careful  examination  reveals  no  disease  of  any  of  the  organs.  Such 
a  patient  may  actually  die  from  weakness,  or  may  become  the  prey 
of  some  disease,  yet  if  taken  in  hand  and  treated  with  rest, 
abundant  feeding  and  massage,  a  most  gratifying  and  complete 
recovery  may  confidently  be  expected. 

In  reference  to  the  treatment  of  traumatic  neurasthenia  the 
same  general  principles  must  be  followed,  but  the  special  character 
of  the  illness  makes  it  desirable  to  add  a  few  particulars.  It  must 
in  the  first  place  be  recognised  that  the  condition  is  a  real  one, 
that  the  headache  and  feeling  of  weight  in  the  head,  the  severe 
backache,  with  actual  acute  pain  in  the  cervical  and  sacral  region, 
the  sleeplessness,  restlessness,  loss  of  sexual  power  and  other 
symptoms  so  familiar  in  cases  seen  in  the  courts  of  law,  are  real 
symptoms  and  occur  not  only  in  those  who  are  suing  for  damages, 
but  also  in  others  with  whom  such  a  question  has  never  arisen  at 
all.  In  all  such  cases  time,  as  a  rule,  effects  a  cure,  but  in  any 
particular  case  it  is  impossible  to  say  what  length  of  time  will  be 
adequate.  Complete  rest  of  body  and  mind  is  necessary,  and  it  is 
well  for  the  patient  to  get  away  from  home.  Treatment  will  be,  as 
a  rule,  symptomatic  ;  but  the  general  condition  of  the  patient  must 
be  kept  prominently  before  the  doctor  responsible  for  his  treat- 
ment. The  nutrition  must  be  attended  to  by  the  use  of  abundant 
easily  digested  meals.  Abundance  of  fresh  air,  the  adoption  of 
almost  a  sanatorium  regime,  is  also  desirable.  Tepid  or  cold 
douching  to  the  irritable  spine,  gentle  massage  to  the  head,  are 
measures  which  will  suggest  themselves  in  the  presence  of  appro- 
priate symptoms.  If  in  spite  of  all  such  measures  a  cure  is  still 
delayed  and  the  patient  remains  thin  and  anxious  and  sleepless, 
recourse  must  be  had  to  a  strict  Weir-Mitchell  course.  And  it 
should  also  be  remembered  that  in  those  cases  in  which  at  first 


Neurasthenia.  1043 

the  diagnosis  of  traumatic  neurasthenia  may  be  the  only  one 
possible,  symptoms  and  signs  may  develop  as  shown  by  the  reflexes 
and  the  state  of  the  sphincters,  which  prove  that  the  condition 
of  functional  derangement  has  become  associated  with  actual 
structural  changes  in  the  nervous  system. 

JAMES    TAYLOR. 


66—2 


1044 


PSYCHASTHENIA. 

BY  psychasthenia  is  to  be  understood  a  mental  condition  which 
is  characterised  broadly  by  deficient  control  over  thoughts  and  over 
actions,  to  use  the  technical  jargon,  by  loss  of  inhibition. 
Several  varieties  of  psychasthenia  may  be  distinguished.  Probably 
the  most  important,  because  the  commonest,  is  characterised  by 
morbid  and  unreasonable  fears  of  certain  conditions.  The  patient 
who  fears  to  cross  a  wide  deserted  space,  or  who  runs  at  once  if  he 
finds  himself  in  a  road  with  no  other  human  being  visible,  are 
victims  of  the  variety  of  psychasthenia  which  we  know  as 
agoraphobia.  In  this  variety  the  fear  is  not  invariably  of  vacant 
spaces  or  roads.  Sometimes  it  applies  also  to  spacious  places  like 
railway  stations  in  which  there  may  be  many  people  present ;  yet 
some  patients  are  unable  to  make  their  way  across  such  places 
unless  they  have  someone  with  them,  not  necessarily  in  actual 
contact. 

Another  class  of  psychasthenic  patients  suffer  in  a  way  ~ which 
is  almost  the  converse  of  this — they  cannot  be  in  closed  places,  in 
places  in  which  there  can  arise  any  difficulty  about  their  ability 
to  get  out  at  once.  Such  a  sufferer,  e.g.,  is  afraid  to  go  in  a  rail- 
way carriage.  If  he  does  go  it  may  cause  him  the  most  acute 
agony.  One  patient,  known  to  the  writer,  cannot  travel  in  an 
express  train  which  goes  long  distances  without  stopping.  He  must 
travel  in  a  stopping  train,  although  even  this  is  a  trying  experience. 
Many  dare  not  enter  a  train  at  all.  Probably  the  disorder  may  be 
regarded  as  of  a  slighter  variety  in  those  who  can  travel  in  an 
ordinary  train,  but  are  positively  afraid  to  do  so  in  a  "  tube."  A 
considerable  number  of  people  are  unable  to  go  to  a  church,  or 
theatre,  or  any  public  meeting,  because  of  this  fear  of  closed  places 
(claustrophobia),  and  among  church-goers  there  are  some  who  only 
dare  go  to  church  if  they  can  sit  in  the  seat  nearest  the  door. 

Another  form  which  these  morbid  fears  take  is  much  more 
vague,  the  fear  being  a  vague  horror  of  the  patient  knows  not 
what,  arising  suddenly  and  unexpectedly  and  almost  overwhelming 
him  with  dread.  To  such  a  patient  the  very  vagueness  of  the 
dread  gives  an  added  horror,  and  anyone  who  has  heard  such  a 
patient  describe  his  feelings  cannot  but  realise  the  extreme  mental 
pain  which  they  connote. 


Psychasthenia.  1045 

The  patient  who  comes  complaining  of  his  uncontrollable 
thoughts  is  really  of  the  same  class  of  psychasthenia  as  those 
already  described.  These  thoughts  of  which  he  complains  are 
usually  on  subjects  of  which  he  is  almost  ashamed  to  speak, 
thoughts  of  a  horrible  character  concerning  his  nearest  and 
dearest,  thoughts  of  himself  in  relation  to  others,  of  a  kind  which 
causes  him  acute  distress,  sometimes  but  not  always  sexual. 

In  another  class  of  patients,  also  mostly  women,  the  appearance 
of  anything  bright  or  sharp  carries  the  suggestion  that  such 
weapons  are  convenient  for  purposes  of  self -in  jury.  Even  knives 
on  a  table  may  suggest  such  an  idea,  the  unexpected  sight  of  a 
razor  nearly  always  produces  it,  and  similarly  looking  from  a 
height,  whether  a  high  building  or  a  precipice,  suggests  the 
temptation  to  throw  oneself  over.  Of  course,  in  the  psychasthenic 
patient  such  ideas  are  merely  uncontrolled  'thoughts  and  never 
eventuate  in  action,  and  they  are  to  be  sharply  distinguished  from 
homicidal  or  suicidal  impulses. 

Closely  related  to  these  is  the  variety  of  the  disorder  in  which 
the  patient,  often  a  pure-minded  virtuous  woman,  repeats  to  her- 
self the  most  horrible  language,  and  is  in  dread  lest  she  may 
repeat  it  aloud.  In  a  less  distressing  variety,  the  patient  simply 
tends  to  repeat  things,  things  usually  meaningless  and  perhaps 
foolish,  but  the  distress  caused  to  the  patient  is  by  the  fact  that  she 
cannot  help  repeating  these  things.  Nearly  allied  to  this  is  the 
condition  of  which  probably  Dr.  Samuel  Johnson  is  the  most 
notorious  example,  the  condition  in  which  in  doing  certain  things 
a  definite  way  of  doing  it  must  be  followed.  Dr.  Johnson,  as  is 
well  known,  had  to  touch  each  rail  as  he  passed  along  the  Fleet 
Street  railings,  and  was  compelled  to  go  back  if  he  missed  one ! 
Some  patients  also  are  uncertain  whether  they  have  locked  a  door 
which  they  intended  to  lock,  and  may  have  to  return  repeatedly  to 
see  whether  they  have;  they  may  suddenly  have  doubts  as  to 
whether  they  have  actually  posted  a  letter  which  they  have  taken 
to  the  pillar  box,  and  they  are  frequently  in  doubt  whether  in  a 
letter  which  they  have  closed,  they  have  not  said  exactly  the 
opposite  of  what  they  meant  to  say,  and  if  the  letter  has  not  been 
posted  it  has  to  be  opened  and  is  always  found  to  be  correctly 
expressed. 

Psychasthenia  also  includes  many  curious  psychoses.  The 
condition  of  cdiolalia,  as  it  is  called,  in  which  the  patient  repeats, 
like  an  echo,  everything  that  is  said  to  him.  The  condition  known 
as  myriachit  in  Siberia,  as  latah  in  Java,  characterised  by  the 
imitation  or  repetition  by  the  patient  of  every  action  carried  out 


1046  Psychasthenia. 

or  word  spoken  before  him,  are  all  examples  of  a  condition  in 
which  control  of  psychical  processes  is  lost.  And  practically  all 
the  other  so-called  "psychical  tics"  are  really  examples  of  a 
psychasthenic  condition. 

The  treatment  of  such  conditions  is  obviously  one  requiring 
skill  and  care  and  time.  Change  of  environment  is  of  the 
essence  of  successful  treatment,  and  the  persons  surrounding  a 
psychasthenic  patient  must  be  recognised  by  him  as  understanding 
his  condition  and  not  merely  laughing  at  it.  Patience  with  the 
apparent  unreasonableness  of  a  psychasthenic  patient  is  absolutely 
necessary ;  good  hygienic  surroundings  are  essential,  as  are 
guidance  and  moral  support  and  physical  companionship  under 
the  conditions  which  are  specially  trying  to  the  patient.  Some- 
times the  patient's  physical  condition  has  become  much  reduced 
in  consequence  of  the  anxiety  and  worry,  and  often  sleeplessness, 
attending  the  disorder.  Such  a  physical  state  must  be  treated  by 
measures  appropriate  to  the  relief  of  any  neurasthenic  condition, 
for  in  such  circumstances  one  is  dealing  with  a  condition  of 
neurasthenia  engrafted  on  one  of  psychasthenia.  Drugs,  except 
such  as  are  good  tonics,  e.g.,  strychnine,  phosphorus,  arsenic  and 
iron,  are  not  of  much  value,  but  these  should  be  given  freely,  and 
sedatives,  such  as  bromide,  are  of  much  value,  more  especially  in 
the  sleepless,  excitable  and  unstable  patient. 

Change  of  environment,  as  has  been  said,  is  most  important; 
good  and  constant  and  intelligent  companionship  is  just  as 
necessary,  and  complete  removal  from  work  is  essential.  A  long 
rest  is  often  necessary,  but  even  with  the  most  industrious  and 
intelligent  and  sympathetic  treatment  the  cure  in  many  cases  is 
an  imperfect  one,  although  in  not  a  few  instances  such  general 
treatment  as  has  been  suggested,  with  the  firm  reassurance 
received  from  a  trusted  medical  adviser,  will  result  in  complete 
cure,  or  at  least  in  very  great  amelioration  of  the  condition  (see 
also  p.  1314). 

JAMES  TAYLOR. 


1047 


TICS  AND  SPASMS. 

Facial  spasm,  in  its  various  forms,  is  one  of  the  commonest 
clonic  muscular  contractions  requiring  treatment.  The  well-known 
twitching  of  the  upper  or  lower  eyelid,  usually  of  one  eye  only, 
commonly  brought  on  by  fatigue  and  nervous  exhaustion,  and 
known  as  "  live  blood "  or  "  bird-in-the-eye,"  may  continue  for 
several  days  and  be  severe  enough  to  'Call  for  treatment.  A  long 
spell  of  sleep,  followed  by  a  day  of  mild  exercise  in  the  open  air, 
will  always  relieve  this,  but  often  immediate  cessation  of  the 
irritating  contractions  may  be  brought  about  by  applying  two  small 
round  electrodes  over  the  closed  eyelids  and  passing  a  mild  rapidly 
interrupted  faradic  current  for  a  couple  of  minutes.  Clonic 
blepharospasm  may  be  due  to  reflex  irritation  from  errors  of  refrac- 
tion, conjunctivitis,  carious  teeth,  etc.,  and  the  appropriate  treat- 
ment of  these  may  cure  the  spasm.  Direct  irritation  of  the  facial 
nerve  by  pressure  of  a  tumour  or  scar  tissue,  or  pachymeningitis, 
may  cause  clonic  facial  spasm  of  the  whole  muscular  distribution 
of  the  facial  nerve  on  one  side.  This  may  be  severe  and  frequent, 
and  when  chronic  may  be  arrested  either  by  stretching  the  facial 
nerve  or  by  deep  alcohol  injection  of  the  facial  nerve  at  its  exit 
from  the  stylo-mastoid  foramen.  This  causes  more  or  less  pro- 
nounced paresis  of  the  nerve,  and  the  cure  of  the  spasm  will  last 
from  three  to  twelve  months  or  longer.  Clonic  facial  spasm 
frequently  follows  incomplete  recovery  from  an  attack  of  facial 
paralysis  or  Bell's  palsy,  the  muscular  twitchings  being  combined 
with  excessive  contracture.  Facial  massage  in  the  slighter  cases 
and  alcohol  injection  of  the  stylo-mastoid  foramen  in  the  more 
severe  types  will  be  the  best  treatment.  Electricity  only  does  harm 
in  these  cases. 

Many  forms  of  partial  facial  spasm,  either  uni-lateral  or  bi-lateral, 
are  psychomotor  in  origin  —  a  convulsive  tic.  This  is  really  a 
gesticulatory  movement,  reflex  or  voluntary  in  its  origin,  but  by 
constant  repetition  becoming  imperative.  Often  associated  with 
other  signs  of  neuroses,  especially  hereditary,  it  must  be  treated  by 
inhibitory  exercises  before  a  mirror,  keeping  the  face  absolutely 
still  for  a  certain  number  of  seconds  or  minutes,  the  periods  being 
gradually  lengthened,  and  followed  by  rhythmic  facial  movements 
according  to  a  concerted  plan,  carried  out  slowly,  with  slow  relaxation. 


1048  Tics  and  Spasms. 

These  contortions  of  the  face  are  often  seen  in  children,  and 
this  treatment  can  be  considerably  aided  by  instituting  a  system  of 
small  rewards  for  lengthening  periods  of  complete  immunity  from 
the  spasm,  this  inducement  having  the  effect  of  producing  a  con- 
stant unconscious  inhibitory  tendency  in  the  patient's  mind.  Fear 
and  punishment  only  make  the  condition  worse.  What  has  been 
said  of  the  treatment  of  facial  tic  or  "  habit-spasm  "  applies  equally 
to  other  forms  of  convulsive  tic,  whose  variety  is  legion. 
Shoulder-shrugging,  sniffing,  scratching,  barking  cough,  and  many 
others  musb  be  treated  on  broad  lines,  having  regard  to  the  spas- 
modic movement  being  only  an  outward  expression  of  a  congenital 
neurosis,  the  particular  movement  often  being  curable  by  the 
above  method  of  inhibitory  exercises  before  a  mirror,  followed  by 
slow  gymnastic  exercises.  Echolalia  or  parrot-like  mimicry  of 
words  and  phrases  just  heard,  echokinesis  or  similar  mimicry  of 
movements  of  others,  and  coprolalia  or  impulsive  outpouring 
of  abusive  and  obscene  language,  are  also  forms  of  tic,  and  may  be 
combined  with  other  motor  tics,  such  as  torticollis.  Training  of 
the  deficient  will-power  and  encouragement  of  the  power  of  moral 
restraint  is  the  line  of  treatment. 

The  tics  show  a  marked  tendency  to  recurrence  under  the 
influence  of  nerve-strain,  or  to  reappear  in  another  form.  The 
weakness  of  will-power  characteristic  of  sufferers  from  tic  is  a 
strong  factor  in  the  persistence  of  the  movements.  Hypnotism  is 
useless  in  the  treatment  of  these  cases.  Self-abuse  in  children  and 
adolescents,  it  must  be  remembered,  is  an  exciting  cause. 

Trismus  may  be  reflex  from  carious  teeth,  or  it  may  be  purely 
hysterical,  though  care  must  be  taken  to  exclude  organic  causes, 
such  as  osteo-arthritis  of  the  temporo-maxillary  joint,  growths 
infiltrating  the  pterygoid  muscles,  tetanus,  etc.  Clonic  trismus  is 
always  functional,  and  often  wakes  the  patient  at  night,  the  teeth 
coming  together  with  a  snap,  sometimes  even  catching  the  tongue 
or  cheek.  Bromide  is  of  some  use  here  (in  20-gr.  doses  morning 
and  evening).  I  have  seen  this  form  combined  with  an  occupation 
neurosis  of  spasm  of  the  lips  in  a  cornet-player. 

Hiccough,  singultus,  or  spasm  of  the  diaphragm  may  be  due  to 
irritation  of  the  phrenic  nerve,  from  the  act  of  swallowing,  from  gastric 
disturbance,  or  reflexly  through  irritation  of  the  lower  bowel.  In 
obstinate  cases  it  may  continue  at  frequent  intervals  for  days,  and 
there  are  often  other  evidences  of  neurosis.  Two  of  the  most 
obstinate  cases  I  have  seen  occurred  in  men  suffering,  one  from 
progressive  muscular  atrophy,  the  other  from  pseudo-hypertrophic 
muscular  paralysis,  and  in  both  cases  strong  general  faradisrn 


Tics  and  Spasms.  1049 

arrested  the  hiccough.  Other  modes  of  treatment  are  making  the 
patient  hold  the  breath  for  long  intervals,  mustard  plasters  to  the 
epigastrium,  blisters,  etc. 

Myoclonus,  originally  described  by  Friedreich,  is  sometimes 
more  or  less  general,  and  is  often  functional  in  origin,  and  is  capable 
of  cure  by  prolonged  rest,  strychnine  injections  and  galvanic  baths. 
The  dose  of  strychnine  should  be  increased  gradually  by  1  minim 
every  other  day  until  T\y  gr.  is  given  twice  daily,  the  whole  course 
lasting  six  to  eight  weeks.  Other  cases,  especially  the  form 
associated  with  epilepsy,  are  inveterate. 

Hysterical  spasm  is  best  treated  by  moderately  strong  faradism, 
the  strength  of  current  being  graduated  according  to  the  depth  of 
the  anaesthesia  which  is  nearly  always  associated  with  it,  the 
patients  being  made  to  feel  the  current.  Suggestion  plays  an  im- 
portant part  in  this  treatment,  and  the  patient  must  be  encouraged 
and  told  she  is  certain  to  get  well.  If  the  spasm  has  existed  already 
for  years  it  is  much  more  resistant  to  treatment,  and  actual  organic 
contracture  may  be  produced. 

Spasm  of  muscles  is  also  met  with  in  the  occupation  neuroses, 
in  spastic  paralysis,  athetosis,  and  post-hemiplegic  chorea,  in  tetany 
and  tetanus,  from  toxic  causes,  as  strychnine  poisoning,  ergotism, 
pellagra  and  lathyrism.  It  is  met  with  in  the  leg  muscles  in 
anaemic  girls  and  in  lead  poisoning,  and  in  intermittent  claudica- 
tion.  Spasm  is  also  a  notable  feature  of  a  congenital  muscular 
condition,  Thomsen's  disease.  In  addition  to  the  obvious  treat- 
ment appropriate  to  these  several  conditions,  massage  is  the  most 
useful  form  of  local  treatment. 

WILFRED  HARRIS. 

REFERENCES. 

Meige,  H.,  and  Feindel,  E.,  "  Tics  et  leur  Traitement,"  English  translation, 
1907,  by  Wilson.  Oppenheim,  H.,  "  Text-book  of  Nervous  Diseases,"  5th  edit., 
English,  translation  by  Bruce,  Vol.  II.,  p.  1237. 


1050 


TORTICOLLIS. 

TORTICOLLIS  is  one  of  a  number  of  nervous  diseases  which  the 
investigations  of  the  last  decade  have  shown  to  possess  no  noso- 
graphical  specificity.  Morbid  processes  differing  widely  enough 
from  each  other  will,  if  their  incidence  is  on  the  neck  musculature, 
produce  forms  of  torticollis  apparently  identical  to  an  uneducated 
eye. 

The  following  description  is  based  on  the  important  studies  of 
Rene  Cruchet,  whose  definition  of  torticollis  is  "  spasmodic  or 
convulsive  movements,  tonic,  clonic  or  tonico-clonic,  intermittent 
in  character,  and  involving  the  muscles  of  the  neck." 

(1)  Neuralgic  Torticollis. — Accompanying  occipital  neuralgia 
are  torticollic  movements,  strictly  analogous  to  tic  douloureux  of 
the  face.     Should  the  convulsive  movements  continue  independently 
of  the  attacks  of  pain,  the  condition  becomes  one  of  habit  torticollis 
(see  below). 

Treatment  must  be  directed  to  the  neuralgia  primarily  (see  under 
Neuralgia).  It  may  be  remarked  here  that  subcutaneous  injections 
of  alcohol  are  often  valuable,  or  of  antipyrin  in  a  50  per  cent, 
solution  (Grandclement).  Just  as  tic  douloureux  of  the  face  entirely 
disappears  after  excision  of  the  Gasserian  ganglion,  it  has  occurred 
to  the  writer  that  in  suitable  cases  removal  of  the  posterior  root 
ganglia  of  the  upper  three  or  four  cervical  nerves,  or  division  of 
the  posterior  roots,  might  be  worth  trying. 

(2)  Professional  Torticollis. — This   type  of   torticollis   occurs 
only  at  the  moment  of  execution  of  a  given  functional  or  profes- 
sional act  which  concerns  the  muscles  of  the  neck ;  at  all  other 
times  the  movements  of  these  muscles  are  perfectly  normal.     The 
condition    is   similar    to   writer's    cramp,    and    not    infrequently 
complicates  that  neurosis.     If  the  movements  become  independent 
of  the  professional  act  they  may  pass  into   the   true   spasmodic 
type. 

The  ideal  treatment,  of  course,  would  be  the  prohibition  of  the 
movements  in  question,  but  this  obviously  is  not  often  acceptable 
to  the  patient  (see  under  Writer's  Cramp).  Massage,  galvanism, 
farado-galvanism,  are  worth  trying.  Dally  has  reported  a  cure  by 
resistance  exercises  to  the  sterno-mastoid,  coupled  with  treatment 
by  interrupted  galvanic  currents.  Duchenne  has  recorded  another 


Torticollis.  1051 

cure  by  continued  voluntary  contraction  of  the  antagonistic  muscles, 
aided  by  a  mechanical  device  for  continuing  their  contraction. 
Surgical  treatment  may  be  advisable,  but  only  if  the  condition  has 
become  typically  spasmodic  (see  below). 

(3)  Paralytic    Torticollis. — Facial    spasm    and     contracture 
secondary  to  facial  palsy  may  be  matched  by  a  paralytic  torticollis 
secondary  to  a  chill  or  traumatism,  or  infective  disease,  where  one 
or  more  muscles  of  the  neck  have  suffered  from  loss  of  function, 
often  unrecognised.     The  torticollis  is  rather  one  of  attitude  than  of 
movement,  and  is  usually  more  pronounced  when  the  patient  walks 
about  or  is  on  his  feet,  owing  to  the  bilateral  action  of  the  neck 
muscles  to  support  the  cephalic  extremity  on  the  vertebral  column. 
By  over-functioning  and  hypertrophy  of  the  non-paralysed  sterno- 
mastoid,    the    paralytic    torticollis    may   develop    into    the    true 
spasmodic  variety. 

Prolonged  electrical  and  massage  manipulation  of  the  affected 
muscles,  should  they  react  at  all,  is  the  best  treatment.  Sedative 
galvanism  to  the  over-functioning  muscles  should  be  added. 

This  variety  of  torticollis  is  somewhat  uncommon,  and  owing  to 
the  fact  that  some  muscles  are  already  very  weak,  if  not  paralysed, 
operative  interference  is  more  likely  to  cause  permanent  deformity 
than  in  the  spasmodic  variety. 

(4)  True     Spasmodic     Torticollis. — A    valuable    diagnostic 
criterion  of  this  type  is  that  the  inhibitory  influence  of  the  will 
on   its   phenomena   is'  practically   nil;   antagonistic   gestures   are 
frequently  if  not  constantly  inefficacious.     Hemispasm  of  the  neck 
of  this  type,  analogous  to  facial   spasm  and  possibly  neuritic  in 
origin,    sometimes,    at   least,   presents   the  characters   of  a   true 
spasm ;  the  whole  of  a  muscle  involved  does  not  necessarily  con- 
tract at  once  ;  the  contractions  may  be  fascicular ;  associated  move- 
ments are  common ;  the  platysma,  the  face,  the  muscles  of  the 
shoulder,  are   often  implicated ;   pain  and   aching   and   muscular 
tenderness  are  not  infrequent;  muscular   hypertrophy  is   almost 
inevitable.     The  condition  may  spread  to  trunk  and  arms.     It  is 
either  idiopathic  or  symptomatic,  arising  in  the  course  of  or  as  the 
sequel  to  various  diseases,  such  as  influenza,  rheumatism,  typhoid 
fever,  diphtheria,  malaria,  etc. ;  or  torticollis  of  the  types  already 
mentioned  may  become  truly  spasmodic  as  the  result  of  the  motor 
centres  concerned  being  constantly  stimulated  by  sensory  impulses 
from  the  contracting  muscles,  as  by  a  sort  of  vicious  circle. 

(a)  It  is  extremely  important  to  search  for  any  possible  source 
of  reflex  irritation,  the  existence  of  which  is  responsible  for  the 
spasms  being  maintained.  Rest  and  quiet  must  be  enjoined. 


1052  Torticollis. 

Sometimes  prolonged  rest  in  bed,  the  head  between  sand-bags, 
produces  excellent  results.  As  a  rule,  mechanical  devices  of  any 
sort  are  to  be  deprecated.  Sedative  galvanism  to  the  affected 
muscles  is  often  very  effective.  As  the  muscles  that  are  not 
involved  in  the  spasm  are  apt  to  weaken  from  relative  disuse,  it  is 
a  good  plan  to  treat  them  also  electrically.  Massage  and  move- 
ments, passive  or  resistive,  are  of  minor  value.  Sometimes  suspen- 
sion by  suitable  apparatus  may  assist  in  the  general  progress 
of  the  case  towards  recovery ;  by  itself  it  is  in  the  writer's  opinion 
comparatively  valueless,  and  also,  perhaps,  not  entirely  innocuous. 

(&)  Medicinal  treatment  by  every  conceivable  sedative  has  been 
tried  over  and  over  again ;  there  is  no  single  drug  that  can  be 
specifically  recommended.  At  one  time  continuous  chloral  drugging 
was  vaunted,  the  patient  remaining  mildly  delirious  for  days  at  a 
time,  but  its  advantages  do  not  outweigh  its  obvious  disadvantages. 
A  much  better  case  can  be  made  out  for  the  use  of  alcohol  injec- 
tions, which  have  been  beneficial  in  many  cases  of  facial  spasm. 
The  difficulty  is  to  reach  all  the  nerves  concerned,  for  the  deep 
posterior  rotators'  of  the  neck  are  commonly  in  action  with  the 
sterno-mastoid.  Counter-irritation  by  blisters,  cautery,  embroca- 
tions, liniments,  etc.,  is  not  of  much  avail. 

(c)  In  true  spasmodic  cases  surgical  treatment  is  more  likely  to 
prove  satisfactory.  The  writer  has  seen  a  fair  number  of  cases 
where  the  results  have  been  good,  and  sometimes  exceedingly  good. 
But  only  the  complete  Keene-Stirling  operation,  viz.,  spinal  acces- 
sory on  one  side  and  posterior  primary  divisions  of  first,  second, 
third,  and  perhaps  fourth  cervical  roots  on  the  opposite  side,  can 
be  considered  "  radical  "  ;  anything  less  than  this  is  almost  certain 
to  be  disappointing.  Nor  is  the  operation  one  to  be  lightly  entered 
on  without  a  serious  and  detailed  scrutiny  of  the  exact  site  of  the 
spasm,  for  many  cases  of  spasmodic  torticollis  show  an  inclination 
of  the  head  to  one  side,  coupled  with  its  rotation  to  the  other,  and 
the  result  of  surgical  interference  is  sometimes  aggravation  of  the 
inclination. 

(5)  Rhythmic  Torticollis. — This  is  a  large  clinical  group  com- 
prising spasmus  nutans,  eclampsia  nutans,  hysterical  tremors,  the 
rhythmical  movements  of  idiocy  and  epilepsy,  toxaemias,  such  as 
alcoholism,  tetanus,  erysipelas,  meningitis,  etc. 

Treatment  must  be  directed  to  the  affection  determining  the 
condition. 

(6)  Tics  of  the  Neck  and  Mental  Torticollis.— Little  need  be 
said  of  these  here,  as  the  subject  is  fully  referred  to  elsewhere. 
Their   treatment    is    often    eminently   satisfactory;  on   the   other 


Torticollis.  1053 

hand,  the  muscular  expression  of  an  innate  neuropathic  diathesis 
may  be  "  cured  "  in  one  region  and  reappear  in  another.  Surgical 
treatment  of  a  true  mental  torticollis  is  as  illogical  as  operation 
in  a  case  of  stammering.  Probably,  however,  the  category  of 
"  psychical "  cases  has  been  unjustifiably  enlarged.  As  Fere  said, 
a  psychical  theory  has  the  immense  advantage  of  dispensing  with 
every  effort  in  search  of  a  physical  cause,  but  it  has  the  disadvantage 
of  destroying  all  chances  of  finding  it. 

S.  A.  KINNIER  WILSON. 


KEFEKENCES. 

Eene  Cruchet,  "Traite  des  Torticolis  Spasmodiques,"  Paris  (Masson),  1907. 
Meige   and  Feindel,    "Tics   and  their  Treatment,"  translated  by  S.  A.  K. 
Wilson,  London  (Appleton),  1907. 


1054 


GENERAL    DISEASES    OF    THE    NERVOUS 

SYSTEM, 

AMYOTROPHIC    LATERAL    SCLEROSIS. 

THE  question  whether  amyotrophic  lateral  sclerosis  and  pro- 
gressive muscular  atrophy  are  pathologically  identical  is  still  vexed. 
However  this  may  be,  from  the  therapeutic  aspect  there  is  little,  if 
any,  distinction  to  be  drawn.  The  reader  is  therefore  referred  to 
the  article  on  Progressive  Muscular  Atrophy. 

It  may  be  remarked  here  that  cases  of  amyotrophic  lateral 
sclerosis  may  exhibit  spasticity  of  the  extremities  in  varying 
degree,  and  where  this  condition  is  at  all  prominent  electrical 
treatment  is  not  desirable.  Massage,  and  in  particular  passive 
movements,  are  preferable  (see  Paraplegia). 

Many  cases  of  amyotrophic  lateral  sclerosis  are  associated  with 
bulbar  palsy,  or,  more  correctly,  the  pathological  changes  charac- 
teristic of  the  disease  may  be  found  in  the  pontine  and  bulbar  nuclei 
as  well  as  in  the  spinal  cord;  sometimes  bulbar  symptoms  occur  at 
the  outset  (see  Bulbar  Palsy). 

S.  A.  KINNIER  WILSON. 


ACUTE    ANTERIOR    POLIO-MYELITIS. 

THE  possibility  that  a  febrile  attack  in  childhood  may  depend  on 
acute  anterior  polio-uiyelitis  should  always  be  borne  in  mind. 
When  this  disease  is  present  it  will  be  noticed  that  the  child  is 
content  to  lie  in  bed,  and  does  not  cry  to  be  taken  on  its  mother's 
knee  as  young  children  do  when  suffering  from  ordinary  ailments, 
and  that  there  is  immobility  of  one  or  more  limbs  In  such  a  case, 
that  is,  when  a  febrile  attack  is  associated  with  paralysis,  rest  in 
bed  should  not  terminate  with  the  cessation  of  fever,  but  should  be 
continued  for  at  least  three  weeks  after  the  temperature  has  become 
normal,  in  order  that  inflammatory  changes  in  the  cord  may  have 
time  to  subside.  It  is  better  for  the  child  to  lie  on  its  side  or  on  its' 
face  than  on  its  back,  but  it  is  not  desirable  to  insist  on  any 
position  which  causes  distress.  The  bowels  should  be  evacuated 
by  calomel,  castor-oil  or  liquorice  powder,  or  by  a  soap  enema,  or  a 
glycerine  suppository. 

During  the  pyrexial  stage  the  patient  should  keep  to  liquid  food, 
and  small  doses  of  aconite  or  salicin  may  be  given  every  four  hours. 
Sometimes  severe  pain  is  present ;  usually  this  is  much  relieved  by 
placing  the  patient  on  a  water-bed  and  wrapping  the  limbs  in 
cotton-wool.  Small  doses  of  phenacetin  or  antipyrine  may  be 
required ;  occasionally  an  opiate  is  necessary.  Mild  counter- 
irritation  to  the  spine,  by  the  application  of  warm  fomentations  or  of 
poultices,  made  with  one  part  of  mustard  and  three  parts  of  linseed 
meal,  has  probably  a  beneficial  influence  over  the  disease ;  it  will  at 
least  ease  any  pain  in  the  back  and  lessen  the  rigidity  of  its  muscles 
which  is  occasionally  present.  If  the  patient  suffers  from  severe 
headache  which  is  not  relieved  by  ordinary  remedies,  the  question 
of  the  withdrawal  of  a  small  quantity  of  cerebro-spinal  fluid  by 
lumbar  puncture  may  be  considered.  Convulsions  which  occur  in 
some  cases  require  the  administration  of  sodium  or  potassium 
bromide.  Attention  must  be  paid  to  the  condition  of  the  bladder, 
for  sometimes  there  are  signs  of  retention ;  the  use  of  the  catheter 
then  becomes  necessary. 

When  the  muscles  of  the  thorax  are  involved,  great  care  should 


1056  Acute  Anterior  Polio-Myelitis. 

be  taken  to  prevent  the  risk  of  bronchitis  or  of  pulmonary  com- 
plications. Embarrassed  breathing  may  be  relieved  by  inhalations 
of  oxygen.  If  life  is  threatened,  artificial  respiration  should  be 
performed  in  the  hope  that  the  wave  of  respiratory  paralysis  may 
subside.  Starr  points  out  that  "  since  it  has  been  shown  by 
Flexner  and  Lewis  that  the  virus  of  epidemic  polio-myelitis  is 
eliminated  by  the  naso-pharyngeal  mucosa,  the  secretions  of  the 
nasal  and  buccal  cavities  should  be  disinfected  and  destroyed." 

When  the  acute  stage  has  subsided  there  is  often  much 
prostration ;  the  greatest  care  is  then  needed  to  ensure  complete 
rest  to  the  patient,  and  to  protect  him  from  excitement  or  other 
form  of  disturbance. 

Gentle  massage  of  the  paralysed  parts  may  be  commenced  at  the 
end  of  the  first  week,  but  it  is  advisable  to  postpone  electrical  treat- 
ment for  four  or  five  weeks  in  order  that  rest,  so  essential  during 
the  early  period  of  the  disease,  is  not  interfered  with.  At  first 
massage  should  be  very  gentle,  and  performed  only  once  a  day ;  but  as 
soon  as  the  patient's  general  condition  is  satisfactory  the  flaccid 
wasted  muscles  should  be  rubbed  and  kneaded  at  least  twice  daily, 
and  with  sufficient  force  to  stimulate  the  circulation,  in  the  hope 
that  an  increased  flow  of  blood  and  lymph  will  promote  nutrition 
in  the  affected  part.  The  circulation  of  a  paralysed  limb  is  also 
improved  by  daily  sponging  in  warm  salt  water,  followed  by  brisk 
rubbing,  and  afterwards  keeping  the  limb  warm  by  cotton-wool  or 
extra  flannel  clothing.  Starr  recommends  a  warm  bath  of  about 
99°  F.,  in  which  the  child  is  allowed  to  play  for  half  an  hour  twice 
a  day ;  this  is  followed  by  sponging  in  cool,  but  not  cold,  water. 

Passive  movements  are  also  of  great  benefit,  and  the  patient 
should  be  encouraged  to  put  forth  as  much  voluntary  powrer  as 
possible,  making  constant  efforts  to  move  the  weakened  limb. 
He  should  also  be  told  to  move  the  healthy  limb  against 
resistance  offered  by  the  attendant,  for  in  this  way  movements  are 
sometimes  excited  in  the  paralysed  limb.  As  soon  as  any  voluntary 
power  is  regained  it  is  desirable  to  institute  a  course  of  muscular 
exercises  ;  a  well-selected  series  of  movements  should  be  prescribed, 
and  much  attention  given  to  their  proper  performance. 

Electricity,  although  less  valuable  than  massage,  is  an  important 
agent  in  the  treatment  of  infantile  paralysis.  It  is  highly  improb- 
able that  its  application  to  the  spine  can  have  any  effect  on  the 
cord  lesion,  but  there  is  satisfactory  evidence  that  its  application  to 
the  paralysed  muscles  is  of  service.  It  must  be  remembered  that  in 
a  localised  polio-myelitis  all  the  cells  are  not  completely  destroyed, 
some  are  only  damaged,  whilst  others  possibly  have  escaped 


Acute  Anterior  Polio-Myelitis.  1057 

altogether.  Now,  electricity  is  powerless  to  restore  muscular  tissue, 
the  nerve-supply  of  which  is  destroyed,  but  it  can  stimulate 
muscular  tissue  which  is  supplied  by  cells  and  fibres  only  partially 
damaged ;  by  causing  the  muscle  to  contract,  electricity  exercises  it, 
and  thus  helps  to  promote  its  nutrition  and  growth,  and  so  prepares 
it  to  react  to  voluntary  stimuli  should  the  cells  in  the  anterior 
horns  ever  regain  their  functions. 

In  infantile  paralysis  it  will  be  found  that  a  certain  number  of 
muscles  respond  to  faradism ;  these  muscles  will  ultimately 
recover,  and  their  recovery  may  be  hastened  by  the  application  of 
either  the  faradic  or  the  galvanic  current.  Many  of  the  muscles, 
however,  do  not  react  to  faradism,  and  then  galvanism  is  alone  of 
service.  Either  form  of  current  may  be  applied  directly  to  the 
paralysed  muscles. 

In  the  case  of  galvanism  it  is  convenient  to  apply  one  large  flat 
electrode,  well  soaked  in  salt  water,  to  the  chest  or  back,  whilst  the 
other,  a  small  one,  similarly  moistened,  is  stroked  over  the  affected 
muscles.  The  stroking  or  treatment  electrode  should  be  the  pole, 
negative  or  positive,  which  causes  the  most  active  contraction.  It 
must  be  lifted  from  the  skin  after  each  stroke,  for  the  muscle  only 
contracts  when  the  current  is  broken.  Another  method  of  inter- 
rupting the  current  is  by  means  of  a  make-and-break  key  attached 
to  the  treatment  electrode.  The  weakest  current  that  will  cause  a 
contraction  should  be  used,  and  in  order  to  avoid  frightening  the 
child  it  is  desirable  to  make  several  applications  of  the  electrodes 
when  no  current  is  passing.  By  this  means  the  child  becomes 
accustomed  to  the  apparatus  and  its  confidence  is  gained.  After 
such  applications  have  been  made  for  a  few  days  a  very  weak 
current  may  be  used,  and  daily  strengthened  until  a  definite  con- 
traction is  elicited.  Each  muscle  should  be  thus  treated  for  a  few 
minutes  twice  a  day  for  at  least  a  year.  If  satisfactory  contractions 
are  not  obtained,  the  method  of  alternately  reversing  the  current 
may  be  tried.  Two  flat  electrodes  are  fastened  to  the  affected  limb 
and  the  current  is  rapidly  reversed  by  the  pole-changer  in  the 
battery.  A  convenient  method  of  applying  galvanism  to  the  lower 
limbs  is  to  place  each  foot  in  a  separate  bath  containing  warm 
water,  with  the  positive  electrode  in  one  bath  and  the  negative  in 
the  other. 

Too  much  stress  cannot  be  laid  on  the  importance  of  persevering 
with  massage,  electricity  and  active  and  passive  movements  of  the 
affected  parts.  It  is  astonishing  how  much  restoration  of  power 
may  often  be  effected  in  a  limb  which  at  first  seemed  hopelessly 
paralysed. 

S.T. — VOL.  u.  67 


1058  Acute  Anterior  Polio-Myelitis. 

During  the  treatment  great  attention  should  be  paid  to  the  position 
of  the  limb,  in  order  to  check  as  far  as  possible  the  development  of 
deformities.  For  example,  if  the  lower  limb  is  paralysed  the 
patient  should  not  lie  in  bed  with  the  knee  and  hip  flexed  ;  if  the 
dorsi-flexors  of  the  ankle  are  paralysed,  the  dropped  foot  should  be 
protected  by  a  cradle  from  the  weight  of  the  bedclothes,  and  it  may 
be  advisable  to  support  the  foot  at  a  right  angle  to  the  leg  by  means 
of  an  artificial  muscle.  The  counteraction  of  other  abnormal  devia- 
tions may  usually  be  accomplished  by  the  exercise  of  care  and 
practical  ingenuity. 

It  is  doubtful  whether  any  medicine  has  an  influence  over  the 
morbid  process.  In  some  cases  strychnine  has  seemed  to  be 
beneficial ;  it  should  be  given  at  first  in  doses  of  -^^  gr.,  the 
amount  being  gradually  increased  until  ^  gr.  is  taken  twice  or 
thrice  daily.  It  is  advisable  to  intermit  the  drug  from  time  to 
time ;  thus  to  have  an  interval  of  three  or  four  days  between  each 
week  in  which  the  drug  is  taken  daily.  General  tonics,  such  as 
iron,  quinine,  or  arsenic  and  cod-liver  oil,  are  also  useful. 

When  after  prolonged  treatment  there  is  no  hope  of  further  im- 
provement the  skill  of  the  orthopaedic  surgeon  is  required  to  correct 
deformities,  to  support  loose  joints,  and  in  other  ways  to  minimise 
the  effects  of  paralysis.  Various  mechanical  appliances,  tenotomy, 
re-section  of  joints,  tendon  transplanting,  nerve  grafting,  and  even 
amputation  are  measures  which  have  to  be  considered  in  different 
cases. 

JUDSON  S.  BURY. 


1059 


INFANTILE   PARALYSIS,  NERVE   ANASTOMOSIS  IN. 

THE  success  which  followed  the  employment  of  anastomosis  in 
nerve  injuries  turned  the  attention  of  surgeons  to  the  possibility  of 
its  employment  in  cases  of  paralysis  due  to  lesions  of  the  central 
nervous  system,  particularly  in  that  form  due  to  acute  anterior 
poliomyelitis  or  infantile  paralysis. 

The  scope  of  the  operation  is  limited,  but  in  suitable  cases  improve- 
ment results  and  almost  complete  restoration  of  function  has 
occurred.  In  1906  I  published  the  results  of  sixteen  cases,  including 
three  of  my  own.  Out  of  fourteen  cases  reported  sufficiently  long  after 
operation  to  admit  of  recovery,  power  was  restored  to  some  extent 
in  each  and  in  two  the  recovery  was  good.  Since  then  I  have 
operated  on  seven  further  cases,  making  ten  in  all.  In  two,  in 
which  the  external  popliteal  group  were  paralysed,  almost  perfect 
recovery  has  ensued.  Had  treatment  been  faithfully  carried  out 
after  the  operation  I  believe  recovery  would  have  been  perfect.  In 
two  cases  of  Erb's  paralysis,  in  which  the  fifth  cervical  nerve 
was  anastomosed  to  the  sixth,  slight  recovery  ensued,  but  not 
sufficient  to  be  of  value.  In  one  case,  in  which  the  anterior 
tibial  nerve  was  anastomosed  to  the  musculo-cutaneous,  the  muscles 
regained  faradic  irritability,  but  return  of  voluntary  power  was 
very  slight.  The  results  obtained  have  not  been  so  encouraging 
in  all  cases ;  thus  Warrington  and  Murray  have  written  on  "  The 
Failure  of  Nerve  Anastomosis  in  Infantile  Palsy,"  based  on  five 
personal  cases,  in  none  of  which  did  any  improvement  result.  The 
improvement,  however,  which  has  so  far  resulted  in  certain  of  my 
own  cases,  and  in  those  recorded  by  Mr.  A.  H.  Tubby  and  others, 
is  such  that  the  operation  has  a  definite  place  in  the  treatment  of 
this  condition. 

Certain  rules  may  be  laid  down  in  the  choice  of  cases.  The 
operation  must  never  be  undertaken  until  six  months  have 
elapsed  since  the  date  of  onset  of  the  disease  and  the  patient 
has  had  thorough  treatment  for  at  least  three  months  by  massage  and 
galvanism,  the  paralysed  muscles  being  maintained  relaxed  by  suit- 
able apparatus.  It  is  indicated  when  single  muscles,  such  as 
soleus  or  gastrocnemius,  or  a  group  supplied  by  a  single  nerve, 
such  as  the  external  popliteal,  are  affected,  or  in  cases  of  Erb's 
paralysis. 

67—2 


1060      Infantile  Paralysis,   Nerve  Anastomosis  in. 

The  nerve  of  supply  to  the  affected  muscles  must  be  completely 
divided  and  anastomosed  to  a  neighbouring  sound  nerve.  In  the 
cases  of  small  nerves,  such  as  those  supplying  the  soleus  and 
gastrocnemius,  it  is  enough  to  insert  them  in  transverse  slits  in  the 
external  popliteal.  When  a  larger  nerve  is  divided  it  should  be 
united  end  to  end  with  a  flap  raised  from  the  sound  nerve. 
Suture  material  must  be  absorbable  and  the  junction  surrounded 
with  membrane.  The  time  at  which  the  first  sign  of  recovery  is  seen 
depends  on  the  distance  to  be  traversed  by  the  new  nerve  fibres. 
In  the  cases  of  the  nerves  supplying  the  soleus  and  gastrocnemius 
the  distance  is  short  and  signs  of  recovery  should  be  present  in 
three  to  six  months  ;  in  the  external  popliteal  and  brachial  plexus 
in  from  eighteen  months  to  two  years.  Treatment  after  operation 
must  be  prolonged,  and  so  soon  as  voluntary  power  returns  to  a 
muscle  exercises  must  be  instituted  and  persevered  in  to  obtain 
co-ordinate  movements.  If  treatment  is  carried  out  on  these  lines 
considerable  improvement  may  be  anticipated. 

JAMES  SHERREN- 


io6i 


BULBAR  PALSY. 

BULBAR  PALSY  may  be  either  acute  or  progressive. 

(1)  Acute  bulbar  palsy  is  the  result  of  thrombosis  of  one  or  other 
of  the  bulbar  blood-vessels,  viz.,  vertebral  or  basilar  artery,  or  of 
branches,  e.g.,  usually  the  posterior  inferior  cerebellar.     In  such 
cases   suitable   treatment   on   the   lines   suggested   elsewhere   (see 
Thrombosis)  must  be  adopted  without  delay. 

It  may  also  arise  from  intoxication  by  a  virus  no  doubt  analogous 
to  that  of  acute  poliomyelitis,  so-called  polioencephalitis  inferior. 
In  cases  of  this  description  treatment  as  for  poliomyelitis  must  be 
pursued. 

In  hemiplegia  a  second  stroke  on  the  side  opposite  to  the  one  first 
affected  may  occasion  a  "  pseudo-bulbar  palsy  "  of  an  acute  type, 
owing  to  supranuclear  interference  with  the  motor  fibres  supplying 
bulbar  nuclei.  Clinically  the  condition  intimately  resembles  bulbar 
palsy,  although  the  pathological  lesion  is  different.  Treatment  of 
pseudo-bulbar  paralysis  is  that  of  the  underlying  pathological  state, 
which  is  usually  vascular  and  thrombotic. 

For  the  above-mentioned  types  of  bulbar  paralysis,  in  addition 
to  specific  measures,  treatment  on  general  therapeutic  principles, 
to  be  described  below,  ought  to  be  followed  out. 

(2)  Progressive  bulbar  palsy  is  a  disease  that  forms  part  of 
the  clinical  picture  of  amyotrophic  lateral  sclerosis  (q.v.),  though 
it  may  occur  by  itself.     Bulbar  palsy  is  unfortunately  a  therapeutic 
bete  noire.     No  drug  is  known  to  exercise  an  arresting,  still  less  a 
curative,  action  on  the  malady.     Injections  of  strychnine,    how- 
ever, are  supposed  to  be  of  value.     Local  electrical  treatment  (sterno- 
hyoids,  sterno-thyroids,  tongue,  orbicular  facial  muscles)  may  be 
persevered  with. 

The  following  general  principles  may  serve  to  guide  those  who 
have  cases  under  their  care. 

It  is  apt  to  go  very  hard  with  bulbar  cases  should  any  inter- 
current  condition  arise,  especially  one  which  affects  the  air-passages 
and  respiratory  system.  Hence  all  exposure  to  chill  or  cold  must 
be  avoided.  Exertion  or  strain,  similarly,  must  be  prevented. 
The  patients  should  seek  a  quiet  existence  in  an  equable 
temperature. 

The   process  of   feeding  must   be   taken   seriously.     Inhalation 


1062  Bulbar  Palsy. 

pneumonia  is  more  than  a  merely  hypothetical  complication.  The 
risk  of  exhaustion  from  a  bout  of  coughing  produced  by  inspiration 
of  food  particles,  or  of  choking  during  a  meal,  is  a  very  real  one. 
Some  patients  experience  difficulty  in  swallowing  fluids,  others  in 
swallowing  solids.  Nasal  feeding  may  have  to  be  resorted  to.  An 
excellent  substance  to  lubricate  the  tube,  which  is  of  soft  rubber,  is- 
fresh  butter.  Where  milk  forms  the  staple  constituent  of  the  nasal 
feed,  it  is  a  good  plan  to  add  sodium  phosphate  (20  gr.)  to  it. 

A  rigorous  oral  toilette  is  called  for,  otherwise  unswallowed 
particles  float  about  the  buccal  cavity  and  sepsis  is  inevitable. 
The  mouth  should  be  frequently  washed  out  with  boiled  water. 
Abrahams  gives  a  most  valuable  mouth  wash  as  follows:  Thymol, 
3  gr. ;  acidi  benzoici,  6£  drachms  ;  tineturae  eucalypti,  2^  drachms  ; 
aquae  destillatse,  1  pint.  This  may  be  used  immediately  after 
meals  and  at  other  times. 

Sialorrhcea  (whether  mechanical  or  vital)  may  be  checked  with 
atropine  or  belladonna,  or  by  opium,  in  pill  or  liquid  form,  or 
hypodermically,  according  to  circumstances.  Sometimes,  however, 
all  these  remedies  prove  unsatisfactory.  Potassium  chlorate  has 
been  recommended  for  the  same  purpose. 


S.  A.  KINNIER  WILSON. 


KEFERENCE. 


Beevor,  C.  E.,  and  Batten,  F.  E.,  article  in  "  Allbutt's  System  of  Medicine," 
2nd  edition,  1910,  VII.,  p.  716  (bibliography). 


1063 


CEREBRO-SPINAL  SYPHILIS. 

ALTHOUGH  cerebro-spinal  syphilis  cannot,  strictly  speaking,  be 
called  a  disease,  with  a  definite  symptomatology  and  a  recognised 
course,  yet  it  is  convenient  to  describe  under  this  title  the  treatment 
of  a  frequent  and  important  condition  manifested  by  a  large  variety 
of  symptoms.  In  one  case  a  paraplegia,  in  another  a  hemiplegia, 
and  in  a  third  some  form  of  ophthalmoplegia  may  constitute  the 
obvious  evidence  of  disease,  but  the  treatment  of  all  three  cases 
will  in  its  most  essential  feature  be  the  same  owing  to  their 
common  etiological  factor.  It  is  equally  true  that  the  exact  nature 
of  the  pathological  process  may  present  considerable  variations ; 
for  instance  a  gummatous  neoplasm,  a  gummatous  meningitis,  or 
thrombosis  of  an  artery  which  is  the  seat  of  syphilitic  changes  may, 
in  different  instances,  be  responsible  for  the  clinical  picture  or  may 
be  associated  in  the  case  of  one  person.  Each  morbid  condition 
may  be  found  either  in  the  brain  or  in  the  spinal  cord,  and  their 
concurrence  anywhere  in  the  central  nervous  system  is  notoriously 
frequent.  This  is  important  to  bear  in  mind,  because  once  the 
brain  or  spinal  cord  has  been  the  seat  of  a  syphilitic  lesion  recur- 
rences are  liable  to  occur  and  one  of  the  main  objects  of  treatment 
will  be  their  prevention.  When  a  man  has  suffered  from  an 
ophthalmoplegia  due  to  gummatous  meningitis  involving  a  third 
nerve,  the  next  manifestation  of  the  disease  is  as  likely  to  be  a 
hemiplegia  secondary  to  thrombosis  of  a  middle  cerebral  artery  or 
paraplegia  due  to  syphilitic  myelitis  as  any  local  recrudescence  of 
the  initial  trouble.  The  aim  of  prophylaxis  must  therefore  be  to 
strengthen  the  defences  of  the  nervous  system  as  a  whole  rather 
than  to  patch  up  a  spot  in  its  armour  which  is  known  to  be  weak. 

It  will  be  convenient  to  discuss  the  subject  of  general  treatment 
under  the  headings  "prophylaxis"  and  "anti-syphilitic  therapy" 
and  then  to  take  into  consideration  some  special  forms  of  the 
disease  which  may  require  special  measures  in  their  management. 

Prophylaxis. — The  prophylaxis  of  cerebro-spinal  syphilis  has 
only  to  be  considered  in  persons  who  have  contracted  syphilis.  It 
has,  however,  to  be  considered  in  regard  to  all  such  persons,  because 
we  have  no  means  of  ascertaining  when  or  whether  a  syphilised 
individual  has  been  cured  of  his  disease.  Variations  in  individual 
susceptibility  and  in  the  virulence  of  infection  as  well  as  in  the 


1064  Cerebro-Spinal  Syphilis. 

ability  to  tolerate  treatment  are  probably  largely  responsible  for 
this  difficulty.  A  year's  mercurial  treatment  may  doubtless  per- 
manently eradicate  the  disease  in  some  persons,  but  it  is  impossible 
to  distinguish  such  persons  from  others  who  appear  to  be  equally 
well  after  a  similar  course  and  who  yet  develop  syphilitic  lesions 
two,  five,  ten  or  twenty  years  after  their  primary  chancre.  It 
cannot  be  said  that  the  Wassermann  test  affords  much  assistance  in 
solving  this  problem,  because,  although  a  positive  reaction  may  be 
replaced  by  a  negative  reaction  as  the  result  of  a  course  of  treat- 
ment, the  positive  reaction  may  reappear  six  months  later.  More- 
over, it  is  not  proved  that  an  attitude  of  inactivity  is  a  perfectly  safe 
one  for  a  medical  man  to  adopt  so  long  as  he  is  faced  by  a  negative 
Wassermann  reaction  in  his  patients.  Experience  teaches  us  that 
the  ideal  treatment  of  a  syphilised  person  is  periodical  recourse  to 
mercury  for  an  indefinite  length  of  time,  the  frequency  with  which 
courses  of  the  drug  are  administered  being  regulated  more  or  less, 
but  not  too  dogmatically,  by  the  information  gained  by  the 
Wassermann  test. 

This  is  not  the  place  to  describe  in  detail  the  measures  which 
should  be  adopted  to  prevent  a  syphilised  person  from  developing 
tertiary  lesions  such  as  those  of  cerebro-spinal.  syphilis.  In  the 
first  place,  the  prophylactic  treatment  of  cerebro-spinal  syphilis  is 
the  remedial  treatment  of  syphilis,  and  the  latter  is  fully  discussed 
in  the  article  devoted  to  it.  In  the  second  place,  it  is  necessary  to 
refer  to  the  administration  of  anti-syphilitic  remedies  when  dealing 
with  the  immediate  treatment  of  cerebro-spinal  syphilis.  In  the 
third  place,  this  article  is  being  written  at  a  time  when  reports  from 
all  over  the  world  are  tending  to  show  that  a  new  preparation 
discovered  by  Ehrlich  is  likely  to  revolutionise  the  treatment  of 
syphilis  and  to  make  it  necessary  to  modify  what  has  been  written 
above.  Even  if  allowance  is  made  for  the  natural  enthusiasm  with 
which  a  new  discovery  is  welcomed,  much  is  to  be  hoped  for  from 
Ehrlich's  "606"  remedy,  and  if  time  shows  that  its  administration 
is  successful  in  eradicating  syphilis  from  the  system  the  indefinite 
prolongation  of  mercurial  treatment  will  be  rendered  quite  unneces- 
sary and  an  incalculable  boon  conferred  on  mankind  in  general. 

Apart  from  the  medicinal  element  in  the  prophylaxis  of  cerebro- 
spinal  syphilis  there  is  not  very  much  to  be  done,  but  it  is  impor- 
tant to  remember  that  a  person  who  has  contracted  syphilis  should 
not  be  content  with  courses  of  anti-syphilitic  treatment,  but  should 
take  every  possible  care  to  keep  up  his  general  health  and  to  avoid 
excesses,  mental,  physical,  sexual  and  dietetic,  which  are  calculated 
to  undermine  his  natural  resistance. 


Cerebro-Spinal  Syphilis.  1065 

Anti-syphilitic  Therapy. — The  discovery  of  an  organic  disease 
of  a  patient's  central  nervous  system  nearly  always  suggests  the 
question — has  it  a  syphilitic  basis  ?  Any  reference  to  the  means 
which  must  be  adopted  in  order  to  answer  this  question  does  not 
come  within  the  scope  of  this  article,  but  if  the  medical  man  arrives 
at  the  conclusion  that  the  disease  is  luetic  in  origin  his  first  duty 
will  be  to  apply  anti-syphilitic  remedies.  Putting  aside  for  the 
moment  the  new  preparation  of  Ehrlich,  he  will  have  to  rely  chiefly 
on  mercury  and  the  iodide  salts.  The  methods  of  using  them  are 
numerous  enough  to  give  him  a  wide  choice.  Before  referring  to 
them  in  detail  the  writer  desires  to  express  his  opinion,  based  on 
his  own  experience,  that  the  failure  of  anti-syphilitic  remedies  to 
give  results  which  might  reasonably  be  expected  from  them  is 
frequently  due  to  one  of  two  causes.  Either  the  treatment  is  not 
ordered  to  be  pushed  to  the  extent  which  is  often  necessary,  or  the 
actual  method  of  administration  is  faulty  and  has  not  been  properly 
supervised.  In  all  probability  surgical  interference  has  not  infre- 
quently been  invoked  in  cases  in  which  the  failure  of  medical 
measures  could  be  properly  ascribed  to  one  or  other  of  the  above- 
mentioned  causes. 

Mercury  and  Iodides. — It  is  always  advisable  to  give  mercury 
in  tertiary  syphilis  of  the  nervous  system,  and  iodide  of  potassium 
may  be  given  either  at  the  same  time  or  subsequently.  Some 
authorities  believe  that  the  latter  method  is  the  more  advantageous. 
Mercury  may  be  given  by  mouth,  through  the  skin,  or  by  injection. 

If  oral  treatment  is  decided  upon,  the  liquor  hydrargyri 
perchloridi  in  drachm  [U.S.P.  hydrarg.  chlorid.  corrosiv.,  gr.  ^] 
doses  may  be  given  in  a  mixture  thrice  daily  or  the  red  iodide  of 
mercury  (^  to  £  gr.)  in  the  form  of  a  pill  at  the  same  intervals. 
Slight  salivation  is  an  indication  that  enough  has  been  given  and 
that  the  administration  must  be  stopped  or  the  dosage  reduced. 

There  is  no  better  way  of  carrying  out  mercurial  treatment  than 
by  inunction.  The  dose  can  be  carefully  regulated  and  dis- 
turbances of  digestion  are  usually  avoided  by  this  method. 
Unfortunately,  it  is  too  often  adopted  in  a  perfunctory  manner,  and 
the  results  are  unsatisfactory  in  consequence.  The  patient  should 
have  a  warm  bath  before  each  inunction.  He  should  stay  in  the 
bath  at  a  temperature  of  87°  to  90°  F.  for  about  fifteen  or  twenty 
minutes,  and  the  part  which  is  to  be  used  for  inunction  should  be 
washed  with  soap  and  water.  A  drachm  of  mercurial  ointment 
mixed  with  some  lanoline,  or  a  similar  quantity  of  oleatum 
hydrargyri  (10  per  cent.)  should  be  carefully  rubbed  into  the 
selected  part  during  a  period  of  twenty  to  thirty  minutes.  The 


io66  Cerebro-Spinal  Syphilis. 

part  should  be  covered  by  linen  or  flannel,  and  this  should  not  be 
removed  until  the  bath  on  the  following  day.  A  fresh  site  must  be 
chosen  each  day  and  the  rubbings  continued  for  forty  to  fifty  days, 
or  until  signs  of  salivation  present  themselves.  The  arms,  back, 
calves  and  thighs  are  suitable  parts  for  the  rubbing  and  may  be 
used  in  turn.  Salivation  or  gingivitis  will  be  delayed  if  proper 
attention  is  paid  to  the  cleansing  of  the  mouth.  A  toothbrush 
should  be  used  after  each  meal  and  a  lotion  of  chlorate  of  potash 
employed  for  washing  out  the  mouth  and  gargling  the  throat  two 
or  three  times  a  day.  In  some  cases  of  cerebral  syphilis  it  is 
necessary  to  obtain  results  as  rapidly  as  possible,  and  the  com- 
bination of  inunctions  with  oral  treatment  may  attain  this  object 
without  the  risk  which  attends  large  intramuscular  injections, 
although  in  some  ways  the  latter  are  more  simple  in  their 
administration. 

When  the  attack  of  cerebro-spinal  syphilis  has  been  cured  by  a 
course  of  mercury  at  home  it  will  be  well,  if  circumstances  allow, 
to  send  the  patient  away  for  further  courses.  The  inunction 
treatment  is  well  carried  out  at  Harrogate  or  Matlock  in  this 
country,  or  at  Aachen  on  the  Continent.  During  or  between  the 
courses,  iodide  of  potassium  (10  to  40  gr.)  may  be  given  three 
times  a  day  with  some  bitter  infusion  about  one  hour  before  meals. 
It  is  well  to  increase  the  dose  of  iodide  rapidly  up  to  30  or  40  gr. 
as  the  disagreeable  effects  of  the  drug  are  often  more  noticeable 
when  taking  the  smaller  quantities.  It  is  unnecessary  to  continue 
with  the  iodide  as  long  as  with  the  mercury. 

Of  late  years  the  injection  method  of  giving  mercury  has  been 
largely  used,  particularly  in  the  treatment  of  syphilis  in  the  army. 
A  number  of  different  preparations  have  been  tried,  some  of 
which  are  insoluble,  slowly  absorbed  and  slowly  eliminated,  and 
others  just  the  opposite.  The  injection  of  some  of  the  more 
soluble  salts  is  usually  attended  by  less  pain  than  that  of 
substances  like  calomel  suspended  in  oil. 

Salicylate  of  mercury  in  doses  of  £  to  1  gr.  suspended  in  about 
ten  drops  of  liquid  paraffin  may  be  injected  deeply  into  the  buttock 
at  intervals  of  four  to  seven  days.  This  is  an  efficient  method  of 
quickly  exerting  mercurial  influence  and  may  sometimes  be  useful 
in  urgent  cases  of  cerebral  syphilis  to  begin  with,  even  if  inunc- 
tion is  resorted  to  for  continuing  treatment.  Intramuscular 
injections  of  metallic  mercury  (1  gr.)  suspended  in  a  fatty  base 
are  practically  painless,  but  absorption  is  slower  and  the  results 
more  delayed.  The  objection  to  the  intramuscular  injection 
method  lies  in  the  difficulty  of  avoiding  excess  while  being  sure 


Cerebro-Spinal  Syphilis.  1067 

that  enough  of  the  drug  is  being  administered.  The  advantages 
of  simplicity,  cleanliness,  and  saving  of  time  are  obvious. 

In  acute  attacks  of  cerebro-spinal  syphilis  an  intramuscular 
injection  may  well  be  used  for  the  purpose  of  getting  a  maximal 
early  effect,  but  in  the  more  subacute  and  chronic  conditions 
inunction  is  probably  the  most  satisfactory  method  to  employ. 

Emphasis  has  already  been  laid  on  the  importance  of  oral 
cleanliness  during  courses  of  mercurial  treatment,  and  a  word  must 
be  said  as  to  the  effect  of  mercury  on  other  organs. 

The  fear  of  untoward  effects,  especially  of  producing  cardiac  or 
nervous  depression  or  anaemia,  is  apt  to  be  exaggerated  ;  as  a 
general  rule,  the  effect  of  giving  mercury  to  a  patient  suffering 
from  syphilis  of  the  nervous  system  is  more  striking  than  that  of 
any  tonic.  The  body  weight  increases,  blood  counts  improve  and 
the  general  health  improves  in  every  way.  Even  if  albuminuria 
is  present  to  start  with,  it  is  quite  likely  to  disappear  under  the 
treatment.  On  the  other  hand,  if  albumin  makes  its  appearance 
during  treatment,  if  the  patient  steadily  loses  weight  or  develops 
palpitation,  cramps,  tremors,  colic,  or  gingivitis,  these  are  signs 
that  toxic  effects  are  being  produced  and  that  the  treatment  must 
be  stopped  for  the  time  being. 

Arsenic. — The  value  of  arsenic  in  syphilis  has  been  known  for 
a  long  time,  but  it  is  only  within  recent  years  that  this  metal  has 
been  extensively  employed  as  a  remedy.  The  future  of  the  various 
arsenical  preparations,  such  as  atoxyl  and  Ehrlich's  "  606,"  cannot 
at  present  be  determined  owing  to  the  fact  that  the  use  of  some 
of  them  has  been  attended  by  severe  toxic  effects  resulting  in 
amblyopia,  etc.,  in  certain  cases.  At  first  it  was  generally  believed 
that  mercury  and  arsenic  should  not  be  given  simultaneously,  but 
more  recently  favourable  results  have  been  reported  from  their 
combined  use.  It  is  safe  to  say  that  arsenic  is  a  useful  drug  to 
give  between  courses  of  mercury,  and  it  may  be  that  in  the  near 
future  it  will  have  established  its  position  as  the  most  potent 
weapon  at  our  disposal  both  in  the  prevention  and  in  the  cure  of 
cerebro-spinal  syphilis. 

Intracranial  Gummata. — In  most  cases  the  proper  treatment 
for  intracranial  gummata  is  the  energetic  use  of  anti-syphilitic 
remedies.  On  the  other  hand,  a  medical  man  may  every  now  and 
then  be  faced  by  a  case  of  intracranial  neoplasm,  which  may  or 
may  not  be  gummatous,  and  in  which  the  condition  of  the  patient 
renders  any  delay  in  relieving  symptoms  a  matter  of  great  danger. 
For  instance,  the  patient  may  be  comatose  with  slow  pulse  and 
respiration  and  with  intense  optic  neuritis,  all  the  symptoms  being 


io68  Cerebro-Spinal  Syphilis. 

the  result  of  greatly  increased  intracranial  tension.  The  medical 
man  knows  that  his  patient's  life  and  sight  will  probably  be  saved 
by  immediate  trephining  of  the  skull,  and  that  unless  anti- syphilitic 
remedies  take  immediate  effect  there  is  serious  risk  of  the  patient 
losing  one  or  the  other.  In  cases  where  the  syphilitic  nature  of 
the  lesion  is  doubtful,  it  is  good  practice  to  open  the  skull  and 
dura  mater  over  a  wide  area  and,  if  necessary,  administer  mercury 
and  iodides  afterwards.  If,  on  the  other  hand,  the  syphilitic 
nature  of  the  growth  is  tolerably  certain,  if  mercury  and  iodides 
have  not  already  been  employed  without  success,  and  if  the 
condition  of  the  patient  is  not  really  desperate,  energetic  treat- 
ment with  mercury  and  iodide  of  potassium  will  generally  be  all 
that  is  necessary.  When  trephining  is  decided  upon,  it  is  well  to 
choose  some  area  such  as  the  right  frontal  or  right  temporal  region 
for  the  opening  unless  the  physical  signs  clearly  point  to  some 
other  part  as  the  site  of  the  growth. 

In  the  writer's  experience  the  removal  of  gummata  by  the  knife 
has  not  been  attended  with  good  results.  On  the  other  hand,  both 
in  spinal  and  in  cerebral  syphilis,  the  subsequent  effects  of  anti- 
syphilitic  treatment  are  sometimes  materially  improved  by  merely 
opening  the  cranial  or  vertebral  cavities  and  exposing  the  lesion. 
This  may  probably  be  explained  on  the  ground  that  injury  to  the 
tissue  in  the  immediate  neighbourhood  of  the  disease  attracts  more 
blood,  together  with  the  drugs  in  solution,  to  the  part.  The 
operation  is,  in  fact,  a  somewhat  drastic  counter-irritant. 

Syphilitic  Cerebral  Thrombosis. — Syphilitic  arteritis  followed 
by  thrombosis  of  one  of  the  main  branches  of  the  middle  cerebral 
artery  is  a  frequent  cause  of  hemiplegia  and  must  be  met  by  anti- 
syphilitic  remedies  as  well  as  by  other  measures  which  the  reader 
will  find  described  in  the  article  on  Hemiplegia. 

Spinal  Gummatous  Meningitis. — This  is  a  condition  in  which 
the  response  to  mercury  and  iodide  of  potassium  is  sometimes 
disappointing  and  may  be  stimulated  by  a  laminectomy  followed 
by  an  attempt  to  clear  the  spinal  roots  from  the  surrounding 
fibrous  adhesions.  Here  again  the  local  reaction  probably  exerts  a 
beneficial  influence  in  bringing  the  disease  into  closer  contact  with 
the  circulating  drugs.  Cases  of  gumrnatous  meningitis  of  the 
cauda  equina  and  cases  of  pachymeningitis  of  the  cervical  region 
are  particularly  benefited  by  surgical  interference  when  recovery 
under  medicinal  treatment  is  delayed.  Syphilis  of  the  meninges  is 
also  responsible  at  times  for  the  formation  of  localised  cysts 
within  the  theca,  the  evacuation  of  which  may  relieve  the  cord  of 
pressure. 


Cerebro-Spinal  Syphilis.  1069 

Syphilitic  Paraplegia.  —  In  the  general  treatment  of  the 
paralysis,  atrophic  or  spastic,  which  results  from  syphilitic  myelitis 
and  meningo-myelitis,  the  reader  is  referred  to  the  article  on 
Myelitis.  In  addition  to  the  use  of  anti-syphilitic  remedies, 
measures  described  in  that  article  for  the  prevention  of  bedsores, 
cystitis,  etc.,  are  of  urgent  importance. 

E.  FARQUHAR  BUZZARD. 


1070 


DISSEMINATED   SCLEROSIS. 

FEW  things  are  more  unsatisfactory  than  the  treatment  of  a 
disease  like  disseminated  sclerosis,  for  we  are  so  ignorant  as  to  its 
etiology  that  all  treatment  must  of  necessity  be  largely  empirical. 
All  that  we  have  to  guide  us  in  the  treatment  of  the  affection  is 
what  can  be  deduced  from  its  morbid  anatomy,  together  with  our 
clinical  experience  that  certain  conditions  of  life  prove  prejudicial 
to  persons  affected  by  the  disease  and  are  responsible  for  aggravation 
of  the  symptoms,  while  decided  benefit  results  when  certain  other 
conditions  can  be  secured.  Whether  the  disease  is  ever  perma- 
nently arrested  after  having  revealed  itself  by  some  of  its  character- 
istic earlier  manifestations  it  is  impossible  to  say,  although  there 
are  good  reasons  to  suppose  that  this  does  happen.  The  malady  is 
usually  regarded  as  one  of  those  in  which  nothing  short  of  a  fatal 
issue  is  to  be  expected,  although  a  great  many  years  may  elapse 
before  the  end  is  reached.  What  is  known  of  the  long  intervals 
that  may  elapse  between  the  time  when  the  first  manifestations  of 
the  affection  appear  and  the  complete  picture  of  the  disease  is 
established  justifies  the  speculation  as  to  whether  there  are  cases  in 
which  these  earlier  manifestations  occur  without  being  followed  by 
those  which  characterise  the  fully  developed  disease.  Furthermore, 
cases  occur  in  which  the  patient,  damaged  with  certain  irreparable 
defects,  nevertheless  remains  at  a  standstill  so  long  that  it  is  not 
unreasonable  to  speculate  as  to  whether  any  of  these  cases  ever 
remain  permanently  arrested.  There  are  many  difficulties  that 
arise  in  connection  with  such  considerations,  however,  notably  the 
fact  that  syphilis  may  account  for  cases  that  appear  to  be  dissemi- 
nated sclerosis  and  that  seem  arrested.  The  modern  tests  for 
syphilis  will,  however,  assist  in  elucidating  this  problem,  though 
leaving  it  still  hedged  round  with  other  difficulties,  including  that  of 
keeping  in  touch  with  the  patient  over  periods  sufficiently  long  to 
come  to  any  positive  conclusion  on  this  point.  Nevertheless,  some 
cases  have  been  followed  for  a  sufficiently  long  time  to  make  it 
probable  that  arrest  of  the  disease  does  sometimes  occur.  • 

A  study  of  the  morbid  anatomy  of  disseminated  sclerosis  reveals 
certain  indications  which  appear  to  justify  the  belief  that  some 
toxic  agent  is  responsible  for  the  earlier  morbid  changes  which 
result  in  the  sclerosis.  We  know  so  little  about  the  etiology  of  the 
affection,  however,  that  there  is  not  much  that  can  be  done  in  the 


Disseminated  Sclerosis.  1071 

way  of  prophylaxis.  Nevertheless,  the  number  of  cases  that  first 
reveal  themselves  after  one  or  other  of  the  infective  fevers  makes  it 
important  that  we  should  enjoin  a  sufficient  amount  of  rest  in  the 
convalescence  from  such  infective  diseases,  more  especially  when 
there  have  been  any  manifestations  pointing  to  disordered  action  of 
the  nervous  system  during  the  febrile  illness.  For  similar  reasons 
those  engaged  in  trades  which  expose  them  to  the  influence  of 
metallic  and  other  poisons  should  be  protected  as  far  as  possible 
from  their  baneful  influences. 

General  Treatment. — There  are  certain  general  considerations 
that  are  of  paramount  importance  in  the  treatment  of  this  affection. 
The  patient's  nutrition  must  be  maintained  at  as  high  a  level  as 
possible,  so  that  it  may  be  necessary  to  supplement  a  liberal  nutri- 
tious diet  by  the  administration  of  cod-liver  oil  or  preparations  of 
malt.  It  is  especially  important  that  those  who  have  had  any  of 
the  earlier  manifestations  that  may  mean  the  commencing  of  this 
disease  should  keep  their  general  nutrition  at  a  high  standard  of 
perfection,  and  should  avoid  all  excesses,  fatigue  and  other  depress- 
ing conditions  that  might  aggravate  their  complaint.  There  can  be 
no  doubt  that  the  more  restful  the  conditions  that  can  be  secured 
for  the  patient,  the  better  the  effect  on  the  course  of  the  malady. 
The  patient  should,  accordingly,  be  placed  under  conditions  that 
secure  the  maximum  of  peace  of  mind,  and  that  degree  of  physical 
repose  that  is  found  necessary  to  the  individual  case.  "While  the 
avoidance  of  mental  worry  and  strain  is  essential  as  far  as  this 
state  of  things  can  be  secured,  absolute  physical  rest  is  not  called 
for  in  all  cases.  The  amount  of  rest  must  be  estimated  according 
to  the  ease  with  which  fatigue  is  induced,  so  that  all  physical 
exercise  should  be  taken  short  of  undue  fatigue.  Whenever  there 
is  an  acute  exacerbation  of  the  disease,  with  sudden  or  rapid  increase 
in  the  loss  of  power  in  the  lower  limbs,  or  increasing  difficulty  in 
locomotion  in  consequence  of  spasticity,  the  patient  should  be  kept 
at  absolute  rest  for  a  time.  Similarly,  even  when  increasing  diffi- 
culty in  locomotion  is  much  slower  in  its  progress,  the  patient 
derives  distinct  benefit  from  periods  of  complete  physical  rest. 
Whether  or  not  there  is  a  good  deal  of  additional  neurasthenia  in 
the  clinical  picture,  some  of  the  more  acute  cases  of  the  malady 
benefit  by  a  complete  "  rest  cure."  But  while  the  securing  of 
mental  rest  is  such  an  important  factor  in  their  treatment,  care 
must  be  observed  not  to  allow  the  patient  to  become  depressed  by 
too  much  isolation,  so  that  this  part  of  the  regime  of  an  ordinary 
"  rest  cure  "  may  have  to  be  modified  to  suit  the  needs  of  individual 
cases. 


1072  Disseminated  Sclerosis. 

Excesses  of  all  kinds,  including  wine  and  venery,  must  be  carefully 
avoided,  and  the  frequency  with  which  the  manifestations  of  the 
malady  first  appear  after  parturition,  or  during  pregnancy,  makes 
it  imperative  that  female  patients  suffering  from  the  disease  should 
be  carefully  warned  to  avoid  the  possibility  of  becoming  pregnant. 

While  the  avoidance  of  fatigue  is  so  essential,  a  liberal  amount  of 
fresh  air  should  be  secured  for  patients  suffering  from  disseminated 
sclerosis,  by  drives  in  an  easy  motor  or  carriage  or  in  a  wheeled 
chair,  when  the  powers  of  locomotion  are  so  impaired  that  walking 
cannot  be  undertaken  without  a  degree  of  effort  that  quickly  induces 
fatigue,  and  when  the  climatic  conditions  will  not  permit  of  rest  in 
the  open  air.  Undue  vibration  is,  however,  to  be  avoided  as  far  as 
possible  during  motor  or  carriage  exercise.  Cold  and  damp  are  to 
be  studiously  avoided,  as  many  of  the  symptoms  of  the  malady  are 
undoubtedly  aggravated  by  these  conditions,  so  that  when  the 
patients'  circumstances  permit  of  this  it  is  best  for  them  to  secure 
residence  in  a  warm  dry  climate,  notably  during  our  winter  months. 
Care  must,  however,  be  taken  to  secure  the  change  to  these  favour- 
able conditions  of  climate  with  the  minimum  of  fatigue  on  the 
journey,  which  should  be  made  as  restful  as  possible. 

Nothing  is  known  as  to  the  real  nature  of  the  toxic  agent  that  is 
supposed  to  occasion  the  disease,  but  the  surmise  that  it  may  be 
infective  in  origin  has  been  responsible  for  the  hope  that  mercury, 
administered  in  the  earlier  stages  of  the  affection,  may  prove  of 
some  service  in  arresting  or  retarding  the  progress  of  the  morbid 
process.  It  is  always  exceedingly  difficult  to  estimate,  with  any 
degree  of  certainty,  the  therapeutic  effects  of  a  remedy  in  a  disease 
which  is  subject  to  such  natural  remissions  as  occur  in  disseminated 
sclerosis.  Nevertheless,  it  has  appeared  to  me  that  courses  of 
mercurial  inunction,  combined  with  measures  calculated  to  build 
up  the  strength  of  the  patient  on  "  rest-cure  "  principles,  have  been 
of  distinct  service  in  some  cases.  This  is  not  the  experience  of  all 
neurologists,  however,  and  there  are  those  who  consider  that 
mercury  is  not  only  not  helpful  but  actually  harmful  to  the  subjects 
of  disseminated  sclerosis.  The  plan  that  I  have  employed,  in 
suitable  cases,  is  as  follows :  1  drachm  of  blue  ointment  is 
rubbed  in  along  one  side  of  the  spinal  column  every  night.  The 
part  is  well  sponged  with  hot  water,  then  dried,  and  the  ointment 
rubbed  in  for  half  an  hour  along  the  whole  length  of  the  spinal 
column  on  one  side.  The  next  night  the  opposite  side  is  selected 
for  exactly  the  same  treatment,  and  in  each  case  the  ointment  is 
allowed  to  remain  in  contact  with  the  part  for  forty-eight  hours, 
that  is,  until  the  time  has  arrived  for  a  fresh  application  of  it.  The 


Disseminated  Sclerosis.  1073 

treatment  is  continued  in  this  way  for  two  or  three  months  at  a 
time,  unless  any  symptoms  arise  which  may  be  ascribed  to  the 
mercury,  in  which  case  it  must,  of  course,  be  discontinued  until  they 
have  passed  off.  The  patient  is  ordered  to  clean  the  teeth  after 
each  meal,  and  to  follow  this  by  the  use  of  a  mouth-wash  of  chlorate 
of  potash  (10  gr.  to  1  oz.). 

In  view  of  what  has  been  said  as  to  the  possible  infective  origin 
of  the  disease,  it  is  significant  that  arsenic  has  long  enjoyed  a 
reputation  in  the  treatment  of  disseminated  sclerosis.  It  is  not 
surprising,  therefore,  that  attention  has  been  called  to  the  possible 
advantage  to  be  derived  from  salvarsan — "  606,"  in  spite  of  the  fact 
that  syphilis  cannot  be  blamed  for  disseminated  sclerosis.  The  use 
of  "  606  "  cannot,  however,  be  recommended  in  this  way  as  long  as 
there  is  any  reasonable  suspicion  that  this  preparation  may  lead  to 
blindness  or  any  other  serious  defect.  Some  observers  have  recom- 
mended the  subcutaneous  injection  of  other  preparations  of  arsenic, 
such  as  cacodylate  of  soda  (f  gr.  once  a  day)  or  atoxyl  (arsamin) 
(f  to  3  gr.  two  or  three  times  a  week) ;  but  the  plan  that  has  found 
most  acceptance  in  this  country  has  been  that  of  administering  the 
arsenic  by  the  mouth,  in  the  form  of  Fowler's  solution.  Various 
plans  have  been  recommended  as  to  the  best  way  to  give  the  arsenic, 
but  one  that  will  probably  be  found  to  be  as  satisfactory  as  any 
other  is  to  begin  with  3  minims  of  Fowler's  solution  three  times 
a  day  after  food,  and  to  increase  the  dose  up  to  8  or  10  minims 
in  the  course  of  two  or  three  weeks,  and  then  to  diminish  it  again 
gradually  until  the  original  dose  is  reached  at  the  end  of  a  further 
period  of  two  to  three  weeks.  Courses  of  arsenic  are  given  in  this 
way  at  intervals,  and  certainly  appear  to  do  good. 

Charcot,  Erb  and  others  have  employed  silver  in  the  treatment 
of  the  affection  with  apparent  benefit ;  and  more  recently  collargol 
has  been  so  employed  by  the  mouth  (1  gr.  in  pill  or  tabloid  form, 
suppositories  of  2£  gr.,  and  even  intra-venous  injection  of  J  to  1 
per  cent,  solution),  with  results  sufficiently  satisfactory  to  induce 
those  who  have  tried  it  to  advocate  a  more  extended  trial  of  this 
method  of  treating  the  disease,  especially  as  no  risk  attaches  to  the 
use  of  collargol. 

In  the  intervals  between  the  courses  of  arsenic  or  silver  various 
tonic  medicines  may  be  substituted,  including  strychnine,  which 
has,  however,  to  be  employed  with  care,  so  as  not  to  allow  it  to 
aggravate  any  spastic  phenomena  that  may  obtain  in  the  clinical 
picture  of  the  malady.  Phosphorus  has,  of  course,  been  employed, 
and  during  recent  years  phytin  (in  4£  gr.  doses  in  capsule  three 
times  a  day)  has  been  substituted  for  the  ordinary  preparations  of 

S.T. — VOL.  ii.  68 


1074  Disseminated  Sclerosis. 

phosphorus.  Lecithin  in  different  forms  has  also  been  tried,  and 
appears  to  prove  of  distinct  benefit  in  some  cases.  A  good  way 
of  exhibiting  this  drug  is  in  the  form  of  ovo-lecithin,  2  gr.  of 
which  may  be  given  in  pill  three  times  a  day.  Glycero-phosphates 
supply  another  useful  substitute  when  arsenic  has  to  be  interrupted, 
and  may  sometimes  be  combined  with  the  arsenic  with  advantage. 
The  preparation  of  glycero-phosphates  with  formates  is  similarly 
useful.  The  attempts  to  influence  the  course  of  the  disease  by 
tonics  has  led  to  the  use  of  certain  gland  extracts,  including  that  of 
the  testicle,  thymus  and  thyroid,  with  apparent  benefit  in  some 
cases ;  although  it  cannot  be  supposed  that  these  have  any  influence 
on  the  organic  changes  which  obtain  in  the  central  nervous  system. 
In  view  of  the  marked  effect  which  fibrolysin  has  on  cicatricial 
tissue,  much  was  hoped  from  its  use  in  affections  like  that  now 
under  consideration,  in  which  sclerosis  forms  a  prominent  part  in 
the  morbid  changes  which  obtain  in  the  central  nervous  system. 
According  to  some  observers,  good  results  have  followed  the  use  of 
fibrolysin  in  such  conditions,  so  that  it  is  a  form  of  treatment  that 
must  be  considered.  It  has  not  been  my  experience,  however,  that 
any  good  has  resulted  from  its  use  in  affections  of  the  central 
nervous  system ;  and  in  view  of  the  fact  that  it  is  not  a  form  of 
treatment  that  is  entirely  without  risk  of  harm  resulting  to  the 
patient,  it  cannot  be  recommended. 

The  belief  that  disseminated  sclerosis  is  infective  in  origin,  and 
the  beneficial  effects  that  have  been  observed  by  Eaymond  and 
others  by  the  use  of  X-rays  in  the  treatment  of  syringomyelia,  has 
led  to  the  use  of  the  rays  in  this  affection.  They  are,  of  course, 
applied  to  different  parts  of  the  spine,  notably  the  cervical  and 
lumbar  regions.  The  results  have  been  discrepant ;  but  those  who 
have  seen  improvement  under  the  rays  advocate  their  use  in  the 
earliest  possible  stages  of  the  malady,  before  permanent  sclerotic 
changes  have  occurred  in  the  spinal  cord. 

No  form  of  electrical  or  hydropathic  treatment  can  be  said  to  be 
of  material  advantage  in  combating  the  disease,  although  they  have 
their  advocates,  notably  amongst  Continental  physicians,  and  may 
possibly  prove  helpful  in  treating  individual  symptoms.  Faradism 
is  sometimes  helpful  when  the  subjective  sensation  of  numbness  is 
troublesome  in  some  part ;  but  this  and  all  other  forms  of  electrical 
treatment  must  be  employed  with  caution  when  there  is  much 
spasticity,  as  harm,  rather  than  good,  may  result  under  such  circum- 
stances. If  any  form  of  hydropathic  treatment  is  adopted,  great 
care  is  necessary  not  to  allow  the  patient  to  be  unduly  fatigued  by  it. 
Special  symptoms,  of  course,  call  for  special  lines  of  treatment. 


Disseminated  Sclerosis.  IO75 

One  of  the  most  notable  of  these  is  the  tvcakness  of  the  sphincter  of 
the  bladder,  which  is  such  a  common  feature,  and  often  an  early 
manifestation  of  the  malady.     This  is  often*  very  decidedly  influ- 
enced by  the  administration  of  belladonna,  5  or  10  minims  of  the 
tincture  being  given  in  conjunction  with  arsenic,  if  the  patient 
happens  to  be  taking  this  drug,  or  the  belladonna  may  be  combined 
with  strychnine  with  advantage  in   some  cases.     Ergot  enjoys  a 
similar  reputation.    Urotropine  (in  10  gr.  doses  once  or  twice  a  day) 
may  be  employed  as  a  prophylactic  against  cystitis  when  there  is 
incontinence,  or  in  the  treatment  of  a  cystitis  already  developed 
which  may  call  for  lavage  of  the  bladder  as  an  additional  measure. 
Pain  is  rarely  the  prominent  symptom  in  disseminated  sclerosis, 
which   it    is    in    tabes    dorsalis.      Nevertheless,    a   fixed   pain   in 
the  back  or  in  some  other  situation  may  call  for  the  exhibition  of 
one  or  other  of  the  analgesic  medicines  at  our  disposal.     Aspirin 
(in  5  or  10  gr.  doses)    alone,  or   with   10   gr.   of  pyramidon   or 
phenacetin,  usually  proves  most  helpful,  and  it  must  be  rare  to  find 
any  real  justification  for  the  administration  of  morphia  or  any  other 
form  of  opium.     When  reflex  spasms  prove  distressing,  these  same 
drugs  may  prove  helpful ;  but  when  they  fail,  veronal  (in  small  doses 
of  3  or  4  gr.,  repeated  every  four  or  six  hours)  sometimes  gives 
relief.     This  is,  however,  one  of  the  most  intractable  symptoms  of 
an  affection  of  the  spinal  cord,  and  often  baffles  all  attempts  at 
treatment.     Small  doses  of  veronal  employed  in  this  way  are  also 
said  to  be  helpful  in  lessening  the  tremor  which  is  such  a  character- 
istic feature  of  the  disease.     Vertigo  may  be  quite  severe  in  some 
instances,  and  may  make  it  impossible  for  the  patient  to  do  otherwise 
than  keep  in  the  recumbent  posture.     One  of  the  bromide  salts  (in 
doses  of  10  to  20  gr.)  is  best  for  this,  and  either  the  sodium  or 
ammonium  salt  is  to  be  preferred,  given  alone  or  in  combination 
with  arsenic,  and  further  combined  with  strychnine  or  belladonna, 
according   as   other    concomitant   symptoms   may   demand.     The 
patient's  power  of  locomotion   may   sometimes   be  hampered   by 
spastic  it  y  rather  than  by  actual  motor  paralysis,  so  that  various 
attempts  have  been  made  to  influence  this  symptom  of  the  affection, 
but  with  small  success  in  a  large  proportion  of  the  cases.     There 
can  be  no  doubt,  however,  that  rest  proves  an  important  element  in 
the  treatment  of  this  manifestation,  and  to  this,  more  than  to  any 
other  concomitant  element  in  treatment,  is  usually  to  be  ascribed 
any  improvement  which  may  fortunately  result.     It  is  certain  that, 
in  addition  to  the  general  good  which  results  to  the  individual  from 
rest,  this  special  feature  is  favourably  influenced.     The  idea  which 
commonly  obtains  that  the  patients  can  walk  off  their  stiffness  is 

68—2 


1076  Disseminated  Sclerosis. 

accordingly  a  mistake,  for  in  reality  what  is  wanted  is  rest  and  the 
avoidance  of  fatigue.  While  general  massage  is  usually  to  be 
deprecated,  as  proving  too  exhausting,  massage  and  passive  move- 
ments confined  to  the  parts  affected  by  spastic  paralysis,  which 
usually  happens  to  be  the  lower  limbs,  is  often  of  distinct  service, 
although  it  is  naturally  always  a  difficult  matter  to  estimate  how 
much  of  the  relaxation  of  the  limbs  has  been  due  to  the  rest  to  the 
spinal  cord  and  how  much  to  the  massage.  There  can  be  little  doubt, 
however,  that  the  massage  and  passive  movements  lessen  the 
liability  to  permanent  contractures  and  the  disabilities  inseparable 
from  them. 

J.  S.  RISIEN  RUSSELL. 


1077 


GENERAL  PARALYSIS  OF  THE  INSANE. 

IT  is  a  general  and  popular  belief  that  every  disease  must  have 
an  appropriate  cure,  and  that  the  lack  of  a  curative  method  for  any 
particular  disease  constitutes  evidence  of  medical  ignorance  of  the 
nature  of  the  disease.  Even  if  medical  men  believe  that  it  is  possible 
to  be  acquainted  thoroughly  with  the  etiology  and  pathogenesis  of 
a  disease  and  yet  to  admit  its  incurability,  many  years  must  elapse 
before  the  public  mind  can  be  expected  to  fall  in  with  an  idea  so 
contrary  to  preconceived  notions. 

General  paralysis  may  be  cited  as  an  instance  of  a  disease  the 
essential  cause  of  which  is  as  firmly  established  as  any  in  the 
sphere  of  medicine.  The  knowledge  that  without  syphilis  there  can 
be  no  general  paralysis,  although  invaluable  from  a  prophylactic 
point  of  view,  is  nevertheless  at  the  present  moment  of  little  help 
in  the  curative  treatment  of  the  established  disease. 

In  spite  of  the  accepted  view  that  general  paralysis  is  an  incurable 
and  fatal  disease,  a  view  based  on  only  too  substantial  a  basis,  there 
are  equally  good  reasons  for  believing  that  appropriate  treatment 
of  individual  cases  can  do  much  towards  diminishing  the  suffering 
of  the  patient  and,  perhaps  still  more,  that  of  the  patient's  imme- 
diate relations  and  friends.  The  fact,  therefore,  that  there  can  be 
only  one  end  in  sight  does  not  relieve  the  medical  attendant  of 
many  and  serious  responsibilities.  On  the  contrary,  the  manage- 
ment of  these  cases  is  full  of  difficulty  and  affords  the  physician 
opportunities  of  displaying  resource  and  of  rendering  invaluable 
help,  in  other  words,  of  performing  duties  which  are  professionally 
as  important  if  not  so  much  appreciated  or  so  superficially  brilliant 
as  those  involved  in  bringing  about  a  radical  cure. 

As  in  so  many  diseases,  the  first  essential  for  successful  treatment, 
and  "  successful  treatment  "  does  not  necessarily  mean  cure  to 
a  medical  man,  is  early  diagnosis.  Late  recognition  is  not  always 
the  fault  of  the  physician,  because  it  is  the  rule  rather  than  the 
exception  for  the  patient  or  his  relations  to  seek  help  only  when 
serious  mental  symptoms  begin  to  display  themselves,  and  often 
not  before  money  has  been  squandered  in  grandiose  schemes  or 
a  business  ruined  by  rapidly  growing  incapacity.  Early  diagnosis 
will  enable  the  physician  to  give  the  warning  necessary  for  the 
salvation  of  material  effects,  and  at  the  same  time  to  remove  the 


1078        General  Paralysis  of  the  Insane. 

patient  from  an  environment  which  is  calculated  to  aggravate  his 
symptoms  and  hasten  the  progress  of  his  disease.  He  should  be 
taken  away  from  business  and  shielded  from  worries  of  all  kinds. 
Mental  and  physical  rest  is  necessary  all  the  more  urgently  when 
the  patient,  as  is  often  the  case,  is  anxious  to  over-exert  himself  in 
every  direction  and  believes  himself  possessed  of  superhuman 
strength  and  endurance.  If  certifiable,  the  earlier  he  is  removed 
to  an  asylum  the  better  for  the  patient  and  his  relations.  When 
certification  is  impossible,  a  quiet  country  house  with  grounds  is 
more  beneficial  than  a  voyage  and  much  more  convenient  if  serious 
symptoms  requiring  restraint  or  constant  medical  attention  suddenly 
develop,  as  they  are  very  likely  to  do.  The  majority  of  patients 
can  be  induced  to  retire  into  the  country  and  to  submit  themselves 
to  regular  hours  of  rest  and  exercise  if  they  are  persuaded  that  they 
are  ill.  Whoever  is  in  charge  should  have  adequate  assistance 
within  reach  in  case  a  violent  phase  should  present  itself.  The 
diet  should  include  a  maximum  of  milk,  milk  puddings,  eggs  and 
fresh  vegetables,  and  a  very  moderate  quantity  of  meat.  Alcohol 
must  not  be  given  and  sexual  intercourse  must  be  forbidden. 
Insomnia  is  sometimes  a  troublesome  symptom  and  the  use  of 
hypnotics  is  not  only  justifiable  but  very  necessary.  If  bromides 
or  chloral  or  sulphonal  are  not  effectual,  paraldehyde  or  amylene 
hydrate  may  be  substituted  (sec  Insomnia). 

Anti-syphilitic  Treatment. — While  most  authorities  agree  that 
anti-syphilitic  remedies  are  rarely  followed  by  complete  arrest 
of  the  disease,  much  difference  of  opinion  is  expressed  in  regard  to 
the  advantage  of  employing  them.  In  a  disease  which  is  notable 
for  its  natural  remissions  under  favourable  conditions,  it  is  difficult 
to  gauge  the  effect  of  drugs.  Bianchi  and  Craig,  amongst  others, 
do  not  favour  the  use  of  mercury;  on  the  other  hand,  Leduc, 
Lemoine,  Leredde  and  Sachs  record  more  or  less  successful  results. 
In  considering  statistical  records  allowance  must  be  made  for  the 
possible  and  sometimes  excusable  error  of  mistaking  cases  of 
cerebral  syphilis  for  incipient  general  paralysis.  At  the  same 
time,  it  is  scarcely  fair  to  say  that  the  successful  mercurial  treat- 
ment of  a  case  in  which  parasyphilis  has  been  diagnosed  affords 
proof  that  the  diagnosis  is  erroneous. 

The  fact  that  patients  suffering  from  tabes,  a  disease  which  is 
regarded  by  many  eminent  authorities  as  the  spinal  counterpart  of 
general  paralysis,  are  undoubtedly  benefited  by  mercury  may  be 
taken  as  an  additional  argument  for  trying  anti-syphilitic  remedies 
in  the  early  stages  of  general  paralysis.  The  writer  is  of  the 
opinion  that  a  course  of  mercurial  inunction  should  be  given  in  all 


General  Paralysis  of  the  Insane.          1079 

early  cases  if  a  positive  Wassermann  reaction  is  obtained,  and  that 
the  course  should  be  repeated  at  short  intervals  as  long  as  it 
appears  to  arrest  any  progress  of-  the  malady.  If  this  line  is 
adopted  care  should  be  taken  that  the  inunction  is  properly  carried 
out  by  persons  who  understand  the  business  and  that  at  least  fifty 
or  one  hundred  daily  rubbings  should  be  given  when  the  treatment 
is  well  tolerated. 

It  is  too  early  as  yet  to  gauge  what  effect  Ehrlich's  "  606 " 
preparation  may  have  on  the  established  disease,  although,  if 
present  hopes  are  realised,  the  general  use  of  the  preparation  in 
early  syphilis  may  reasonably  be  expected  to  have  an  important 
preventive  influence. 

Surgery. — Trephining  the  skull  has  been  tried  in  several  cases 
without  permanently  influencing  the  course  of  the  disease. 

Serum  Therapy. — An  anti-diphtheritic  serum  introduced  by 
Ford  Robertson  has  not  proved  to  be  as  successful  as  early  experi- 
ments suggested  it  might  be,  and  no  other  remedy  on  similar  lines 
has  yet  established  any  reputation. 

SYMPTOMATIC    TREATMENT. 

Congestive  Attacks. — Rest  and  attention  to  the  bowels,  etc., 
are  all  that  is  required  in  dealing  with  a  congestive  attack  from 
which  the  patient  usually  makes  a  spontaneous  recovery  with 
impaired  mental  power.  It  is  said  that  the  continuous  adminis- 
tration of  liquid  extract  of  ergot  [U.S.P.  fluid  extract  of  ergot]  in 
doses  of  forty  drops  three  times  daily  over  a  long  period  decreases 
the  liability  to  these  seizures. 

Irritability  and  Excitement. — Rest  is  the  most  valuable  factor 
in  preventing  these  symptoms,  and,  although  hydro-therapy 
generally  is  of  little  use  in  the  treatment  of  general  paralysis, 
daily  baths  of  a  temperature  of  about  30°  to  32°  C.  (86°  to  90°  F.) 
have  been  found  useful  in  allaying  excitement.  Antifebrin  (2  to 
5  gr.)  is  a  drug  which  has  been  recommended  for  irritable  patients, 
and  its  efficacy  is  insisted  on  by  Bianchi. 

Refusal  of  Food. — This  must  be  met  by  forcible  feeding. 
A  nasal  rubber  tube  should  be  passed  into  the  lower  part  of  the 
O3sophagus  through  the  nares  three  or  four  times  in  the  twenty- 
four  hours,  and  each  feed  should  contain  nearly  a  pint  of  milk, 
vegetable  extracts,  one  or  two  eggs,  salt,  and  any  drugs  which  it  is 
desired  that  the  patient  should  take. 

Constipation.— A  careful  watch  should  be  kept  on  the  excretions 
and  any  tendency  to  constipation  overcome  by  the  administration 
of  aperients  or  enemata.  If  symptoms  of  auto-intoxication  present 


io8o  Landry's  Paralysis. 

themselves  intestinal  disinfectants  such  as  salol  or  beta-naphthol, 
in  5-gr.  doses,  may  be  given  an  hour  or  two  after  food. 

Late  Stages. — With  advancing  dementia  and  increasing  motor 
paralysis  the  treatment  of  the  patient  resolves  itself  into  careful 
nursing  and  attention  to  the  functions  of  the  alimentary  canal 
and  excretory  organs.  Meals  should  be  supervised  by  the  atten- 
dant and  the  food  given  in  such  a  form  that  little  mastication  is 
necessary.  The  tendency  to  bedsores  and  bruises  as  well  as  to 
bony  fractures  must  be  remembered  in  managing  and  nursing  the 
patient.  The  use  of  a  water  bed,  strict  attention  to  the  bowels 
and  bladder,  and  careful  cleansing  of  the  skin  are  the  chief  pre- 
cautions to  be  taken.  The  advent  of  some  serious  complication, 
such  as  pneumonia,  can  generally  be  recognised  at  an  early  stage 
by  keeping  a  record  of  the  temperature. 

E.  FARQUHAR  BUZZARD. 


LANDRY'S    PARALYSIS. 

THE  treatment  of  acute  ascending  motor  paralysis  must  remain 
essentially  empirical  and  symptomatic  until  the  problem  of  its 
etiology  is  solved.  In  the  majority  of  cases  it  appears  to  be  an 
acute  infective  condition,  and  treatment  such  as  is  suitable  for  any 
acute  infection  must  be  adopted.  The  chief  danger  to  life  results 
from  respiratory  embarrassment,  to  the  relief  of  which,  therefore, 
special  attention  is  to  be  directed.  Buzzard  thinks  the  adminis- 
tration of  atropine  or  belladonna,  with  strychnine,  may  relieve 
respiratory  distress  by  diminishing  bronchial  secretion  w7hen  the 
intercostal  muscles  and  diaphragm  become  involved.  Treatment 
on  hygienic  lines,  such  as  for  acute  myelitis,  is  to  be  prosecuted  in 
this  disease. 

In  some  recent  epidemics  of  acute  poliomyelitis  a  number  of 
cases  clinically  indistinguishable  from  Landry's  paralysis  have 
been  recorded. 


S.    A.    KINNIER    WILSON. 


REFERENCES. 


Buzzard,  E.  F.,  Goulstonian  Lectures,  "Brain,"  1907,  XXX.,  p.  1. 

"  Epidemic  Poliomyelitis,"  Eeport  of  the  Collective  Investigation  Committee 
of  the  New  York  Epidemic  of  1907,  New  York  (Journal  of  Nervous  and  Mental 
Disease  Publishing  Co.),  1910. 


io8i 


PROGRESSIVE    MUSCULAR  ATROPHY. 

PROGKBSSIVB  MUSCULAR  ATROPHY  of  spinal  origin,  with  which,  for 
the  purposes  of  this  article,  chronic  anterior  poliomyelitis  may  be 
taken  to  be  synonymous,  is  a  disease  which,  unfortunately,  does 
not  offer  much  scope  for  therapeutic  consideration.  It  is  a  sound 
rule  in  therapeutics  that  where  numerous  medicaments  are  in 
vogue  for  a  particular  disease  no  one  of  them  is  of  any  striking 
value.  All  ordinary  nerve  tonics  have  been  utilised  to  combat  the 
progress  of  the  spinal  degeneration  that  characterises  this 
condition,  but  the  consensus  of  neurological  opinion  to-day  declares 
one  and  all  equally  inefficacious.  Sir  William  Gowers,  it  is  true, 
holds  that  the  administration  of  strychnine  by  hypodermic 
injection  is  a  method  of  treatment  capable  of  arresting  the  disease 
in  50  per  cent,  of  cases.  "  In  seven  almost  consecutive  cases,  in 
middle  life,  this  treatment  has  been  followed  by  arrest  within  a 
month  of  its  commencement,  and  the  arrest  has  been  permanent 
in  all  the  cases  but  one.  In  the  senile  cases  the  treatment 
has  failed.  .  .  .  One  injection  daily  has  been  given.  .  .  . 
The  nitrate  is  the  most  convenient  salt,  g1^  gr.  at  first, 
quickly  increased  to  ^  or  j1-.  The  injections  need  to  be 
continued  for  months.  .  .  ."  The  authority  which  Sir  William 
Gowers'  experience  lends  to  any  statement  published  by  him 
is  sufficient  excuse  for  the  quotation  of  the  above,  yet 
strychnine  has  often  been  tried  in  vain.  While  at  present  the 
belief  is  general  that  no  drug  is  proved  to  have  a  specific  action 
in  the  treatment  of  progressive  muscular  atrophy,  we  need  not 
consider  ourselves  therapeutically  helpless  in  face  of  the  disease. 
Any  treatment  that  maintains  the  patient's  general  nutrition  is 
indirectly  serviceable,  hence  the  administration  of  nerve  and 
general  tonics  ought  to  be  systematically  pursued.  Possibly  some 
of  the  newer  combinations  of  arsenic  deserve  a  thorough  trial. 
Formic  acid  and  the  formates  are  apparently  of  little  use. 
Phosphorus  in  different  forms  has  been  employed.  Organic 
compounds  such  as  lecithin  or  nuclein  may  be  worth  a  trial.  If 
the  reports  of  the  remarkably  beneficial  use  of  the  latter  in  general 
paralysis  are  substantiated  it  should  be  tried  in  progressive 
muscular  atrophy.  Where  such  a  grave  disease  is  concerned  no 
treatment  should  be  ignored  because  of  its  novelty  or  apparent 
bizarrerie. 


1082          Progressive  Muscular  Atrophy. 

Electrical  treatment  has  been  faithfully  administered  over 
prolonged  periods  in  many  cases  which  the  writer  has  had  oppor- 
tunities of  following,  but  its  ultimate  value  is  questionable,  and 
even  temporary  improvement  is  the  exception.  The  same  may  be 
said  of  massage.  In  regard  to  the  former  Sir  W.  Gowers  makes 
the  shrewd  remark  that  the  disease  is  one  of  those  in  which 
patients  find  it  hard  to  believe  that  electricity  cannot  help  them, 
and  for  this  reason  and  others,  and  also  because  of  the 
tendency  of  the  lay  mind  to  exalt  the  importance  of  local  as 
opposed  to  general  treatment,  electrical  and  massage  treatment 
to  the  affected  muscles  ought  to  be  adopted.  The  galvanic  current 
is  preferable  to  the  faradic,  and  only  currents  of  very  moderate 
strength  should  be  employed. 

Progressive  muscular  atrophy  of  syphilitic  origin  undoubtedly 
occurs,  and  other  etiological  factors  such  as  lead  can  sometimes  be 
traced,  but  the  treatment  of  these  types  with  suitable  drugs  is  none 
the  less  disappointing.  Occasionally,  however,  apparent  improve- 
ment has  followed  the  exhibition  of  mercury  and  the  iodides,  and 
this  is  recommended  by  Marie  and  Leri  as  a  routine  measure  in 
all  cases  of  progressive  muscular  atrophy,  unless  it  is  contra- 
indicated. 

With  progressive  muscular  atrophy  involvement  of  motor  cranial 
nerve  nuclei  is  not  infrequently  associated.  Sometimes  the  disease 
begins  in  this  way  (see  Bulbar  Palsy). 

In  various  spinal  cord  diseases,  referred  to  elsewhere,  muscular 
atrophy  may  occur  as  a  clinical  symptom  (see  Syringomyelia, 
Haematomyelia,  Tabes  Dorsalis).  It  may  be  a  symptom  in  spinal 
tumour. 

S.    A.    KINNIER    WILSON. 

KEFEBENCES. 

Gowers,  Sir  W.  E.,  "  Diseases  of  the  Nervous  System,"  3rd  edition  (Gowers 
and  Taylor),  London  (Churchill),  1899,  p.  531. 

Marie,  P.,  and  Leri,  A.,  article  "  Atrophie  Musculaire  Progressive  Spinale," 
in  Charcot- Bouchard  "  Traite  de  Medecine,"  Paris,  1904,  IX.,  632. 

Wilfred  Harris,  Lancet,  1910,  II.,  551. 


io83 


SUB-ACUTE    COMBINED    DEGENERATION    OF   THE 
SPINAL  CORD. 

THIS  disease,  which  is  practically  confined  to  the  latter  half  of  life, 
is  characterised  by  primary  diffuse  focal  lesions  of  the  spinal  cord, 
with  system  degenerations  secondary  thereto.  It  usually  runs  a 
steadily  progressive  course  to  a  fatal  termination  in  from  one  to  four 
years,  but  under  careful  treatment  many  cases  improve  temporarily, 
and  remissions  of  considerable  length  may  occur.  It  is  doubtful  if 
any  cases  really  recover,  but  occasionally  patients  who  present  many 
of  its  symptoms  remain  in  an  unchanging  state  for  long  periods. 

The  nervous  symptoms  are  very  frequently  associated  with  a  severe 
anaemia,  occasionally  a  true  pernicious  anaemia,  but  more  commonly 
a  secondary  anaemia  of  varying  intensity.  This  anaemia  has  been 
regarded  as  the  causal  factor  of  the  spinal  degeneration,  but  it  is 
now  generally  believed  that  they  are  related  not  as  cause  and  effect, 
but  as  concomitant  effects  of  a  single  pathological  agent  (Collier). 
We  are  as  yet  unaware  of  the  nature  of  this  etiological  factor,  but 
it  has  been  assumed  that  it  is  a  toxin  due  to  disturbed  meta- 
bolism, or  one  absorbed  from  the  intestinal  tract. 

Treatment  has  been  generally  directed  by  the  association  of  the 
spinal  disease  with  the  anaemia,  and  on  the  hypothesis  that  the 
latter  is  due  to  chronic  oral  or  intestinal  affections  attention  has 
been  given  to  the  treatment  of  septic  and  infective  conditions  of 
the  mouth  and  gastro-intestinal  tract,  but  apparently  with  little 
satisfactory  result.  Intestinal  antiseptics,  which  are  frequently 
recommended,  should,  however,  be  tried. 

The  drug  that  gives  the  best  result  is  arsenic  in  moderately  large 
doses  extended  over  a  long  period  ;  it  frequently  produces  a  remark- 
able temporary  improvement  in  the  spinal  symptoms  as  well  as  in 
the  anaemia.  It  may  advantageously  be  combined  with  iron.  Its 
organic  combinations,  as  atoxyl  and  soamin,  have  been  recom- 
mended for  hypodermic  administration,  but  the  dangerous  toxic 
effects  they  occasionally  manifest  makes  it  imperative  to  employ 
them  with  care  in  a  disease  in  which  the  resistance  of  the  tissues  is 
unquestionably  lowered. 

We  can  unfortunately  rarely  hope  to  relieve  the  symptoms  that 
are  fully  developed,  but  in  the  middle  and  early  stages  of  the  disease 
the  gait  and  the  use  of  the  arms  may  be  much  improved  by  careful 
massage  of  the  limbs,  and  in  cases  in  which  remissions  occur  at  the 


1084     Combined  Degeneration  of  the  Spinal  Cord. 

stage  in  which  ataxia  of  movement,  and  especially  of  the  legs,  is  the 
most  troublesome  symptom,  I  have  seen  remarkable  benefit  obtained 
by  the  re-education  of  movement  on  Fraenkel's  system. 

The  panesthesiae  are  often  the  symptoms  of  which  the  patient 
complains  the  most ;  it  is  difficult  and  often  impossible  to  remove 
these  sensations  of  numbness,  tingling  or  formication,  but  relief 
may  be  often  obtained  by  gentle  faradism  applied  with  a  brush  to 
the  skin.  Bromides  in  moderate  doses  and  coal-tar  drugs,  as 
phenacetin  and  ammonol,  often  alleviate  the  discomfort. 

The  sphincter  disturbances  must  be  carefully  considered.  Con- 
stipation is  almost  the  rule,  and  must  be  treated  by  the  ordinary 
appropriate  means.  The  tendency  to  retention  of  urine  and  over- 
distension  of  the  bladder  is  more  serious.  Catheterisation  becomes 
almost  invariably  necessary,  but  should  be  delayed  as  long  as 
possible,  owing  to  the  danger  of  urinary  infection  and  the 
difficulty  in  avoiding  it.  As  any  sudden  distension  of  the  bladder 
and  stretching  of  its  walls  may  seriously  impair  its  functions,  over- 
distension  must  be  regarded  as  a  serious  danger.  It  is  best  obviated 
by  careful  and  constant  observation,  and  especially  by  urging  the 
patients  from  the  early  stage  of  the  disease  to  attempt  to  empty 
the  bladder  at  regular  intervals,  for  instance,  every  two  or  three 
hours,  whether  they  feel  the  need  of  it  or  not.  If  cystitis  occurs, 
systematic  antiseptic  irrigation  of  the  bladder  is  imperative, 
combined  with  the  administration  of  urinary  antiseptics,  of  which 
urotropine  is  the  most  effective. 

The  troublesome  reflex  spasms  of  the  latter  stages  of  the  disease  can 
be  best  relieved  by  moderate  but  frequently  repeated  doses  of  veronal. 

Sub-acute  combined  degeneration  is,  however,  a  disease  in  which 
the  regulation  of  the  patient's  mode  of  life  and  careful  nursing  are 
more  important  than  any  medicinal  treatment.  A  regular  out-door 
life  and  plenty  of  fresh  air  should  be  prescribed,  and  food  should  be 
as  simple  but  as  nourishing  as  possible.  Bedsores,  which  often 
develop  relatively  early  in  the  bed-ridden  stage,  owing  to  the 
anaemia  and  the  low  vitality  of  the  tissues,  hasten  the  fatal  ter- 
mination of  the  illness.  They  can  be  avoided  only  by  careful 
nursing  and  the  use  of  water-  or  air-beds  or  cushions.  The  ordinary 
draw-sheets  may  be  replaced  or  covered  by  sheets  of  chamois  leather, 
as  these  are  less  liable  to  become  wrinkled  or  folded,  and  thus  exert 
unequal  pressure  on  the  skin. 

GORDON  HOLMES. 

EEFERENCE. 
Collier,  J.,  "Allbutt's  System  of  Medicine,"  2nd  edit.,  1910,  VII.,  p.  786. 


io85 


TABES   DORSALIS. 

A  CONSIDERABLE  change  has  been  effected  in  the  treatment  of  tabes 
by  the  growing  belief  that  the  affection  is  syphilitic  in  origin. 
There  are,  however,  those  who,  while  admitting  that  there  are  good 
reasons  to  believe  that  without  syphilis  there  would  be  no  such 
disease  as  tabes,  nevertheless  deny  the  possibility  of  good  from 
anti-syphilitic  treatment  of  patients  affected  by  the  malady,  and 
who,  accordingly,  rely  entirely  on  a  tonic  line  of  treatment  in  the 
affection.  It  is  assumed  that  the  effects  of  syphilis  which  result  in 
the  disease  are  too  remote  from  the  original  infection  to  make  it  in 
the  least  likely  that  remedies  which  are  known  to  produce  beneficial 
results  in  the  earlier  manifestations  of  syphilis  can  possibly  effect 
good  in  the  so-called  para-syphilitic  affections,  tabes  and  general 
paralysis.  However  true  this  may  be  of  general  paralysis,  the 
argument  does  not  apply  to  tabes ;  for  no  one  who  has  had  much 
experience  of  the  results  of  anti-syphilitic  treatment  of  this  affection 
can  fail  to  recognise  the  good  that  results  in  many  cases.  The  fact 
that  the  Wassermann  test  for  syphilis  proves  positive  in  so  many 
of  those  suffering  from  tabes  is  good  evidence  that  the  syphilitic 
virus  is  still  active  in  these  people,  and  that  anti-syphilitic  treat- 
ment may  accordingly  be  reasonably  expected  to  do  good  if  properly 
employed.  It  is  not  suggested  that  any  amount  of  mercury  or 
iodide  of  potassium  can  be  expected  to  remove  sclerosis  of  the  dorsal 
tracts  after  this  condition  has  been  definitely  established,  but  it  is 
contended  in  all  reasonableness  that,  whatever  view  we  accept  as  to 
the  way  in  which  syphilis  brings  about  this  sclerosis,  there  must  be 
an  early  stage  in  which,  antecedent  to  the  actual  establishment 
of  sclerosis,  the  early  lesions  which  ultimately  result  in  this  can 
be  influenced  by  anti-syphilitic  treatment ;  and,  moreover,  that  the 
toxins  of  syphilis  can  be  so  neutralised  that  fresh  lesions  and 
further  progress  of  the  affection  of  the  nervous  system  can  be  pre- 
vented. All  that  is  claimed  for  the  anti-syphilitic  treatment  of 
tabes,  therefore,  is  the  arrest  of  the  morbid  process  at  various  stages 
of  its  progress,  and  not  cure  in  the  sense  of  removal  of  damage, 
such  as  sclerosis  of  the  dorsal  tracts  of  the  cord,  a  condition 
of  things  which,  if  once  established,  must  apparently  remain 
permanent. 

The  attempt  is,  however,  made  to  influence  the  process  also  by 


io86  Tabes  Dorsal  is. 

the  administration  of  fibrolysin  concurrently  with  the  anti-syphilitic 
treatment.  The  wonderful  effects  produced  by  this  drug  on  scar 
tissue  of  external  parts  which  can  be  reached  directly  encourage 
the  hope  that  it  may  even  exert  a  favourable  influence  on  deep- 
seated  internal  structures.  Favourable  as  have  been  the  results 
recorded  by  some  observers,  however,  it  does  not  seem  probable 
that  much  good  is  to  be  expected  from  the  use  of  fibrolysin,  in  so 
far  as  we  are  concerned  with  the  removal  of  sclerotic  tissue  from 
the  central  nervous  system.  This  treatment  is  worthy  of  trial,  in 
the  hope  that,  although  it  does  not  appear  to  influence  sclerosis  of 
long  standing,  it  may  nevertheless  produce  some  effect  on  the 
earlier  manifestations  of  this  process  in  the  central  nervous  system. 
The  treatment  is  not  without  its  risks,  so  that  some  caution  is 
needed  in  the  way  that  it  is  employed. 

The  essential  part  of  the  treatment  of  tabes,  however,  consists  in 
attempting  to  counteract  the  syphilitic  toxins,  and  to  influence  the 
earlier  lesions  of  the  disease   by  means  of  mercury.     Iodide  of 
potassium  has  its  place  in  the  treatment  of  the  affection,  but  this 
must  be  regarded  as  secondary  to  that  which  may  be  justly  claimed 
for  mercury.     Of  the  different  methods  of  employing  the  mercury, 
that   which   consists   in  giving  one  or  other  preparation  by  the 
mouth  should  never  be  selected,  as  this  method  cannot  compare  in  effi- 
cacy with  that  of  administering  the  drug  by  inunction  or  by  intra- 
muscular   injection.     There    are    advantages    and    disadvantages 
attaching  to  both  of  the  latter  methods  of  treatment ;  but  when  it 
is  possible  to  do  so  it  is  best  to  subject  the  patients  to  treatment  by 
inunction,  on  the  plan  adopted  at  Aachen  (Aix  la  Chapelle).     There 
are,  however,  cases  in  which,  for  various  private  and  other  reasons, 
it  is  not  politic  for  the  patient  to  undergo  a  cure  of  the  kind,  either  in 
this  country,  at  Aachen,  or  some  other  place  where  such  treatment 
can  be  secured,  so  that  preference  has  to  be  given  to  intra-muscular 
injections,  in  which  case  grey  oil  proves  one  of  the  most  satisfactory 
preparations  of  mercury  for  use  in  this  way,  and  may  be  given  in 
10-minim  doses  once  a  week.    Then,  again,  in  the  treatment  of  tabes 
among   out-patients   in  hospital  practice  the  injection  treatment 
proves  of  decided  advantage,  for  the  reason  that  administration  of 
mercury  by  the  mouth  is  not  to  be  recommended,  and  the  practice 
of  giving  patients  mercurial  ointment  to  be  rubbed  in  by  themselves 
cannot  be  too  strongly  deprecated,  as  it  is  only  calculated  to  bring 
discredit  on  a  plan  of  treatment  which,  if  carried  out  properly  in 
suitable  cases,  results  in  so  much  benefit  to  many  of  those  who 
suffer  from  this  disease.     In  the  selection  of  cases  for  treatment  by 
mercury  the  interval  which  has  elapsed  between  the  primary  lesion 


Tabes  Dorsal  is.  1087 

and  the  first  manifestations  of  the  affection  of  the  spinal  cord 
should  not  be  allowed  to  influence  us;  for  although,  as  may 
reasonably  be  expected,  the  shorter  the  interval  the  more  benefit  is 
to  be  expected,  the  opposite  does  riot  hold  good,  for  benefit  may  be 
expected  from  mercurial  treatment  even  where  the  interval  has 
been  long,  provided  that  the  treatment  is  instituted  at  an  early 
stage  of  the  spinal  affection. 

It  must  not  be  concluded  that  the  mercurial  treatment  is  only  to 
be  recommended  when  the  Wassermann  reaction  proves  positive ; 
for  although  this  test  often  proves  a  useful  guide  as  to  how  soon  a 
course  of  mercurial  treatment  should  be  repeated,  a  negative  result 
of  the  test  should  not  be  allowed  to  influence  us  to  the  extent  of 
withholding  either  the  first  or  some  subsequent  course  of  mercurial 
treatment  in  the  case  of  a  person  suffering  from  tabes.  Where  it  is 
at  all  possible,  the  patient  should  be  advised  to  go  to  Aachen  for  the 
treatment ;  but  when  this  is  not  possible  there  are,  of  course,  other 
health  resorts  abroad  and  in  this  country  where  the  treatment  can 
be  secured.  With  few  exceptions,  however,  the  treatment  is  carried 
out  in  the  most  perfunctory  fashion  in  this  country,  even  at  many 
places  where  the  cure  is  undertaken  ;  but  there  are  some  places 
where  the  treatment  is  properly  carried  out,  although  these  are  few. 
Nowhere  is  the  treatment  so  thorough  as  at  Aachen,  so  that  there 
can  be  no  doubt  that  patients  should  be  encouraged  to  go  there  for 
their  cure  when  this  is  possible. 

•  Various  modifications  of  the  treatment  as  carried  out  at  Aachen 
have  to  be  adopted  according  to  circumstances.  When  it  is 
not  possible  for  the  cure  to  be  undertaken  there,  a  good  plan  is  to 
encourage  the  patient  to  have  daily  rubbings  of  1  drachm  of  blue 
ointment  for  a  period  of  about  three  months,  or  about  100  in  all,  to 
be  followed  by  fifty  more  similar  rubbings  in  three  to  six  months. 
Similar  courses  of  fifty  inunctions  should  be  repeated  every  six 
months  during  the  next  three  years  or  more,  the  exact  length  of 
time  that  the  treatment  is  continued  being  determined  by  the  course 
of  the  disease.  When  sulphur  baths  cannot  be  conveniently  obtained, 
an  ordinary  hot  bath  may  be  substituted,  or  a  hot  compress  may  be 
applied  for  about  twenty  minutes  to  the  part  immediately  before 
the  ointment  is  applied  to  it.  Careful  attention  must  be  given  to 
the  gums,  so  that  the  patient  should  be  encouraged  to  clean  the 
teeth  after  each  meal,  and  to  follow  this  by  using  a  mouth-wash 
consisting  of  10  gr.  to  1  oz.  of  chlorate  of  potash.  The  kidneys 
and  bowels  must,  of  course,  be  carefully  watched  for  any  indications 
of  affection  of  them  by  the  mercury. 

Iodide  of  potassium  has  its  place  in  the  treatment  of  the  disease, 


io88  Tabes  Dorsalis. 

and  is  sometimes  administered  by  the  mouth  concurrently  with  the 
course  of  mercury.  A  plan  to  be  preferred,  however,  is  to  give 
the  iodide  in  the  intervals  between  the  courses  of  mercury. 
Whichever  plan  is  adopted,  a  dose  of  20  gr.  three  times  a  day, 
in  conjunction  with  \  drachm  of  aromatic  spirits  of  ammonia 
or  3  or  4  minims  of  Fowler's  solution  of  arsenic,  usually 
proves  sufficient.  The  drug  is,  however,  sometimes  effective  in 
cutting  short  a  paroxysm  of  lightning  pains,  in  which  case  even 
larger  doses,  e.g.,  40  gr.  three  times  a  day,  may  be  required  to 
secure  this  result.  Where  ordinary  iodide  is  borne  badly,  iodo- 
glidin,  tiodine  or  iodipin  prove  useful  substitutes ;  while  tiodine 
(3  gr.)  and  iodipin  (30  minims)  have  the  further  advantage  that  they 
can  be  administered  by  subcutaneous  injection  once  daily  without 
the  risk  of  disturbing  the  alimentary  tract. 

The  fact  that  good  is  claimed  for  mercury  and  iodide  naturally 
raises  the  question  as  to  whether  salvarsan  "  606  "  may  be  expected 
to  assist  us  in  the  treatment  of  tabes.  Brilliant  as  have  been  the 
results  of  the  treatment  of  many  syphilitic  affections  by  this  prepara- 
tion, it  cannot  be  said  that  we  are  yet  in  a  position  to  come  to  any 
very  definite  conclusion  in  regard  to  its  efficacy  in  the  treatment  of 
this  disease.  Indeed,  there  is  reason  to  fear  that  we  are  not  to 
derive  much  assistance  from  this  course,  except  that  we  may  hope 
that,  by  its  use  in  the  treatment  of  the  primary  syphilitic  lesion, 
diseases  like  tabes  and  general  paralysis  may  be  rendered  less 
liable  to  follow  in  the  wake  of  syphilis.  The  treatment  cannot, 
however,  be  said  to  have  had  a  sufficiently  extensive  trial  in  the 
treatment  of  tabes  to  justify  our  withholding  it  in  what  wrould 
otherwise  appear  to  be  suitable  cases  for  its  use.  The  unfortunate 
circumstances  that  have  attended  the  use  of  another  arsenical 
preparation,  soamin,  have  naturally  led  to  the  suspicion  that 
"606"  may  not  be  entirely  free  from  risk  in  so  far  as  sight  is 
concerned,  and  thus  many  have  had  considerable  hesitation  in 
using  this  preparation  of  arsenic  in  a  disease  like  tabes,  in  which 
optic  atrophy  is  one  of  the  conditions  to  be  feared  in  the  ordinary 
course  of  the  malady.  The  evidence  as  to  whether  or  not  "  606  " 
does  cause  optic  neuritis  or  atrophy  is  conflicting  at  present,  so 
that  until  we  are  in  a  position  to  be  sure  that  this  danger  does  not 
exist,  or  that  it  is  sufficiently  remote  to  justify  our  accepting  the 
risk,  there  must  be  a  certain  amount  of  hesitation  in  recommending 
a  line  of  treatment  in  which  as  yet  there  have  been  no  large  amount 
of  successes  to  be  recorded  in  so  far  as  tabes  is  concerned. 

Other  Medicinal  Remedies.— Nitrate  of  silver  was  at  one  time 
much  used  in  the  treatment  of  tabes,  and  there  are  those  who  still 


Tabes  Dorsal  is.  1089 

advocate  the  use  of  silver,  either  in  this  or  in  some  other  form. 
Tonics  of  various  kinds  are  called  for  as  adjuncts  in  the  treatment 
of  patients  suffering  from  tabes,  and  strychnine  claims  a  prominent 
place  among  these.  Strychnine  is,  of  course,  specially  indicated  in 
those  cases  in  which  paralysis  and  muscular  atrophy  form  part  of 
the  clinical  picture  of  the  disease,  and  may  be  given  by  the  mouth, 
or  by  intra-muscular  injection.  The  drug  is,  however,  useful  in 
the  treatment  of  any  case  of  the  affection,  irrespective  of  whether 
or  not  paralysis  exists,  and  may  be  given  in  the  intervals  between 
the  courses  of  anti-syphilitic  treatment ;  or  in  the  form  of  nux 
vomica  combined  with  iodide  of  potassium  when  this  is  being  used 
in  the  treatment  of  the  patient.  It  is  well  not  to  give  strychnine 
too  freely,  however,  when  lightning  pains  are  troublesome,  for,  like 
alcohol,  it  may  tend  to  increase  these.  Arsenic,  in  the  form  of 
Fowler's  solution,  may  be  similarly  employed,  as  may  iron  or  any 
other  form  of  tonic  for  which  there  may  be  any  preference  on  the 
part  of  the  patient  or  his  doctor.  Cod-liver  oil  and  the  various 
preparations  of  malt  similarly  find  a  place  in  the  treatment  of 
these  patients,  in  view  of  the  fact  that  progressive  loss  of  flesh 
proves  such  a  striking  feature  in  so  many  cases. 

No  special  symptom  calls  for  assistance  so  frequently  as  pain. 
Indeed,  not  only  is  this  such  a  constant  and  prominent  symptom 
of  the  disease,  but  it  usually  occasions  distress  so  early  in  the 
life-history  of  the  malady  that  it  is  commonly  mistaken  for 
"  rheumatism,"  "  neuritis,"  or  some  other  condition,  and  its  real 
cause  is  not  suspected  for  a  long  time.  There  was  a  time  when 
opium,  in  some  form,  could  alone  be  relied  on  to  quell  the  pains 
of  tabes ;  but,  thanks  to  the  introduction  of  the  various  modern 
analgesics,  it  is  now  rarely  necessary  to  prescribe  morphia 
for  the  relief  of  lightning  and  other  pains  that  occur  in  tabes. 
Various  analgesics,  including  aspirin,  pyramidon,  phenacetin, 
phenazone,  antifebrin,  exalgin,  phenalgin,  etc.,  must  be  tried  in 
turn  or  in  different  combinations  until  it  is  determined  which  suits 
the  patient  best ;  for  that  which  succeeds  in  one  patient  may  fail  in 
another.  A  combination  that  often  proves  useful  in  cachet  is : 
1  gr.  of  citrate  of  caffeine,  7  gr.  of  aspirin  and  10  gr.  of 
either  pyramidon  or  phenacetin.  It  sometimes  happens  that 
obstinate  cases  are  met  with  in  which  none  of  -these  preparations 
give  any  relief,  and  in  which  we  are  reluctantly  compelled  to  resort 
to  morphia.  As  has  already  been  said,  large  doses  of  iodide  of 
potassium,  given  continuously  for  some  weeks,  have  a  very  decided 
influence  in  checking  the  tendency  to  paroxysms  of  pain  in  some 
cases.  Counter-irritation  of  the  spine,  by  the  cautery  or  otherwise, 

S.T. — VOL.  ii.  69 


1090  Tabes  Dorsal  is. 

may  similarly  prove  helpful.  When  pain  is  localised  to  a  given 
region  and  of  a  fixed  character,  considerable  relief  is  often  obtained 
by  the  application  of  a  stimulating  liniment  to  the  part,  a  plan  of 
treatment  that  is  more  especially  likely  to  succeed  when  the  pain 
appears  to  be  superficial  in  character. 

Whatever  other  plans  are  adopted  in  the  treatment  of  the  pains 
of  tabes,  it  is  certain  that  physical  and  mental  rest  are  important 
factors,  and  that  warmth,  with  the  avoidance  of  cold  and  damp,  are 
equally  important  conditions  to  be  secured.  Similar  methods  of 
treatment  must  be  employed  for  the  various  crises  to  which  these 
patients  are  liable,  but  for  which  it  may  become  necessary  to  have 
recourse  to  morphia.  Nothing  short  of  morphia  is  usually  of  much 
avail  in  the  treatment  of  severe  gastric  crises,  but  bismuth  and 
other  gastric  sedatives  may  be  of  some  assistance,  as  may  lavage  of 
the  stomach  and  the  avoidance  of  all  food  by  the  mouth  for  a  time, 
the  patient  being  fed  by  the  bowel.  A  mustard  leaf  to  the 
epigastrium,  and  counter-irritation  to  the  spine  in  the  region  of  the 
seventh  to  the  tenth  thoracic  nerves,  are  supplementary  measures 
that  may  be  tried  in  the  treatment  of  these  crises.  It  is  of  great 
importance  that  such  patients  should  be  fed  liberally  in  the 
intervals  between  their  attacks  of  pain  and  vomiting,  so  as  to 
assist  them  to  combat  the  exhaustion  induced  by  the  severity  of  the 
crises,  and  their  inability  to  retain  food  in  the  stomach  during  the 
attacks.  In  severe  and  obstinate  cases  of  the  kind,  complete  relief 
has  been  obtained  by  section  of  the  dorsal  roots  of  the  seventh 
to  the  tenth  thoracic  nerves,  a  procedure  that  should,  however,  be 
reserved  for  cases  that  have  resisted  all  other  methods  of  treatment. 

W7hen  the  sphincter  of  the  bladder  proves  troublesome,  belladonna 
(5  to  10  minims  of  the  tincture  three  times  a  day)  often  is  most 
helpful ;  but  the  difficulties  may  be  such  that  cystitis  is  to  be  feared, 
in  which  case,  even  where  catheterisation  has  not  become  necessary, 
it  is  a  wise  precaution  to  give  the  patient  10  gr.  of  urotropine  by 
the  mouth  once  or  twice  a  day.  If  the  use  of  the  catheter  becomes 
necessary,  the  strictest  aseptic  precautions  must  be  enjoined  in  its 
use ;  while  cystitis  must  be  treated  by  daily  lavage  of  the  bladder,  in 
addition  to  the  use  of  urotropine  by  the  mouth. 

Rest  and  the  avoidance  of  undue  fatigue  are  important  adjuncts 
in  the  treatment  of  the  disease  in  general ;  but  in  recommending 
patients  suffering  from  tabes  to  take  physical  rest,  they  must  always 
be  warned  not  to  remain  entirely  in  bed  or  on  a  couch,  for  the 
reason  that  such  absolute  rest  carries  with  it  the  risk  that  the 
longer  the  patient  is  off  his  feet  the  greater  the  danger  of  his 
increasing  the  inco-ordination  which  exists  or  is  threatened  in  the 


Tabes  Dorsalis.  1091 

lower  limbs.  When  it  is  at  all  possible,  therefore,  the  patient  should 
at  least  walk  about  his  room  for  a  short  time  every  day,  even  if  he 
does  nothing  more  ;  and  when  there  are  reasons  why  he  is  unable 
to  leave  his  bed  or  couch,  some  of  the  exercises  to  be  recommended 
in  the  treatment  of  the  inco-ordination  which  results  in  the  disease 
ought  to  be  carried  out  if  the  conditions  permit  of  these. 

The  inco-ordination,  which  is  such  a  source  of  inconvenience, 
and  which  causes  so  much  disability  in  tabes,  is  capable  of 
being  most  favourably  influenced  in  a  large  proportion  of  cases, 
notably  in  the  earlier  stages  of  the  disease,  by  means  of  a  series 
of  exercises  devised  by  Professor  Fraenkel  for  the  re-educa- 
tion of  the  affected  muscles.  Some  have  been  devised  for  the 
arms,  and  others  for  the  legs ;  and  in  the  case  of  the  lower  limbs 
there  are  exercises  which  the  patient  can  perform  in  a  recumbent 
posture,  and  others  which  necessitate  his  standing  and  walking. 
The  essential  feature  of  the  exercises  is  that  the  muscles  are  trained 
to  perform,  slowly  and  with  precision,  a  series  of  movements  which 
are  at  first  simple,  and  which  are  made  more  and  more  complex  as 
the  treatment  is  in  progress.  The  patient  must  be  made  to  under- 
stand that  he  must  concentrate  his  whole  attention  on  the' exercises 
when  they  are  being  performed,  and  that  while  sight  permits  him  to 
recognise  his  mistakes,  and  allows  of  his  attempting  to  correct 
them,  he  must  learn  to  give  the  fullest  possible  attention  to  the 
appreciation  of  the  sensations  engendered  in  the  limbs  by  the 
movements,  so  that  he  is  enabled,  in  time,  to  rely  on  these  sensations 
for  his  guidance  in  the  execution  of  the  various  movements  of  the 
limbs  without  the  assistance  of  vision.  The  mental  concentration 
that  is  necessary  readily  induces  mental  as  well  as  physical  fatigue 
at  first,  so  that  it  is  important  that  the  patient  should  only  perform 
the  exercises  for  so  short  a  time  each  day  that  fatigue  is  avoided 
This  is  usually  best  secured  by  only  allowing  the  exercises  to  be 
practised  for  ten  minutes  three  times  a  day.  The  time  can  be 
gradually  increased  until  half  an  hour,  and  it  may  be  even  an  hour, 
is  devoted  to  their  performance  three  times  a  day. 

In  addition  to  their  value  in  cases  in  which  paralytic  manifesta- 
tions complicate  the  more  usual  picture  of  tabes,  massage  and 
electrical  treatment  are  useful  adjuncts  to  the  exercises  for  the 
improvement  of  inco-ordination,  for  they  assist  in  keeping  up  the 
tone  of  the  muscles,  and  are  helpful  in  making  numbness  and 
cutaneous  anaesthesia  less  obtrusive.  Care  must  be  taken  to  see 
that  the  amount  of  massage  given  does  not  cause  undue  fatigue,  and 
that  a  proper  rest  is  secured  for  the  patient  in  the  recumbent  posture 
after  the  treatment.  Faradism  is  the  form  of  electricity  which 

69—2 


1092  Tabes  Dorsalis. 

usually  proves  most  helpful,  but  galvanism  may  be  called  for  in 
cases  with  peripheral  paralysis  and  muscular  atrophy.  It  has  also 
been  supposed  to  do  good  when  applied  to  the  spine,  but  it  cannot 
be  said  that  this  plan  has  much  to  recommend  it. 

Apart  from  the  place  which  sulphur  baths  take  in  the  Aachen 
treatment,  it  cannot  be  said  that  hydropathic  measures  are  of 
much  advantage  in  the  treatment  of  tabes ;  and  neither  very  hot 
nor  very  cold  baths  are  usually  at  all  well  borne  by  the  subjects  of 
this  disease. 

As  these  patients  usually  lose  flesh  to  a  marked  degree,  their  diet 
should  be  liberal  and  nutritious,  and  should  include  as  much  milk 
food  and  cream  as  they  can  digest.  Alcohol  is  best  avoided,  as  a 
rule,  for  the  reason  that  although  whisky  or  some  other  form  of 
alcoholic  stimulant  may  relieve  an  attack  of  pain,  there  can  be 
little  doubt  that  alcohol  keeps  up  the  tendency  to  recurrence  of  the 
pains.  Patients  suffering  from  tabes  should  try  to  secure  a  climate 
that  is  dry  and  warm,  and  those  who  usually  reside  in  this  country 
should  seek  a  climate  of  the  kind  abroad  during  our  winter  months. 
Cold  and  damp  are  both  best  avoided,  as  far  as  possible,  for  the  reason 
that  those  affected  by  tabes  are  never  so  well  under  such  conditions, 
and  the  pains  often  are  made  considerably  worse. 

J.  S.  RISIEN  RUSSELL. 


1093 


DISEASES  AND  AFFECTIONS  OF  THE  NERVES. 

FACIAL    PARALYSIS. 

PARALYSIS  of  the  facial  muscles  may  result  from  any  interrup- 
tion of  the  nerve  path  between  the  cerebral  cortex  and  the  muscles. 
Thus  the  lesion  may  be  in  the  upper  neurons,  which  extend  from 
the  ganglionic  centre  in  the  ascending  frontal  convolution  to  the 
nucleus  in  the  pons  ;  or  in  the  lower  neurons,  which  include  the 
facial  nucleus  and  the  motor  fibres  which  extend  from  it  to  the 
muscles. 

For  the  purposes  of  this  article  the  internal  auditory  meatus 
may  be  taken  as  a  point  of  separation  between  two  portions  of  the 
path,  namely :  (1)  an  intra-cranial  part,  or  the  path  through  the 
brain  and  across  the  posterior  cranial  fossa ;  and  (2)  a  peripheral 
part,  constituted  by  the  nerve  as  it  passes  along  the  Fallopian  canal 
and  out  through  the  stylo-mastoid  foramen,  to  be  distributed  to  the 
facial  muscles  of  expression,  the  platysma,  the  stylo-hyoid  and  the 
posterior  belly  of  the  digastric. 

When  facial  paralysis  is  caused  by  a  lesion  of  the  intra-cranial 
path,  as  above  defined,  it  is  associated  with  symptoms  indicating 
disturbance  of  the  functions  of  other  portions  of  the  brain,  or  of 
other  cranial  nerves.  Thus  if  the  lesion  involves  the  internal 
capsule  there  is  hemiplegia,  if  the  nuclei  of  the  lower  cranial 
nerves  as  well  as  the  nucleus  of  the  seventh,  there  is  bulbar 
paralysis,  and  so  on.  The  treatment  of  these  conditions  is  that  of 
the  haemorrhage,  tumour,  meningitis  or  degeneration  producing 
them,  and  is  considered  elsewhere  (see  Meningitis,  Hemiplegia, 
Tumours  of  the  Brain,  etc.). 

It  is  with  the  treatment  of  disease  of  the  peripheral  part  of  the 
path  that  we  are  now  concerned.  Apart  from  wounds  and  other 
injuries,  the  most  frequent  causes  of  peripheral  facial  palsy  are 
suppurative  middle-ear  disease  and  neuritis.  In  cases  arising  from 
ear  disease  the  treatment  of  this  is  essential  before  any  measures 
are  taken  to  improve  the  condition  of  the  muscles. 

Most  frequently  the  paralysis  depends  on  a  parenchymatous 
neuritis,  which  is  usually  most  marked  in  the  nerve  at  the  distal 
end  of  the  Fallopian  canal.  In  about  80  per  cent,  of  the  cases  the 
neuritis  appears  to  be  set  up  by  exposure  to  cold  :  in  some  of  these 


ic>94  Facial  Paralysis. 

cases  syphilis  or  alcohol  has  been  an  essential  or  a  contributory 
factor.  Very  often,  however,  no  cause  can  be  discovered,  and  we 
have  to  consider  the  possibility  of  microbic  infection,  such  as  that 
which  is  assumed  to  initiate  acute  anterior  polio-myelitis. 

If  suitably  treated,  most  cases  of  peripheral  facial  palsy  make  a 
complete  recovery,  the  mildest  forms  in  a  week  or  two,  the  severest 
forms  in  from  six  to  nine  months.  Occasionally  no  recovery  takes 
place,  and  it  is  common  for  a  trace  of  weakness  to  be  permanent. 

Obviously,  if  there  is  reason  to  believe  that  alcohol  has  been  a 
cause,  this  must  be  prohibited  ;  if  syphilis  is  suspected,  mercury  and 
the  iodides  should  be  administered.  In  all  cases  it  is  desirable  for 
the  patient  to  stay  indoors  for  a  time,  and  even  in  bed,  should  there 
be  much  pain  or  any  febrile  symptoms.  The  neuritis  may  be 
beneficially  influenced  by  counter-irritation  to  the  affected  side  by 
means  of  hot  fomentations  every  three  hours  for  the  first  two  or 
three  days,  and  afterwards  by  the  application  of  a  blister  or  a  mustard 
leaf  to  the  mastoid  process.  Such  an  application  should  not  be  made 
in  front  of  the  ear,  owing  to  the  risk  of  cellulitis  being  set  up.  The 
bowels  should  be  kept  freely  open  ;  in  some  cases  a  mixture  contain- 
ing salicylate  of  sodium  and  iodide  of  potassium  appears  to  do  good. 
At  a  later  period  tonics,  especially  strychnine,  are  often  beneficial. 

For  the  restoration  of  voluntary  power  the  chief  reliance  is  to  be 
placed  on  electricity  and  massage,  and  these  methods  of  treat- 
ment should  be  commenced  as  soon  as  possible.  In  applying  the 
constant  current,  which,  even  before  the  reaction  of  degeneration  is 
present,  is  more  useful  than  the  faradic,  two  small  electrodes  are 
necessary.  The  negative  pole  should  be  held  behind  the  ear  near 
the  stylo-mastoid  foramen,  whilst  the  positive  pole,  which  is  less 
painful  than  the  negative,  is  stroked  across  the  forehead,  around 
the  eye,  down  the  cheek  and  along  the  lips.  The  strength  of  the 
current  should  be  just  enough  to  produce  contraction  of  the  muscles. 
At  first  3  to  5  milliamperes  will  be  necessary,  but  after  the  first 
fortnight,  when  the  reaction  of  degeneration  has  developed,  the 
muscles,  owing  to  their  hyper-excitability  to  galvanism,  may  react 
to  a  weaker  current.  This  method  of  stimulating  the  muscles, 
which  can  be  carried  out  quite  well  by  the  patient  with  the  aid  of 
a  mirror,  should  be  repeated  two  or  three  times  a  day  for  a  period 
of  ten  to  fifteen  minutes,  and  should  be  persisted  in  for  many 
months  or  until  voluntary  power  begins  to  return.  In  the  latter 
case  it  is  well  to  discontinue  electrical  treatment  in  order  to  avoid 
the  tendency  to  undue  tonic  contraction,  which  may  draw  the  mouth 
to  the  paralysed  side. 

After  each  application  of  the  battery,  and  indeed  at  other  times, 


Facial  Paralysis.  IO95 

facial  massage  should  be  employed.  This  also  may  be  done  by  the 
patient  himself;  he  should  rub  the  individual  muscles  with  the 
tips  of  his  fingers,  and  knead  and  compress  those  of  the  cheek  and 
lips  between  the  thumb,  placed  in  the  mouth,  and  the  fingers  out- 
side. It  is  useful  to  rub  the  eyelids  over  the  eyeball,  and  at  night 
to  put  a  compress  over  the  eye  in  order  to  keep  it  closed. 

Massage  and  electrical  treatment  should  be  persevered  in  for  a 
period  of  six  months  ;  if  at  the  end  of  that  time  there  are  no  signs 
of  recovery,  or  if  from  the  first  it  is  evident  that  the  nerve  is 
divided  or  so  completely  injured  that  recovery  is  impossible, 
surgical  intervention  is  called  for.  In  some  cases  the  surgeon  may 
be  able  to  join  together  the  two  segments  of  the  nerve  ;  but  when 
this  is  impossible,  and  also  in  the  intractable  cases  of  neuritis,  the 
question  of  nerve  anastomosis  has  to  be  considered.  It  is  believed 
that  better  results  are  obtained  by  uniting  the  facial  to  the 
hypoglossal  nerve  than  to  the  spinal  accessory,  but  for  information 
on  this  subject  the  reader  is  referred  to  p.  1109. 

JUDSON  S.  BURY. 


1096 


HERPES  ZOSTER. 

HERPES  ZOSTER  is  an  acute  febrile  disease  whose  virus  has  a 
specific  incidence  on  the  posterior  root  ganglia  of  the  spinal  cord, 
and  for  purposes  of  therapeutic  description  it  may  be  considered 
as  being  divisible  into  three  stages. 

(1)  Prodromal  Stage,  of  general  malaise,  with  rise  of   tempera- 
ture and  pains,  more  or  less  severe,  radiating  round  one  side  of  the 
body.      The  treatment  here  is  simply  that  of  any  acute  fever,  to  be 
followed  on  general  lines.     The  pain  may  be  relieved  by  the  local 
use  of  soothing  applications,  such  as  hot  fomentations  with  liq. 
morph.    hydrochlor.    (^   drachm)    [U.S.P.    morphin.    hydrochlor., 
gr.  T3(j]    sprinkled  on  the  side  next  the  skin.     In  spite  of   many 
statements  to  the  contrary,  no  treatment  is  effectual  in  aborting 
the  eruption  (Head). 

(2)  Acute   Stage. — The    characteristic    vesicular   rash   usually 
makes  its  appearance  on  the  third  or  fourth  day,  to  the  continued 
accompaniment  of  pain,  which,  however,  may  vary  much  in  intensity. 
Treatment  during  this  period  (which  lasts  perhaps  ten  days  or  less) 
is  both  local  and  general. 

(a)  LOCAL. — The  chief  indication  is  to  protect  the  vesicles  as  they 
appear  and  to  minimise  the  risk  of  their  contamination  through 
friction  or  contact  with  the  patient's  garments.  For  this  purpose 
the  area  affected  may  be  swathed  in  cotton- wool  and  bandaged 
firmly  but  not  tightly,  and  often  this  method  is  all  that  is  required. 
Ointments,  dusting  powders,  lotions  or  paints  may  be  utilised. 
The  following  have  proved  of  practical  value  : 

Ointments  :  Ichthyol ;  boracic  ;  zinc ;  cocaine  (4  per  cent.)  ;  ung. 
borac.,  softened  with  the  admixture  of  soft  paraffin  (.5  oz.),  cocaine 
(22  gr.)  (Head) ;  1  per  cent,  solution  of  cocaine  in  ung.  petrolatum 
(Sinkler). 

Powders :  Pulv.  amyli  co.  (pulv.  amyli  3  parts,  zinci  oxidi  1)  ; 
starch  (2  oz.),  oxide  of  zinc  (1  oz.),  camphor  powder  (15  to  45  gr.), 
with  the  addition  of  15  gr.  of  powdered  opium  if  there  is  much  pain 
(Head). 

Lotions :  Lead  and  opium  ;  calamine  and  zinc  oxide  (of  each 
1  oz.),  glycerine  (2  oz.),  lime-water  to  10  oz. 

Paints :  Collodion  ;  cocaine,  2  per  cent,  in  flexible  collodion ; 
Unna's  zinc  gelatin  (zinc  oxide  3  drachms,  gelatin  2  drachms, 
glycerine  6  fluid  drachms,  water  1  fluid  ounce)  (Walker). 


Herpes  Zoster.  1097 

Should  the  vesicles  suppurate  they  must  be  treated  with  some 
antiseptic  ointment  or  dressing. 

(b)  GENERAL. — In  addition  to  local  measures,  it  is  often  necessary 
to  treat  the  pain  by  suitable  drugs  administered  by  the  mouth, 
such  as  any  of  the  accepted  antalgesics.  Caffein  citrate,  aspirin, 
and  phenacetin  (of  each  5  gr.)  form  a  good  combination;  also 
phenacetin  (10  gr.),  exalgin  (2  gr.).  Sometimes  morphia  in  one  or 
other  of  its  forms  is  the  only  drug  which  gives  relief. 

(3)  Sequelae. — As  a  rule,  scabs  form  on  the  vesicles  after  the  acute 
stage  is  over  and  these  gradually  drop  off,  leaving  not  infrequently 
a  certain  amount  of  scarring.  Where  the  eruption  has  been  over  an 
area  of  the  skin  that  is  exposed  (face  or  neck),  Walker  recommends 
picking  the  scabs  off  and  keeping  the  part  soft  with  a  simple 
antiseptic  ointment,  to  allow  granulations  to  reach  the  level  of  the 
surrounding  skin. 

Much  the  most  serious  sequelae  are  post-herpetic  parsesthesise  and 
neuralgia,  which  are  sometimes  peculiarly  intractable.  Local 
counter-irritation  should  be  tried  (pigmentum  iodi,  actual  cautery, 
blister,, etc.),  or  cataphoresis  of  cocaine  or  sodium  salicylate.  With 
the  latter  drug  excellent  results  have  been  obtained  by  Mackenna. 
It  is  applied  on  the  kathode;  cocaine  on  the  anode.  The  active 
electrode  should  be  placed  over  the  vertebral  column  at  the  level 
affected,  the  indifferent  electrode  may  be  placed  over  the  peripheral 
ends  of  the  primary  divisions  concerned.  A  current  of  5  to 
15  milliamperes  is  sufficient ;  duration  five  to  twenty  minutes, 
according  to  the  patient's  reaction.  If  ionisation  fails  to  give  relief 
the  posterior  roots  involved  may  be  divided  by  operation. 

Other  complications,  such  as  facial  and  other  palsies,  and  more 
rarely  still  medullary  invasion,  must  be  treated  according  to  the 
circumstances. 

S.  A.  KINNIER  WILSON. 

REFERENCES. 

Head,  H.,  and  Campbell,  A.  W.,  "  Brain,"  1900,  XXHL,  p.  353. 

Leduc,  "  Electric  Ions  and  their  Use  in  Medicine,"  translated  by  Mackenna, 
London  (Rebrnan),  1908. 

Walker,  Norman,  "Introduction  to  Dermatology,"  5th  edit,  8vo.,  Bristol, 
1911. 


1098 


INJURIES   OF   NERVES. 

A  NERVE  may  be  injured  as  the  result  of  a  penetrating  wound  ;  by 
pressure,  sudden  or  long  continued,  or  by  overstretching  (traction). 
As  the  consequence  of  any  of  these,  degeneration  may  occur  in 
the  whole  peripheral  end  of  the  nerve  ;  this  is  termed  "  complete 
division."  If  the  naked- eye  continuity  of  the  nerve  is  completely 
interrupted,  it  is  called  complete  "  anatomical  "  division ;  if  the 
division  is  complete  and  the  nerve  is  in  continuity,  complete 
"physiological"  division.  When  the  injury  is  incomplete,  the 
term  "incomplete  division"  is  used,  "anatomical  "  if  the  nerve  is 
partially  severed,  "  physiological"  if  there  is  no  naked-eye  solution 
of  continuity. 

General  Lines  of  Treatment. — The  treatment  of  a  case  of 
nerve  injury  consists  in  keeping  up  the  nutrition  of  the  affected 
parts,  preventing  overstretching  of  paralysed  muscles  and  con- 
tracture  of  their  opponents  and  of  the  joints  moved  by  them,  until 
restoration  of  function  takes  place  through  the  re-establishment 
of  conduction,  by  nature  alone,  or  aided  by  the  surgeon. 
Patience  is  needful  on  the  part  of  both  patient  and  surgeon  if  the 
case  is  to  be  brought  to  a  perfect  recovery.  This  is  possible  even 
after  complete  anatomical  division  and  suture,  if  treatment  is 
faithfully  carried  out. 

Paretic  or  paralysed  muscles  must  be  kept  relaxed  by  suitable 
splints.  Recovery  is  much  delayed  if  the  muscles  are  allowed 
to  become  overstretched,  and  may  be  rendered  incomplete  if  con- 
tractures  are  permitted  to  take  place  in  the  opposing  muscles  and 
changes  in  the  ligaments  surrounding  the  joints  upon  which  they 
act.  Neglect  of  this  is  a  fertile  cause  of  delayed  and  incomplete 
recovery.  While  of  importance  in  dealing  with  nerve  injuries  in 
any  situation,  its  influence  is  seen  most  often  after  injuries  of  the 
ulnar  and  musculo-spiral  nerves  and  the  upper  trunk  of  the  brachial 
plexus. 

The  nutrition  of  the  muscles  should  be  maintained  by  daily 
massage  and  movements,  aided,  if  possible,  by  electrical  stimulation 
with  that  form  of  current,  interrupted  or  constant,  to  which  the 
muscles  react.  The  splint  should  only  be  removed  for  massage 
and  electrical  treatment  and  should  be  worn  until  voluntary 
power  is  restored  to  the  affected  muscles.  On  the  restoration  of 


Injuries  of  Nerves.  1099 

voluntary  power  to  any  muscle  daily  and  systematic  active 
movements  should  be  carried  out. 

Parts  deprived  of  their  sensory  supply  must  be  carefully  pro- 
tected from  injury  until  the  restoration  of  protopathic  sensibility. 
Heat  and  cold  of  a  degree  insufficient  to  give  rise  to  discomfort 
to  sound  parts  will  cause  the  formation  of  blisters  on  the  affected 
part. 

In  many  cases  operation  is  required  to  restore  continuity  or 
release  the  nerve  from  pressure.  The  treatment  outlined  above  is 
necessary  in  every  case  whether  operation  is  carried  out  or  not. 

General  Considerations  regarding  Operations  upon  Nerves. — 
In  every  nerve  operation  gentle  handling  is  essential.  The  nerve 
itself  should  never  be  caught  up  in  forceps  or  lifted  on  a  hook.  It 
should  be  lifted  with  fine-toothed  forceps  by  its  connective  tissue 
sheath  ;  a  flat  retractor  should  be  used  if  the  nerve  has  to  be 
pulled  on  one  side,  as  a  hook  is  liable  to  cause  local  injury. 

The  suture  material  must  be  absorbable  and  as  fine  as  possible. 
Silk,  linen  or  Pagenstecher  thread  should  never  be  employed. 
These  remain  in  the  nerve  as  a  foreign  body,  and  several  cases 
have  come  under  my  notice  in  which  complete  recovery  was 
prevented  by  the  onset  of  inflammation  around  the  unabsorbed 
stitch  several  months  after  suture.  I  have  found  No.  00  Van  Horn 
twenty-day  chromic  catgut  the  most  satisfactory  suture  material. 
The  suture  should  be  passed  with  a  round,  straight  needle.  After 
suture  or  exposure  of  a  nerve  it  should  always  be  -wrapped  with 
Cargile  membrane  to  prevent  the  formation  of  adhesions  to 
surrounding  structures  and  the  ingrowth  of  fibrous  tissue  and 
"  wound  nerve  fibres. " 

Nerve  Injuries  in  Wounds. — Accidental  wounds  in  the  region 
of  the  wrist  are  common  causes  of  nerve  injury.  In  every  patient 
with  an  accidental  wound  the  question  of  nerve  injury  should 
be  settled  before  treatment  is  adopted.  Unless  it  is  known  that 
certain  nerves  have  been  damaged,  it  is  easy  to  overlook  them  in 
lengthy  operations.  That  this  is  not  infrequent  is  evident  by  the 
number  of  cases  of  secondary  suture  that  have  to  be  performed. 

The  affected  nerve  must  be  fully  exposed,  in  most  cases  a  fresh 
incision  is  necessary  at  right  angles  to  the  accidental  wound,  and 
over  the  course  of  the  nerve.  If  it  is  found  completely  divided, 
the  ends  should  be  trimmed  with  a  sharp  scalpel  if  they  are 
irregular  ;  scissors  should  never  be  used  for  this  purpose,  as  during 
their  application  they  crush  the  nerve  and  prevent  complete 
recovery.  The  ends  should  then  be  approximated  by  suture.  One 
stitch  is  sufficient  in  most  cases ;  it  should  be  passed  through 


iioo  Injuries  of  Nerves. 

the  whole  thickness  of  the  nerve  at  right  angles  to  its  long  axis 
and  drawn  sufficiently  tight  just  to  bring  the  ends  into  contact. 

An  attempt  must  always  be  made  to  unite  the  nerve  without 
any  longitudinal  rotation,  bearing  in  mind  that  recovery  will  be 
more  rapid  and  perfect  if  the  corresponding  ends  of  the  divided 
axis  cylinders  in  the  central  and  peripheral  ends  are  opposite  to 
one  another.  The  union,  for  example,  of  axis  cylinders  in  the 
radial  border  of  the  central  end  of  a  divided  median  nerve  with 
those  in  the  ulnar  border  of  its  peripheral  end  must  result  in  delay 
in  complete  restoration  of  function. 

It  occasionally  happens  that  the  nerve  is  divided  at  two  levels, 
a  piece  being  loose  ;  this  should  be  sutured  in.  In  rare  cases 
so  much  nerve  is  destroyed  that  the  ends  cannot  be  brought  into 
contact.  If  the  nerve  is  found  cut  into  but  not  completely  divided, 
the  gap  should  be  closed  by  one  stitch. 

After  wrapping  the  nerve  in  Cargile  membrane  the  wound 
should  be  closed,  drainage  being  provided  if  there  is  much  oozing 
or  if  there  are  doubts  with  regard  to  its  cleanliness,  care  being 
taken  especially  in  wounds  in  the  region  of  the  wrist  to  suture 
up  the  deep  fascia  separately  to  avoid  subsequent  hernia  of 
tendons.  The  part  should  be  put  up  so  that  there  is  no  tension 
on  the  nerve  junction  and  the  paralysed  muscles  are  relaxed. 

Subcutaneous  Injuries. — A  nerve  may  be  injured  sub- 
cutaneously  as  the  result  of  pressure,  or  traction,  or  it  may  be 
wounded  by  the  end  of  a  fractured  bone.  The  pressure  may  be 
external,  the  result  of  the  use  of  crutches,  or  the  effect  of  surgical 
treatment,  the  pressure  of  tight  bandages,  strapping,  splint, 
Clover's  crutch,  or  due  to  a  direct  blow.  Internal  pressure  is 
usually  the  result  of  fractures  or  dislocations.  These  will  be  con- 
sidered separately.  Overstretching  is  responsible  for  the  majority 
of  the  supra-clavicular  injuries  of  the  brachial  plexus,  and  for 
occasional  injury  to  the  great  sciatic  nerve  and  its  branches  and 
the  anterior  crural  in  dislocations  of  the  hip  and  reduction  of  con- 
genital dislocations.  The  median  nerve  suffers  overstretching  in 
rare  instances  from  falls  on  the  palm  of  the  hand. 

As  the  result  of  subcutaneous  injury  any  form  of  division  may 
occur ;  it  may  be  impossible  at  first  to  estimate  its  degree. 

The  treatment  of  subcutaneous  injuries  (apart  from  those 
complicating  fractures  and  dislocations)  is,  with  one  exception,— a 
traction  injury  of  the  brachial  plexus  in  an  adult— that  given 
below.  When  symptoms  indicating  a  lesion  of  the  brachial 
plexus  follow  an  injury,  such  as  a  fall  on  the  head  or  shoulder 
causing  overstretching,  exploration  should  be  undertaken  without 


Injuries  of  Nerves.  1101 

delay  and  the  appropriate  treatment  adopted  to  restore  anatomical 
continuity,  if  this  is  seen  to  be  needed.  In  other  situations  operation 
is  only  undertaken  under  certain  well-defined  circumstances. 

It  may  be  impossible  to  diagnose  between  complete  and  in- 
complete division  until  such  time  has  elapsed  as  would  permit  the 
development  of  changes  in  the  electrical  reactions  of  the  paralysed 
muscles.  If  at  the  end  of  a  fortnight  the  reaction  of  degeneration 
has  developed  or  is  present  in  a  case  coming  under  observation 
later,  exploration  should  be  undertaken.  The  nerve  may  be 
found  anatomically  divided,  in  which  case  secondary  suture  should 
be  carried  out.  If  it  is  in  continuity,  experience  only  will  enable 
a  decision  to  be  arrived  at  as  to  the  best  form  of  treatment. 
General  rules  can,  however,  be  laid  down.  If  there  is  little 
alteration  in  the  appearance  and  feel  of  the  nerve,  it  should  be 
wrapped  and  the  wound  closed.  If  it  is  thin,  fibrous,  and  adherent 
to  the  neighbouring  tissue,  the  ends  being  united  apparently  by 
fibrous  tissue  only,  the  damaged  portion  should  be  resected  and 
anatomical  continuity  re-established. 

Nerve  Injuries  in  Fractures. — The  injury  may  be  primary, 
being  produced  at  the  time  of  the  accident,  or  secondary,  the 
symptoms  appearing  later,  as  the  result  of  involvement  of  the 
nerve  in  callus  or  fibrous  tissue,  or  from  the  pressure  of  displaced 
bone.  The  musculo-spiral  is  the  nerve  most  often  affected  and 
suffers  usually  in  fractures  of  the  lower  and  middle  thirds  of  the 
humerus. 

If  the  injury  is  primary  operation  should  be  carried  out  at  once, 
if  examination  proves  it  to  be  a  grave  one  and  the  diagnosis  of 
incomplete  division  is  doubtful.  Anatomical  injury  to  the  nerve 
should  be  repaired  in  the  usual  way.  If  there  is  no  breach  of 
surface,  the  nerve  should  be  simply  wrapped.  This  will  be  most 
often  required  in  fractures  of  the  humerus ;  at  the  same  time  the 
fracture  should  be  plated  if  necessary. 

If  the  injury,  as  is  so  often  the  case,  is  discovered  on  removal  of 
the  splints,  operation  is  indicated  without  delay  if  the  symptoms 
are  those  of  complete  division.  If  they  are  not,  it  is  only  neces- 
sary if  no  improvement  ensues  after  a  course  of  treatment  faithfully 
carried  out.  If,  as  sometimes  occurs,  symptoms  of  nerve  injury 
first  develop  when  the  patient  starts  to  use  the  limb,  operation 
should  be  immediately  performed. 

In  all  operations  upon  nerves  involved  in  fractures  the  incision 
must  be  of  sufficient  length  to  expose  the  nerve  well  above  and 
below  the  seat  of  fracture,  and  the  nerve  must  be  traced  from  both 
directions  to  the  seat  of  the  injury. 


iiO2  Injuries  of  Nerves. 

If  the  nerve  injury  from  the  symptoms  or  operative  findings  is 
obviously  incomplete,  the  nerve,  after  being  well  freed,  should  be 
wrapped  in  Cargile  membrane  and  the  wound  closed. 

When  the  signs  are  those  of  complete  division  and  the  nerve  is 
found  in  anatomical  continuity,  if  the  appearance  and  consistence 
of  the  nerve  approach  the  normal,  it  will  be  enough  to  free  and 
wrap  it.  If,  however,  it  is  thin,  fibrous  and  adherent,  its  damaged 
portion  should  be  excised  and  continuity  restored. 

Nerve  Injuries  Complicating  Dislocations. — Symptoms  of 
nerve  involvement  are  most  often  associated  with  dislocations  of  the 
humerus.  The  injury  may  be  due  to  the  pressure  of  the  dislocated 
head,  but  more  often  to  efforts  at  reduction,  especially  by  the  "  heel 
in  axilla  "  method.  The  inner  cord  of  the  plexus  suffers  most  often 
and  the  injury  is  usually  incomplete.  Treatment  follows  the  usual 
lines  and  recovery  is  the  rule. 

Injury  to  the  great  sciatic  or  its  branches  is  occasionally  seen 
after  attempts  at  reduction  of  acquired  or  congenital  dislocations  of 
the  hip ;  the  anterior  crural  may  suffer  in  the  same  way.  There 
are  no  special  points  in  the  treatment.  Recovery  generally  follows. 

The  musculo-spiral  nerve  or  its  posterior  interosseous  branch 
may  be  injured  in  forward  dislocations  of  the  head  of  the  radius. 
This  is  especially  likely  to  occur,  as  pointed  out  by  Stettin,  when  it  is 
complicated  by  a  fracture  of  the  ulna.  Treatment  must  be  by  open 
operation.  The  nerve  is  rarely  completely  divided,  but  it  is  impos- 
sible to  ensure  the  safety  of  the  nerve  in  any  other  way  even  in 
recent  cases.  If  the  patient  is  seen  soon  after  the  accident,  it  may 
be  possible  to  replace  the  head  and  suture  up  the  orbicular 
ligament.  In  old  cases  excision  of  the  head  of  the  bone  is  necessary. 
The  nerve  itself  should  be  dealt  with  as  occasion  requires. 

Secondary  Suture. — This  term  is  applied  to  operative  re-estab- 
lishment of  anatomical  continuity  after  degeneration  has  taken  place 
in  the  peripheral  end  of  a  divided  nerve.  This  operation  is 
becoming  rarer  as  nerve  injuries  are  recognised  at  the  time  of  the 
accident.  It  is  a  reproach  to  the  surgeon  who  first  saw  the  case, 
except  in  subcutaneous  injuries,  when  it  may  be  unavoidable. 

Before  proceeding  to  operation  careful  examination  is  essential 
in  order  to  ascertain  how  much  recovery  is  likely  to  ensue.  The 
time  which  has  elapsed  since  the  injury  has  little  bearing  upon  the 
regeneration  of  the  nerve  after  reunion  ;  it  is  probable  that  nerve 
regeneration  takes  place  up  to  many  years  after  injury.  The  con- 
dition of  the  muscles  and  of  the  fibrous  structures  surrounding  the 
joints  is  of  the  utmost  importance.  If  careful  and  repeated  elec- 
trical examinations  reveal  no  reaction  to  the  constant  current 


Injuries  of  Nerves.  1103 

in  the  affected  muscles,  operation  is  of  no  use  from  the  motor 
standpoint.  Again,  if  deformity  has  resulted  from  overstretching 
of  paralysed  muscles  and  contractures  of  their  opponents,  e.g.,  ulnar 
claw  hand,  motor  recovery  will  he  incomplete.  When  the  nerve 
division  is  the  result  of  a  penetrating  wound,  its  original  manner  of 
healing  will  influence  the  prognosis.  If  prolonged  suppuration 
occurred,  complete  recovery  is  unlikely,  owing  to  fibrotic  changes 
in  the  nerve  which  often  supervene  as  the  result  of  infection.  From 
the  sensory  standpoint  it  is  worth  while  undertaking  secondary 
suture  at  any  time  after  division,  from  the  motor,  if  the  paralysed 
muscles  retain  their  irritability  to  the  constant  current,  which  they 
may  do  for  long  periods ;  I  have  seen  this  twenty  years  after 
separation  from  the  central  nervous  system  by  nerve  section. 

In  carrying  out  the  operation  an  incision  should  be  made  over 
the  course  of  the  nerve  of  sufficient  length  to  expose  it  well  above 
and  below  the  seat  of  injury.  It  should  be  traced  from  above  and 
below  towards  this  point  and  freed.  The  ends  are  usually  found 
bound  together  by  fibrous  tissue.  It  is  well  before  separating  these 
ends  to  stretch  the  nerve ;  in  this  way  apposition  can  be  obtained 
in  most  cases  after  removal  of  sufficient  nerve.  The  bulb  on  the 
central  end  should  then  be  excised  with  a  sharp  scalpel ;  the  distal 
end  is  usually  pointed,  and  this  fibrous  extremity  is  all  that  need  be 
sacrificed.  Chromic  catgut  (Van  Horn,  No.  00,  twenty-day)  should  be 
used  to  unite  the  ends ;  two  sutures  are  usually  necessary,  passed 
at  right  angles  to  one  another  through  the  whole  thickness  of  the 
nerve.  If  the  ends  do  not  come  readily  into  apposition,  flexion  of 
the  joints  over  which  the  nerve  passes  will  often  enable  suture  to 
be  carried  out  without  undue  tension.  If  in  spite  of  this  a  gap  is 
left,  resort  must  be  had  to  some  form  of  bridging. 

Nerve  Bridging.— Many  methods  have  been  advised,  but  there 
are  only  four  of  proved  value  :  (1)  Insertion  of  a  portion  of  nerve 
between  the  two  ends  (nerve  transplantation)  ;  (2)  union  of  the 
ends  by  catgut  threads  ;  (8)  union  of  the  peripheral  end  of  the 
divided  nerve  to  a  neighbouring  sound  nerve  (nerve  anastomosis 
and  nerve  crossing) ;  (4)  shortening  the  limb  by  removal  of  bone. 

Much  confusion  has  resulted  from  the  careless  use  of  names  in 
nerve  surgery,  the  term  "nerve  grafting"  having  been  applied  to 
entirely  different  operations.  The  use  of  this  term  should  be  dis- 
continued. 

If  the  gap  between  the  ends  is  short,  less  than  1  inch,  several 
sutures  of  plain  catgut  should  be  passed  between  the  ends  and  the 
whole  surrounded  by  Cargile  membrane.  If  the  gap  is  longer,  up 
to  about  4  inches,  nerve  transplantation  is  the  operation  of 


uo4  Injuries  of  Nerves. 

choice.  In  this  operation  the  employment  of  a  portion  of  nerve  from 
one  of  the  lower  animals  (hetero-transplantation)  is  useless.  The 
results  are  worse  than  if  catgut  sutures  only  are  used,  and  these  are 
not  good  in  long  gaps.  The  best  result  is  obtained  when  a  portion 
of  a  nerve  from  the  patient  (auto-transplantation)  is  loosely  sutured 
into  the  gap  and  surrounded  by  Cargile  membrane.  The  nerve  most 
often  requiring  operation  of  this  nature  is  the  musculo-spiral.  In 
this  instance  the  incision  should  be  prolonged  downwards  and  the 
radial  nerve  exposed  and  sufficient  removed  to  lie  between  the  ends 
without  tension.  Resection  of  the  upper  two-thirds  of  this  nerve  pro- 
duces, as  a  rule,  no  effect  on  sensibility.  The  internal  saphenous  nerve 
also  may  be  used.  Its  division  causes  very  little  inconvenience ;  the 
area  of  altered  sensibility  is  on  the  inner  side  of  the  leg  and  does 
not  extend  to  the  sole  of  the  foot.  In  cases  where  a  portion  of  nerve 
from  the  same  patient  is  unavailable  the  transplant  should  be 
obtained  from  a  nerve  of  the  same  size  from  a  recently  ampu- 
tated limb  (homo-transplantation).  After  removal  it  should  be 
placed  in  warm  normal  saline  solution  and  used  immediately.  In 
all  transplantation  operations  the  transplant  should  be  handled  as 
little  as  possible.  If  gently  handled  the  transplanted  tissue  does 
not  die,  but  degenerates  and  so  takes  an  active  part  in  regeneration. 
If  a  portion  of  nerve  from  an  animal  is  used  (hetero-transplantation) 
it  dies,  hence  its  comparative  uselessness  as  a  bridging  medium. 

Bone  should  be  removed  only  in  cases  in  which  an  ununited 
fracture  complicates  the  nerve  injury. 

In  cases  in  which  the  gap  between  the  ends  of  the  nerve  is  more 
than  about  4  inches  transplantation  is  unsuitable  and  a  neigh- 
bouring nerve  should  be  utilised.  In  this  group  are  included  two 
distinct  operations :  (1)  Nerve  crossing,  in  which  a  neighbouring 
sound  nerve  is  completely  divided  and  its  central  end  united  to  the 
peripheral  end  of  the  affected  ;  this  is  never  justifiable  in  cases  of 
injury ;  (2)  nerve  anastomosis,  in  which  the  peripheral  end  of  the 
divided  nerve  is  united  to  some  of  the  fibres  or  one  of  the  branches 
of  a  sound  nerve. 

Nerve  Anastomosis. — The  aim  in  operations  of  this  nature  is  to 
bring  the  axis  cylinders  in  the  peripheral  end  of  the  divided  nerve 
or  the  nerve  supplying  the  paralysed  muscles  into  end-to-end  union 
with  some  of  those  in  the  sound  nerve.  It  is  only  justifiable  if 
carried  out  so  that  no  permanent  injury  is  done  to  the  structures 
supplied  by  the  sound  nerve,  or  if  the  muscles  whose  motor  supply 
is  sacrificed  are  relatively  unimportant  compared  with  those  it  is 
hoped  to  re-innervate. 

It  has  been  proved  both  clinically  and  experimentally  that  an 


Injuries  of  Nerves.  1105 

incision  may  be  made  into  the  trunk  of  a  nerve  for  one-third  of  its 
diameter  without  producing  more  than  a  temporary  paresis,  even 
this  being  often  absent.  There  is  one  exception,  however  ;  if  the 
incision  is  made  into  the  nerve  close  to  the  point  at  which  a  branch 
is  given  off  it  may  result  in  complete  division  of  the  fibres  going  to 
that  branch. 

Nerve  anastomosis  may  be  divided  into  peripheral  and  central. 
In  peripheral  anastomosis  the  peripheral  end  of  the  affected  nerve 
is  brought  to  the  sound,  in  central  the  sound  nerve  is  divided  and 
brought  to  the  affected;  this  latter  is  rarely,  if  ever,  justifiable. 
When  the  whole  peripheral  end  of  the  affected  nerve  is  used,  and 
this  is  the  usual  method,  the  operation  is  termed  complete  peri- 
pheral anastomosis.  Three  methods  have  been  employed  to  unite 
the  two  nerves :  (1)  Insertion  into  a  vertical  slit  in  the  sound 
nerve;  (2)  insertion  into  a  gap  in  the  sound  nerve  produced  by  an 
oblique  incision  ;  (8)  end-to-end  union  with  a  flap  raised  from  the 
sound  nerve.  In  nerve  anastomosis  in  cases  of  injury  the  last 
is  the  method  of  choice.  In  the  first  two  there  is  a  serious 
chance  of  the  union  of  axis  cylinders  in  the  divided  portion  of  the 
sound  nerve  with  those  in  the  peripheral  end  of  both  sound  and 
affected  nerves. 

In  carrying  out  the  operation  the  greatest  care  must  be  taken  and, 
if  possible,  a  separate  funiculus  of  the  nerve  should  be  raised  as  a  flap. 
The  incision  into  the  sound  nerve  must  be  cleanly  made  with  a  sharp 
scalpel,  and  the  flap  dissected  up  carefully  for  about  finch  to  1  inch. 
After  end-to-end  union  with  the  peripheral  end  both  the  junction 
and  the  bare  surface  left  on  the  sound  nerve  must  be  covered  with 
Cargile  membrane. 

JAMES  SHERREN. 


3.T. VOL.  II.  70 


iio6 


TRAUMATIC    NEURITIS. 

UNDER  this  heading  two  distinct  types  are  included,  the  chronic, 
localised  neuritis  due  to  long  continued  pressure,  such  as  occurs 
in  the  ulnar  nerve  at  the  elbow  and  the  lower  cord  of  the  plexus 
from  the  pressure  of  a  cervical  rib,  and  that  due  to  infection  of  the 
nerve  through  breaches  of  continuity  in  its  trunk  or  involvement 
of  its  terminal  branches  in  scar  tissue.  The  disease  in  this  latter 
type  is  liable  to  spread,  "ascending  neuritis;"  in  the  former  it 
always  remains  localised. 

In  the  first  type  of  case,  muscular  symptoms  are  most  marked ; 
pain,  if  present,  is  slight.  In  the  second  group  pain  is  the  principal 
feature. 

Treatment  of  the  chronic  ,  localised  form  consists  in  removal 
of  the  cause,  followed  by  the  usual  attention  to  the  muscles. 

Neuritis  is  rare  as  the  result  of  wounds  or  subcutaneous  injuries 
of  nerves  in  their  course.  It  has  been  observed  most  often  as  the 
result  of  gunshot  wounds.  There  is  always  a  latent  period  between 
the  injury  and  the  onset  of  symptoms,  viz.,  a  burning  pain  appearing 
in  the  distribution  of  the  nerve  accompanied  by  tenderness  and 
sometimes  by  "  glossy  "  skin.  If  the  inflammation  affects  a  mixed 
nerve,  motor  symptoms  are  present  corresponding  to  the  degree  of 
the  original  injury. 

At  first  the  limb  should  be  kept  absolutely  at  rest,  and  if  the 
symptoms  have  appeared  shortly  after  the  injury  with  obvious 
signs  of  infection  the  wound  should  be  opened  and  drained.  As  a 
rule,  however,  the  wound  has  healed  completely  before  the  onset  of 
symptoms.  If  the  pain  does  not  speedily  subside  the  nerve  should 
be  exposed,  the  damaged  portion  removed  and  end-to-end  union 
carried  out. 

Long  continued  irritation  of  terminal  branches  of  nerves,  such  as 
is  often  seen  after  badly  performed  amputations  of  •  the  finger, 
may  set  up  neuritis.  At  first  the  pain  is  limited  to  the  stump,  but 
there  may  be  tenderness  referred  to  the  whole  area  supplied  by  the 
nerve  from  which  the  branch  arises.  Later  the  pain  spreads  and 
involves  the  whole  area  supplied  by  the  nerve,  the  stump  becomes 
reddish  blue  and  shiny  and  a  similar  condition  may  make  its 
appearance  elsewhere. 

As  these  symptoms  are  common  after  amputations  of  the  fingers, 


Traumatic  Neuritis.  1107 

care  should  always  be  taken  to  see  that  the  digital  nerves  are  cut 
short,  and  if  bone  forceps  are  used  to  divide  the  phalanx  they 
should  never  be  employed  till  the  nerves  have  been  freed  and 
cut  short. 

In  cases  of  this  nature  operation  must  not  be  delayed.  The 
nerves  involved  must  be  carefully  dissected  out  and  cut  short.  It 
is  often  necessary  to  remove  more  bone  in  order  to  get  a  satisfactory 
stump. 

In  early  cases  the  result  is  immediate  and  satisfactory.  Later, 
when  muscular  wasting  has  set  in,  prolonged  treatment  is  necessary 
and  pain  may  persist,  unchecked  by  the  operation.  In  these  cases 
division  of  posterior  roots  must  be  considered. 

Chronic  neuritis  of  a  similar  nature  may  result  from  adhesions 
or  pressure  or  from  excessive  fibrosis,  due  to  suppuration,  of  the 
end-bulbs  of  nerve  divided  in  limb  amputations. 

In  these  cases  operation  must  not  be  delayed.  The  affected 
nerve  must  be  exposed  and  the  bulb,  together  with  an  inch  or  more 
of  nerve,  removed.  In  early  cases  cure  speedily  results.  If 
symptoms  have  persisted  for  a  considerable  time,  this  may  fail  to 
bring  about  a  cure.  The  posterior  roots  from  which  the  affected 
nerve  springs  should  be  divided  intradurally. 

JAMES  SHERREN. 


70—2 


iio8 


INJURIES  OF   SPECIAL  NERVES. 

Facial  Nerve. — For  the  purposes  of  treatment  the  facial  nerve 
consists  of  two  parts,  that  below  and  that  above  its  point  of  exit 
from  the  skull.  Injury  in  the  former  situation  is  uncommon  and 
usually  the  result  of  surgical  operations,  the  terminal  branches 
supplying  the  lower  facial  muscles  usually  suffer,  and  recovery  is 
the  rule  if  the  wound  heals  by  first  intention.  If  a  larger  branch 
or  the  whole  nerve  trunk  is  divided,  the  treatment  for  nerves 
divided  in  wounds  should  be  carried  out. 

During  its  course  through  the  petrous  bone  the  nerve  may  be 
injured  in  fractures  of  the  base  of  the  skull,  or  during  mastoid 
operations,  or  it  may  be  affected  as  the  result  of  middle-ear 
disease.  The  commonest  type  of  facial  paralysis  is  the  so-called 
"rheumatic"  Bell's  palsy.  Treatment  in  all  cases  is  along  the 
usual  lines. 

In  fractures  of  the  base  of  the  skull  the  nerve  is  rarely  completely 
divided,  the  reactions  are  those  of  incomplete  division  and  recovery 
is  the  rule.  If  the  reaction  of  degeneration  develops,  nerve  anasto- 
mosis should  be  undertaken  after  three  months  (vide  infra). 

Nerve  injury  the  result  of  operations  upon  the  middle  ear  is 
usually  incomplete.  If  it  is  discovered  during  the  course  of  the 
operation,  the  Fallopian  aqueduct  should  be  opened  up  and  the  ends 
adjusted  in  the  canal ;  in  this  way  the  advantage  of  tubular  suture 
is  obtained.  This  was  first  suggested  by  Jordan  Lloyd  and  carried 
out  by  Marsh.  If  noticed  immediately  after  the  operation,  as  is 
usually  the  case,  nothing  should  be  done  for  a  fortnight ;  at  the  end 
of  this  time  electrical  examination  will  show  whether  the  nerve  be 
completely  divided.  If  division  is  complete  and  the  mastoid  wound 
clean,  an  attempt  should  be  made  to  bring  the  ends  of  the  nerve 
into  apposition  in  its  aqueduct,  as  carried  out  by  Marsh  and  Syden- 
harn.  If  this  is  impossible,  anastomosis  should  be  performed  (vide 
infra) . 

The  development  of  facial  paralysis  in  middle-ear  disease,,  apart 
from  operative  interference,  is  an  indication  for  a  radical  mastoid 
operation ;  this  should  be  carried  out  without  delay,  and  is  often 
followed  by  restoration  of  function  in  the  nerve. 

In  Bell's  palsy  the  usual  treatment  should  be  carried  out.  If  at 
the  end  of  six  months  no  improvement  has  taken  place,  and  the 
reaction  of  degeneration  is  present,  nerve  anastomosis  is  indicated. 


Injuries  of  Special   Nerves.  1109 

Nerve  Anastomosis  and  Nerve  Crossing  in  Facial  Paralysis. — 
Operation  is  rarely  necessary  in  cases  of  facial  paralysis.  Spon- 
taneous recovery  usually  takes  place.  When  paralysis  follows 
mastoid  operations,  operation  should  never  be  carried  out  until  the 
post-auricular  wound  is  free  from  infection. 

Nerve  crossing  for  facial  paralysis  was  first  performed  in  1879  by 
Drobnik,  who  divided  the  spinal  accessory  nerve  and  united  its 
central  end  to  the  divided  facial.  The  modern  operation  is  chiefly 
due  to  Ballance,  who  first  carried  it  out  in  1895.  The  spinal 
accessory  was  first  employed,  but,  following  the  example  of  Korte 
(1901)  and  Ballance  (1902),  the  hypoglossal  is  now  the  nerve  of 
choice. 

Complete  peripheral  anastomosis  should  be  carried  out,  a  flap  of 
about  one-third  of  the  hypoglossal  nerve  being  raised  and  united 
end  to  end  with  the  peripheral  end  of  the  facial.  Ballance,  how- 
ever, has  recently  suggested  nerve  crossing  with  the  hypoglossal, 
the  distal  end  of  the  divided  hypoglossal  being  then  united  end  to 
end  with  a  flap  of  half  the  spinal  accessory. 

After  anastomosis,  treatment  must  be  patiently  carried  out.  In 
about  six  to  eight  weeks  it  is  noticed  that  the  lower  part  of  the  face  is 
more  symmetrical  when  at  rest,  and  in  three  to  six  months  voluntary 
power  returns  to  the  muscles  around  the  mouth,  the  orbicularis 
palpebrarum  and  frontalis  muscles  being  the  last  to  be  restored. 
At  first  movement  is  associated  with  that  of  the  tongue,  but  soon 
becomes  dissociated,  and  in  from  nine  months  to  a  year,  in  a  favour- 
able case,  the  patient  should  be  able  to  perform  all  movements. 
Emotional  movements  are  restored  at  a  still  later  date,  it  may  be 
many  months  later,  and  in  some  cases  they  are  never  regained.  In 
all  the  recorded  cases  of  facial  nerve  anastomosis  reported  at  a 
sufficient  time  after  operation  some  recovery  took  place,  in  a  few  it 
was  perfect. 

No  more  than  a  temporary  paresis  of  the  tongue  on  the  affected 
side  should  result,  this  disappearing  in  three  or  four  weeks. 

The  operation  is  carried  out  through  an  incision  extending  from 
the  mastoid  at  the  level  of  the  external  auditory  meatus  to  the  great 
cornu  of  the  hyoid  bone.  The  anterior  border  of  the  sterno-mastoid 
is  pulled  backwards  and  the  posterior  belly  of  the  digastric  pulled 
downwards  and  backwards  or  divided.  The  facial  nerve  is  most 
easily  found  by  taking  the  styloid  process  as  a  guide,  the  nerve 
passing  out  immediately  in  front  of  this  to  enter  the  parotid  gland. 
An  attempt  should  be  made  to  pull  the  nerve  out  from  the  canal  in 
cases  in  which  it  has  been  injured  during  mastoid  operations ;  if 
this  cannot  be  done,  and  in  other  cases,  it  should  be  divided  with  a 


1 1 10  Injuries  of   Special  Nerves. 

tenotomy  knife  as  far  up  the  canal  as  possible.  The  hypoglossal 
nerve  is  easily  distinguished  by  its  relation  to  the  occipital  artery. 
The  peripheral  end  of  the  facial  nerve  is  freshened  with  a  sharp 
scalpel  and  then  a  flap  of  the  hypoglossal,  consisting  of  at  least  a 
third  of  the  nerve,  is  raised  and  united  end  to  end  with  the  facial 
by  one  stitch  of  No.  00  chromic  gut.  The  junction  and  the  bare 
surface  of  the  hypoglossal  are  surrounded  with  Cargile  membrane. 

Brachial  Plexus. — There  are  several  points  in  connection  with 
injuries  of  the  plexus  which  require  special  comment. 

Injuries  of  the  plexus  are  usually  supra-clavicular.  Infra- 
clavicular  injuries  are  rare  and  are  due  in  most  cases  to  the  direct 
pressure  of  the  dislocated  head  of  the  humerus.  Recovery  follows 
the  usual  treatment,  and  operation  is  rarely  called  for. 

Lesions  of  the  plexus  in  adults  due  to  overstretching,  the  most 
common  form  of  injury,  should  be  explored  as  soon  as  possible.  If 
treated  on  the  lines  of  subcutaneous  nerve  injuries  elsewhere,  the 
prognosis  is  very  unfavourable.  Secondary  suture  of  the  plexus  is 
a  difficult  operation,  and  if  the  whole  plexus  has  been  affected  the 
attempt  is  never  successful. 

The  presence  of  a  cervical  rib  is  an  unusual  cause  of  supra- 
clavicular  affection  of  the  brachial  plexus,  the  lower  cord  being 
affected.  Before  coming  to  the  conclusion  that  the  symptoms  are 
due  to  the  presence  of  a  cervical  rib  all  other  causes  must  be 
excluded,  particularly  syringomyelia.  Several  instances  have  come 
under  my  notice  in  which  the  two  co-existed,  and  in  which  the 
cervical  rib  was  removed  without  result.  It  must  be  remembered 
that  a  cervical  rib  is  a  common  deformity,  but  the  rarest  cause  of 
interference  with  structures  innervated  by  the  eighth  cervical  and 
first  dorsal  roots.  After  removal  of  the  ribs  recovery  follows  if 
correct  treatment  is  carried  out. 

Brachial  Birth  Paralysis.— The  majority  of  these  cases  fall  into 
the  group  of  traction  injuries.  Treatment  consists  in  relaxation  of 
the  affected  muscles  and  massage.  In  the  usual  upper  arm  type, 
Erb-Duchenne,  the  limb  should  be  bandaged  to  the  side  with  the 
forearm  flexed  and  supinated.  It  should  be  taken  down  every  day 
for  massage,  and  special  precautions  used  to  prevent  forward 
displacement  of  the  shoulder  ;  in  cases  where  these  are  neglected 
division  of  the  pectorals  may  be  necessary. 

If  the  affected  muscles  are  not  kept  relaxed,  permanent  deformity 
will  result,  although  the  paralysed  muscles  may  regain  power  of 
voluntary  movement  and  their  electrical  excitability.  The  electrical 
reactions  should  be  tested  when  the  child  is  twelve  weeks  old ;  in  the 
majority  of  cases  they  are  then  those  of  incomplete  division,  recovery 


Injuries  of   Special  Nerves.  1111 

having  obviously  commenced.  If  the  true  reaction  of  degeneration 
is  present,  operation  should  be  carried  out  as  soon  as  convenient. 
If  the  health  of  the  child  is  not  good,  a  delay  of  a  few  months  will 
probably  affect  the  final  result  very  little. 

In  exposing  the  brachial  plexus  above  the  clavicle  a  free  incision 
should  be  made  starting  above  at  the  junction  of  the  upper  and 
middle  thirds  of  the  posterior  border  of  the  sterno-mastoid,  extend- 
ing downwards  and  outwards  to  the  junction  of  the  middle  and 
outer  thirds  of  the  clavicle.  In  the  lower  arm  type  of  lesion  it  may 
be  necessary  to  divide  this  bone.  If  the  injury  is  extensive,  great 
difficulty  is  experienced  in  identifying  the  nerves  ;  the  deep  fascia  is 
usually  injured,  thickened  and  intimately  bound  up  with  the  fibrous 
tissue  around  the  nerves. 

In  the  usual  upper  arm  type  of  injury  the  anterior  primary 
divisions  of  fifth  and  sixth  cervical  are  found  and  then  traced  to 
their  junction  and  its  division  into  the  supra-clavicular  nerve  and 
branches  to  inner  and  outer  cords  of  the  plexus.  The  supra- 
clavicular  nerve  should  always  be  examined  ;  it  is  sometimes  found 
ruptured  in  addition  to  injury  to  fifth  anterior  primary  division. 
The  phrenic  nerve  exposed  on  anterior  surface  of  scalenus  anticus 
must  be  avoided.  In  cases  in  which  the  deltoid  and  spinati 
muscles  are  alone  paralysed  and  give  the  reaction  of  degeneration, 
the  damaged  portion  of  the  fifth  cervical  anterior  primary  division 
should  be  separated  and  excised  and  a  portion  of  radial  nerve 
inserted,  or  these  fibres  may  be  anastomosed  to  the  sixth  anterior 
division. 

In  all  other  cases,  after  free  exposure  on  the  usual  lines,  the 
damaged  portion  should  be  treated.  If  secondary  suture  has  been 
carried  out,  care  must  be  taken  to  put  the  limb  up  in  such  a  manner 
that  no  weight  falls  on  the  sutured  trunk  and  to  keep  it  in  this 
position  for  at  least  three  weeks. 

In  the  lower  arm  type  of  paralysis  due  to  traction  injuries  the 
lesion  is  situated  too  high  to  admit  of  direct  union.  Anastomosis 
to  the  eighth  cervical  anterior  primary  division  should  be  carried 
out. 

Circumflex  Nerve. — It  should  be  remembered  that  injuries  of 
this  nerve  are  of  great  rarity.  Before  proceeding  to  operation  in 
cases  in  which,  as  the  result  of  a  subcutaneous  injury,  usually 
violence  applied  to  the  shoulder,  paralysis  of  the  deltoid  with 
reaction  of  degeneration  supervenes,  careful  examination  must  be 
carried  out.  In  many  of  these  cases  the  lesion  is  in  the  fifth  or 
fifth  and  sixth  anterior  primary  divisions  or  upper  trunk  of  the 
plexus  above  the  clavicle. 


1 1 12  Injuries  of   Special  Nerves. 

Even  in  cases  in  which  the  circumflex  is  injured  and  the  signs 
of  complete  division  are  present  operation  is  by  no  means  always 
necessary.  The  sensory  loss  is  over  an  unimportant  region,  and  in 
most  cases  sufficient  abduction  of  the  arm  can  be  obtained  by  the 
clavicular  fibres  of  the  pectoralis  major  and  the  supra-spinatus 
muscles.  If,  however,  perfect  abduction  is  essential,  operation 
should  be  carried  out  in  these  cases. 

Posterior  Thoracic  Nerve  (Nerve  of  Bell).— It  is  only  in 
isolated  cases  that-  recovery  does  not  follow  treatment  conducted  on 
the  usual  lines.  In  these  cases  operation  must  be  considered. 
Except  in  rare  cases  in  which  the  nerve  has  been  injured  in  a 
wound,  accidental  or  operative,  direct  treatment  is  out  of  the 
question.  If  the  functional  disability  is  serious,  the  insertion  of 
the  sterno-costal  portion  of  the  pectoralis  major  may  be  transferred 
to  the  inferior  angle  of  the  scapula. 

Musculo-spiral  Nerve. — It  is  of  the  utmost  importance  that 


FIG.  1. — Splint  for  the  prevention  of  "  claw  hand  "  after 
injuries  of  the  ulnar  nerve.  It  is  applied  to  the 
posterior  surface  of  the  forearm,  hand  and  fingers. 

relaxation  of  the  paralysed  muscles  be  insisted  upon  in  all  cases 
until  voluntary  power  is  restored.  The  hand  and  fingers  should  be 
maintained  by  splints  in  a  hyper-extended  position,  and  the  splint 
should  only  be  removed  for  massage  until  voluntary  power  is 
restored. 

Ulnar  Nerve. — After  complete  division  of  the  ulnar  nerve 
recovery  of  function  is  always  imperfect  unless  the  interossei 
muscles  are  kept  relaxed  by  means  of  a  splint  so  arranged  that  the 
fingers  are  maintained  flexed  at  the  metacarpo-phalangeal  and 
extended  at  the  inter-phalangeal  joints  (vide  Fig.  1). 

Special  reference  must  be  made  to  the  treatment  of  two  affections 
of  the  ulnar  nerve  :  (1)  Chronic  neuritis  in  the  region  of  the  elbow, 
and  (2)  dislocation  of  the  nerve. 

(1)  Chronic  Neuritis  of  Ulnar  Nerve  at  the  Elbow. — Long  continued 
irritation  of  the  nerve  due  to  bony  pressure  in  the  region  of  the 
elbow  joint  may  lead  to  a  gradual  interference  with  its  functions. 
This  is  seen  most  often  after  fractures  or  separation  of  epiphyses 


Injuries  of  Special  Nerves.  1113 

which  have  led  to  permanent  deformity.     Symptoms  usually  appear 
at  a  considerable  time  after  the  injury,  often  many  years  after. 

In  all  cases  the  cause  should  he  removed  and  the  usual  treatment 
adopted.  The  nerve  should  be  exposed  behind  the  internal  condyle 
and  a  groove  chiselled  in  the  bone  to  receive  it  and  the  nerve 
wrapped  in  Cargile  membrane.  This  is  all  that  is  necessary  in  the 
majority  of  cases,  but  if  the  reaction  of  degeneration  is  present, 
the  spindle-shaped  enlargement  of  the  nerve  should  be  excised  and 
continuity  restored. 

(2)  Dislocation  of  the  Ulnar  Nerve. — Operation  must  be  undertaken 
in  all  cases  in  which  symptoms  are  present  due  to  interference  with 
the  functions  of  the  nerve.  After  exposure  of  the  nerve  behind  the 
internal  condyle,  the  groove  in  the  bone  should  be  deepened  if 
necessary  and  the  nerve  wrapped  in  Cargile  membrane.  The 
groove  should  then  be  converted  into  a  canal  by  stitching  a  portion 
of  the  fascia  of  the  triceps  over  it.  The  results  of  this  operation 
are  very  good. 

JAMES  SHERREN. 


1 1 14 


NEURALGIA. 

NEURALGIA  is  essentially  a  neurosis  of  adult  life,  and  is  considerably 
more  cqmmon  in  women  than  in  men,  and  is  frequently  hereditary. 
Although  there  is,  perhaps,  no  portion  of  the  body  which  may  not 
be  afflicted  with  neuralgia,  by  far  the  most  important  and  numerous 
types  of  the  affection  are  found  in  the  distribution  of  the  fifth  cranial 
or  trigeminal  nerve. 

DENTAL   NEURALGIA. 

When  this  is  due  to  caries  with  an  exposed  pulp,  not  only  may 
the  tooth  itself  be  tender  and  react  sharply  to  hot  and  cold  or  to 
sweet  food,  but  the  pain  may  radiate  from  the  affected  tooth 
along  all  the  teeth  in  that  side  of  the  jaw,  and  may  at  times  be 
reflected  on  to  the  other  jaw  of  the  same  side,  so  that  the  patient 
may  be  completely  mistaken  as  to  the  tooth  and  even  as  to  the  jaw 
affected.  The  pain  is  never  referred  to  the  opposite  side  of  the  face, 
but  may  spread  beyond  the  area  of  the  gums  into  the  ear  or  forehead, 
or  even  over  the  whole  of  that  side  of  the  head,  back  and  front,  and 
even  down  into  the  neck.  With  this  spreading  neuralgia  there  are 
likely  to  be  very  definite  areas  of  tenderness  of  the  skin,  varying 
with  the  tooth  affected.  The  severity  of  the  pain  in  such  dental 
neuralgia  may  be  most  intense,  and  it  may  be  mistaken  for  tic 
douloureux,  or  it  may  even  set  up  hysterical  delirium.  When  the 
pain  is  due  to  exposed  pulp  in  a  carious  tooth  immediate  relief  may 
invariably  be  obtained  for  at  least  several  hours  by  gently  swabbing 
out  the  cavity  with  a  piece  of  cotton-wool  on  the  end  of  a  probe 
dipped  in  a  solution  of  equal  parts  of  oil  of  cloves,  carbolic  acid  and 
menthol.  With  a  dead  tooth  which  is  no  longer  sensitive  in  itself, 
severe  neuralgic  pain  may  be  produced  by  inflammation  of  the 
periodontal  membrane,  and  the  formation  of  abscess  at  the  root. 
The  tooth  then  "  stands  up,"  and  the  jaws  can  scarcely  be  closed 
owing  to  pain  from  pressure  of  the  opponent  tooth.  Sometimes 
the  pain  will  quiet  down  under  the  use  of  lin.  iodi  to  the  gum,  only 
to  recur  probably  at  a  later  date.  Sometimes  the  inferior  dental 
nerve  trunk  in  its  bony  canal  becomes  irritated  or  inflamed  by 
direct  pressure  of  the  roots  of  the  second  or  third  lower  molars,  and 
extraction  of  either  of  these  teeth  may  partially  damage  the  nerve, 
giving  rise  to  recurrent  spasms  of  neuralgic  pain  and  tenderness 


Neuralgia.  1115 

along  the  lower  jaw  and  lip  and  side  of  neck.  To  arrest  this  pain 
the  nerve  trunk  must  be  totally  destroyed  by  scraping  out  the 
canal. in  the  bone. 

A  full  dose  (10  to  15  gr.)  of  quinine  sometimes  will  arrest  at 
once  the  radiating  neuralgia  of  dental  origin,  while  in  other  cases 
a  better  result  may  be  obtained  by  repeated  doses  of  10  gr.  of 
butyl  chloral  hydrate  in  combination  with  5  to  7  gr.  of  phenazone. 
This  may  be  given  hourly  for  three  doses,  and  then  every  four 
hours  if  necessary.  Very  severe  dental  neuralgia,  affecting  the 
whole  of  the  area  of  the  fifth  nerve,  ear  and  side  of  neck,  may  be 
due  to  an  impacted  molar,  a  pulp  stone,  or  to  an  erupting  wisdom 
tooth.  Lancing  the  swollen  gum  in  the  latter  case  may  relieve 
the  pain  instantaneously,  but  removal  of  the  offending  cause  is 
necessary  in  the  first  two  cases. 

Severe  paroxysmal  neuralgia  may  be  referred  to  the  gum  after 
removal  of  the  teeth,  and  it  may  often  be  arrested  by  painting 
the  gum  with  a  solution  of  4  per  cent,  each  of  cocaine  and 
menthol  in  equal  parts  of  sp.  vini  rect.  and  water,  together  with 
the  administration  of  a  few  doses  of  butyl  chloral  hydrate  and 
phenazone. 

SUPRA-ORBITAL  NEURALGIA. 

Pain  starting  over  the  eyebrow  and  shooting  up  over  the  forehead 
is  not  infrequently  the  result  of  ocular  troubles,  as  errors  of 
refraction,  especially  astigmatism,  or  it  may  be  caused  by  glaucoma. 
Neuralgic  pain  in  this  distribution  is  a  not  uncommon  affection  in 
certain  subjects,  generally  women,  and  it  is  especially  common 
during  the  monthly  periods,  during  gestation,  or  when  run  down  in 
health  from  any  cause.  Small  doses  of  quinine  or  of  the  coal-tar 
analgesics  here  too  may  give  relief ;  massage  to  the  head,  especially 
in  the  evening,  may  be  useful,  but  attention  must  be  paid  to  the 
general  health,  and  iron  and  other  tonics  administered  when 
necessary.  Strychnine,  however,  must  be  used  with  caution,  as 
sometimes  trifacial  neuralgia  is  greatly  aggravated  thereby. 

Periodic  supra-orbital  neuralgia,  or  brow-ague,  often  of  the 
greatest  intensity,  may  be  of  malarial  origin,  or  may  follow  an 
attack  of  influenza;  the  attacks  in  the  latter  case  are  usually 
of  daily  occurrence,  starting  about  10  to  11  a.m.  and  lasting 
till  late  afternoon.  There  is  usually  marked  tenderness  over  the 
supra-orbital  notch,  and  the  agony  of  the  pain  during  the  attack 
may  be  almost  unendurable,  though  it  usually  disappears  before 
evening.  Drugs  in  this  condition  are  practically  useless,  except 
morphia  hypodermically,  which  may  be  given  in  j-gr.  doses 


iii6  Neuralgia. 

daily  for  a  few  days  half  an  hour  before  the  expected  onset 
of  the  pain  ;  this  treatment  may  stave  off  the  attacks  completely. 
Failing  relief  by  this  means,  certain  cure  may  be  brought  about  by 
injection  of  4  or  5  drops  of  80  per  cent,  alcohol  into  the  supra- 
orbital  notch,  as  in  tic  douloureux. 

Neuralgic  headache  accompanied  by  soreness  of  the  scalp 
may  sometimes  be  relieved  by  rubbing  the  forehead  and  scalp  with 
solid  menthol ;  in  other  cases  a  full  dose  (15  to  20  gr.)  of 
aspirin  will  relieve  this  type  of  headache,  which  is  distressingly 
frequent  in  some  individuals,  and  is  to  be  distinguished  from 
migraine. 

TRIGEMINAL  NEURALGIA  :  TIC  DOULOUREUX. 
This  severe  and  intractable  form  of  neuralgia  affects  both  sexes 
equally,  usually  after  the  age  of  thirty.  I  have,  however,  known  it 
start  as  early  as  seventeen  and  as  late  as  eighty-one.  The  pain 
rarely  affects  all  three  divisions  of  the  nerve,  usually  either  the 
second  or  third  division  separately,  or  both  together,  on  one  side 
of  the  face  :  very  rarely  indeed  is  the  disease  bi-lateral.  The  first 
division  is  the  least  frequently  affected,  and  then  the  pain  is 
limited  to  the  supra-orbital  distribution.  In  some  patients  the 
spasms  of  pain  are  frequent  and  of  daily  occurrence,  continu- 
ing for  years ;  in  others  the  attacks  are  more  or  less  periodical, 
continuing  for  some  weeks,  and  then  disappearing  for 
months.  These  intermissions  of  total  freedom  from  pain 
are  frequently  observed  as  a  peculiarity  of  the  disease, 
and  are  not  necessarily  the  result  of  the  treatment  employed. 
In  the  majority  of  cases  drugs  are  of  little  or  no  avail,  even 
morphia  often  failing  to  give  relief,  and  there  is  a  special  danger  of 
morphinism  being  set  up  in  these  cases.  Electricity,  ionic  medi- 
cation and  X-rays  in  my  experience  are  all  worse  than  useless, 
and  may  considerably  augment  the  severity  of  the  attacks.  Of  the 
drugs  which  may  be  tried,  full  doses  of  butyl  chloral  hydrate  (15  gr. 
to  20  gr.)  and  tinct.  gelsemii  (20  minims  to  30  minims)  are  the  most 
successful  in  mitigating  the  pain.  Aconitine  (^^  gr.)  appears  some- 
times to  be  of  service,  given  in  pill  three  times  a  day.  Extrac- 
tion of  the  teeth  is  useless,  and  should  not  be  undertaken  except 
by  the  advice  of  a  competent  dentist.  Practically  the  only  sure 
way  of  arresting  the  pain  in  tic  douloureux  is  to  destroy  the  branch 
of  the  fifth  nerve  supplying  the  painful  area.  This  may  be  done  by 
resection  of  the  nerve,  or  by  destroying  the  nerve  trunk  at  its  deep 
foramen  of  exit  from  the  skull  by  injecting  it  with  strong  alcohol. 
These  methods  will  give  relief  from  pain  for  a  period  varying  from 


Neuralgia.  1117 

six  months  to  three  years.  Permanent  cure  can  only  be  obtained 
by  excision  of  the  Gasserian  ganglion,  or  by  a  division  of  the 
sensory  root  of  the  fifth  between  the  ganglion  and  the  pons.  This 
is  an  operation  of  considerable  severity,  with  a  total  mortality  of  about 
7  per  cent.,  the  fatal  cases  being  practically  limited  to  subjects  over 
the  age  of  fifty.  Ulcerative  keratitis  and  loss  of  the  eye  through 
destruction  of  the  cornea  has  sometimes  followed  total  excision  of 
the  ganglion,  but  in  the  hands  of  a  good  surgeon  this  would 
not  occur.  On  account  of  this  danger,  partial  excision  of  the 
ganglion,  leaving  the  ophthalmic  portion,  has  been  advocated ; 
but,  although  this  procedure  may  be  successful  in  removing  the 
pain  for  some  years,  recurrence  may  and  does  occur.  Division 
of  the  trunk  of  the  fifth  nerve  between  the  ganglion  and  the  pons 
has  been  said  to  give  an  ideal  result,  there  being  no  danger  of 
any  trophic  ulceration,  and  yet  complete  anaesthesia,  with  no 
liability  to  regeneration  of  the  nerve  fibres. 

Alcohol  injection  is  the  most  successful  treatment  for  tic 
douloureux  at  present  available  next  to  excision  of  the  Gasserian 
ganglion,  and  in  view  of  the  severity  of  the  latter  operation, 
alcohol  injection  should  always  be  tried  first.  This  is  done  at  the 
supra-orbital  notch  for  neuralgia  affecting  this  branch  of  the  first 
division  of  the  nerve,  at  the  infra-orbital  foramen  and  at  the  foramen 
rotundumforpainin  the  second  division  affecting  the  upper  jaw  and 
cheek,  nose  and  upper  lip,  and  at  the  foramen  ovale  for  neuralgia  of 
the  third  division  affecting  the  lower  jaw,  lower  lip,  tongue  and  side 
of  the  temple.  The  supra-orbital  appears  to  be  the  only  branch  of 
the  first  division  that  is  affected  by  this  neuralgia.  The  supra-arbital 
notch  should  be  felt  for  with  the  finger-nail,  and  its  position  marked 
by  a  vertical  line  drawn  from  it  over  the  forehead.  A  hypodermic 
syringe  is  fitted  with  a  fine  needle  and  filled  with  80  per  cent, 
alcohol,  and  the  skin  is  cleansed  with  ether  soap.  The  needle 
is  then  inserted  through  the  skin  over  the  notch,  about 
\  inch  below  the  eyebrow,  and  the  point  is  slowly  and  carefully 
pushed  in  the  direction  of  the  notch,  feeling  for  the  nerve.  The 
moment  this  is  reached  by  the  point  of  the  needle  a  sharp  twinge 
of  pain  is  felt  by  the  patient,  running  like  an  electric  shock 
straight  up  to  the  top  of  the  head.  Holding  the  needle  perfectly 
still,  a  few  drops  of  the  alcohol  are  slowly  injected,  and  if  the 
point  of  the  needle  has  been  properly  pushed  into  the  nerve  at 
the  notch,  there  will  be  instantly  felt  a  strong  burning  feeling 
spreading  up  over  the  forehead  as  far  back  as  the  crown,  and  after 
the  lapse  of  a  minute  the  whole  area  of  skin  supplied  by  the  supra- 
orbital  nerve  will  be  found  to  be  completely  anaesthetic  to  all 


in8  Neuralgia. 

forms  of  sensation,  including  pressure.  The  neuralgic  pain  over 
this  area  should  cease  from  the  moment  of  the  injection.  Con- 
siderable swelling  of  the  upper  eyelid  follows  the  injection,  and 
after  two  or  three  hours  the  eye  may  be  nearly  closed  with  the 
swelling,  and  there  may  occasionally  be  some  ecchymosis.  The 
swelling  begins  to  diminish  by  the  next  day,  and  will  be  scarcely 
visible  after  three  or  four  days.  The  anaesthesia,  at  first  com- 
plete, begins  to  diminish  after  some  weeks,  tactile  sensation  slowly 
returning,  while  yet  a  pin-prick  is  felt  only  as  a  touch  for  six 
months  or  longer. 

The  infra-orbital  foramen  may  be  injected  with  advantage  in  those 
cases  of  tic  affecting  the  second  division  of  the  nerve,  in  which  the 
pain  radiates  especially  in  the  skin  of  the  cheek,  side  of  nose  and 
upper  lip,  and  in  which  even  slight  touches  of  the  skin  of  this 
area  are  liable  to  provoke  the  spasms.  A  stronger  needle  must 
be  used  for  this  injection,  3  to  5  centimetres  in  length,  and  two 
syringes  to  fit  the  needle,  one  containing  sterilised  2  per  cent,  eucaine 
solution,  the  other  90  per  cent,  alcohol.  The  skin  is  frozen  by  the  ethyl 
chloride  spray,  and  when  the  needle-point  has  found  the  nerve 
at  the  notch  a  few  drops  of  the  eucaine  are  first  slowly  injected 
into  it,  and  then,  without  moving  the  needle,  the  syringes  are 
changed,  and  from  10  to  15  minims  of  the  90  per  cent,  alcohol  injected 
into  the  nerve.  After  two  or  three  minutes  there  will  be  deep 
anaesthesia  to  touch  and  pin-prick  over  the  cheek,  lip,  side  of 
nose  and  inside  of  nostril,  and  inside  of  the  cheek.  The  preli- 
minary eucaine  injection  almost  abolishes  the  intense  pain  that 
would  otherwise  be  caused  by  the  alcoholic  injection. 

Foramen  Eotundum. — In  most  cases  of  tic  affecting  the  second 
division  of  the  fifth  nerve  the  pain  is  not  confined  to  the  skin  of 
the  cheek  and  nose,  but  is  referred  also  to  the  upper  gum  and 
palate.  Injection  of  the  infra-orbital  nerve  will  not  be  sufficient  in 
these  cases  to  arrest  the  pain,  and  the  nerve  must  be  attacked 
further  back  at  its  exit  from  the  skull  at  the  foramen  rotundum. 
This  is  best  reached  through  the  cheek,  just  in  front  of  the  coro- 
noid  process  of  the  lower  jaw,  using  a  needle  8  to  9  centimetres 
long  and  1*2  millimetres  in  diameter,  with  a  short  point.  The 
needle  is  pushed  inwards  and  upwards  at  an  angle  of  about  40° 
until  the  external  pterygoid  plate  is  reached,  when  the  point  is 
then  slowly  worked  forwards  until  it  slips  in  front  of  the  edge  of 
this  bone,  and  is  pushed  inwards  for  another  5  or  6  millimetres, 
when  the  superior  maxillary  nerve  should  be  struck,  at  a  total 
depth  from  the  surface  of  5  to  5|  centimetres.  The  nerve  may  not 
be  hit  at  first,  and  it  must  be  carefully  searched  for  until  found. 


Neuralgia.  1119 

This  is  not  an  easy  operation,  and  should  not  be  undertaken  by 
anyone  unless  he  has  previously  carefully  studied  the  relationship 
of  the  parts  in  the  pterygoid  region  and  in  the  spheno-maxillary 
fossa,  both  on  the  skull  and  on  the  dead  body. 

With  a  successful  injection  of  the  superior  maxillary  nerve  at  the 
foramen  rotundum,  in  addition  to  anaesthesia  of  the  skin  of  the 
cheek,  lip  and  nose,  there  will  also  be  complete  anaesthesia  of 
the  upper  gum  and  teeth  and  palate  as  far  back  as  the  middle  of 
the  soft  palate. 

Neuralgia  of  the  third  division  affecting  the  lower  jaw  and  chin, 
side   of  tongue  and  temple,  must  be  dealt  with    by  injecting  the 
nerve  at  its  exit  from  the  foramen  ovalc.     Using  a  needle  6'5  centi- 
metres in  length  and  from  '8  to  1  millimetre  in  diameter,  this  is 
pushed  through  the  side  of  the  cheek  between  the  lower  border  of  the 
zygoma  and  the  sigmoid  notch  of  the  lower  jaw,  at  a  point  3'2  centi- 
metres in  front  of  the  external  auditory  meatus.    Pushing  the  needle 
through  the  pterygoid  muscles  very  slightly  backwards  and  upwards, 
the  inferior  maxillary  nerve  will  be  hit  at  a  depth  of  4'5  centimetres. 
Should  the  needle  be  sunk  too  deeply,  to  a  depth  of  2  inches  or 
more,  the  Eustachian  tube    may    be   punctured,  causing  a  sharp 
pain   in    the    ear ;  or  the    wall  of  the    pharynx    may  be  pierced. 
Almost  immediately  after  a  successful  injection   of   the   nerve  at 
the  foramen  ovale  the  patient  feels  that  the  lower  lip  and  chin  and 
tongue  are  feeling  numb  and  swollen,  and  testing  with  a  pin  shows 
this  area  to  be  anaesthetic ;  in  addition  the  lower  gum  and  teeth, 
and  the  side  of  the  temple  corresponding  to  the  auriculo-temporal 
nerve  will  be  found  to  be  anaesthetic.     Usually  also  there  will  be 
motor  palsy  of  the  masseter,  temporal  and  pterygoids,  but  little  or  no 
disability  ensues  from  this.    Some  slight  stiffness  on  opening  the  jaw 
is  sometimes  complained  of  for  a  day  or  two,  but  soon  passes  off. 

The  cessation  of  the  neuralgia  is  generally  instant  and  complete, 
though  very  occasionally  several  days  elapse  before  the  pain 
disappears  entirely,  the  duration  of  the  cure  perhaps  lasting  as 
long  as  two  to  three  years.  In  cases  of  severe  tic  douloureux,  in 
which  the  second  and  third  divisions  are  involved,  or  even  all  three 
divisions,  it  may  be  advisable  to  attempt  injection  of  the  Gasserian 
ganglion  itself  with  alcohol.  This  I  have  done  successfully  in  four 
cases,  by  pushing  the  needle  on  into  the  ganglion  through  the 
foramen  ovale  to  the  depth  of  5J  centimetres.  In  these  cases 
anaesthesia  of  the  whole  distribution  of  the  fifth  nerve  is  produced, 
and  in  all  probability  the  cure  of  the  pain  will  last  much  longer, 
owing  to  the  trophic  centre  of  the  nerve  fibres  being  destroyed,  and 
it  may  even  be  permanent. 


II2O  Neuralgia. 

Alcohol  injection  of  a  nerve  trunk  may  be  followed  for  a  day  or 
two  by  considerable  pruritus,  which  is  quite  unrelieved  by 
scratching  the  anaesthetic  area.  No  trophic  lesion  ever  results, 
with  the  possible  exception  of  slight  falling  out  of  hair  on  the 
temple  after  successful  injection  of  the  supra-orbital  nerve;  this 
does  not  always  occur. 

In  its  origin  trifacial  neuralgia  may  be  due  to  central  disease,  or 
involvement  of  the  ganglion,  nerve  trunk,  or  peripheral  filaments. 
Of  these  the  first  is  much  the  most  rare.  Persistent  trigeminal 
neuralgia  I  have  once  seen  due  to  an  area  of  sclerosis  in  the 
medulla  involving  the  spinal  root  of  the  fifth  nerve,  and  in  tabes 
trigeminal  shooting  pains  are  sometimes  met  with.  Tumours  in 
the  pons  or  at  the  base  of  the  brain  involving  the  fifth  nerve,  or  a 
gummatous  neuritis  damaging  the  nerve,  may  each  in  turn  be 
mistaken  for  tic  douloureux.  Outside  the  skull  malignant  growths 
may  invade  the  nerve  at  the  foramen  ovale,  and  a  slow-growing 
endothelioma  may  thus  for  many  months  give  rise  to  intense 
pain  along  the  third  division  of  the  fifth  nerve,  and  later  may 
invade  the  floor  of  the  skull  and  the  Gasserian  ganglion,  when 
the  pain  will  spread  into  the  upper  jaw  and  cheek.  Herpes 
zoster  usually  affects  the  ophthalmic  division  of  the  ganglion  only, 
and  in  rare  cases  frontal  parsesthesise  or  even  actual  pain  may 
persist  over  the  frontal  area  of  the  herpetic  scarring.  In  all 
these  cases  careful  examination  will  reveal  definite  evidence  of 
disturbance  of  the  function  of  the  fifth  nerve,  such  as  analgesia, 
slight  tactile  loss  to  cotton-wool,  etc.  Alcohol  injection  should 
never  be  used  in  such  cases. 


OCCIPITAL    NEURALGIA. 

This  is  often  uni-lateral,  involving  the  area  of  the  great  occipital 
nerve  and  the  back  of  the  neck  and  scalp.  When  persistent  and 
intractable  to  ordinary  remedies,  such  as  mustard  leaves  or 
blistering,  full  doses  of  aspirin  or  phenacetin,  injection  of  the  nerve 
with  strong  alcohol  may  be  successful.  With  a  hypodermic  needle 
attached  to  a  syringe  containing  2  per  cent,  eucaine,  the  scalp 
is  punctured  on  a  level  with  the  auditory  meatus  at  a  point 
|  inch  to  one  side  of  the  middle  line  of  the  occiput ;  the  point  of 
the  needle  is  slowly  moved  in  different  directions  until  a  radiating 
pain  darting  up  to  the  crown  indicates  that  the  nerve  has  been 
reached.  Taking  care  to  hold  the  needle  perfectly  steady,  2 
drops  of  eucaine  followed  by  5  drops  of  90  per  cent,  alcohol 
should  then  be  injected. 


Neuralgia.  1121 

BRACHIAL    AND    SCAPULAR    NEURALGIA,    RHEUMATIC 
FIBROSITIS. 

Brachial  neuritis  is  a  fairly  common  and  often  a  very  trouble- 
some and  painful  complaint,  like  sciatica,  often  lasting  many 
weeks  or  even  months  ;  indeed,  the  affection  is  almost  precisely 
comparable  to  sciatica.  The  evidences  of  actual  inflammation 
of  the  nerves  are  by  no  means  always  present,  and  as  in  the 
case  of  sciatica,  pain  in  many  cases  is  the  only  symptom.  The 
pains  radiate  from  the  neck  and  shoulder  down  the  arm  to  the 
wrist  and  even  to  the  fingers,  but  are  not  referable  to  the  course  of 
any  particular  nerve  trunk.  Various  tender  points  on  pressure 
may  be  met  with,  often  varying  from  day  to  day,  and  the  severity 
of  the  pain  may  also  vary  considerably,  sometimes  disappearing 
for  a  few  hours  or  a  day  or  two,  and  then  returning  with  renewed 
intensity.  This  point  must  be  remembered  in  estimating  the 
effects  of  treatment.  Though  movements  of  the  limb  do  not  always 
increase  the  pain,  rest  in  bed  with  the  arm  and  shoulder  lightly 
bandaged  with  cotton-wool,  with  the  arm  supported  on  a  pillow,  is 
advisable.  Packing  the  limb  with  antiphlogistine  sometimes 
relieves  the  pain  greatly,  and  may  be  done  every  night.  Cata- 
phoresis  with  salicylate  of  soda  on  the  negative  pole,  applied  as  a 
sponge  above  the  clavicle,  the  anode  being  moistened  with  lithium 
carbonate  and  wrapped  round  the  wrist  and  lower  forearm,  should 
be  tried  twice  daily  for  twenty  minutes,  using  a  steady  current, 
without  any  interruptions,  of  8  to  15  milliamperes,  according  to 
what  can  comfortably  be  borne.  Some  cases  do  better  with  radiant 
heat  applied  locally  by  means  of  strong  incandescent  lamps  backed 
by  a  reflector ;  this  should  be  done  preferably  in  the  patient's  own 
house,  or  else  in  a  nursing  home,  as  the  risk  of  chill  from  going  to 
an  institution  daily  for  the  treatment  is  considerable.  Various 
liniments,  such  as  lin.  A.B.C.,  or  methyl  salicylate,  menthol,  and 
lin.  pot.  iod.  c.  saponis  in  various  combinations  may  be  tried, 
often  with  great  benefit.  In  addition,  sleep  can  only  be  obtained 
in  severe  cases  by  the  use  of  phenacetin,  pyramid  on  or  aspirin  in 
full  doses.  In  certain  cases,  which  must  be  carefully  chosen,  the 
radiating  neuralgic  pains  around  the  shoulder  and  down  the  arm, 
even  as  far  as  the  hand,  can  be  quickly  cured  by  the  injection  of  a 
few  drops  of  strong  alcohol  at  certain  points.  In  these  cases 
careful  examination  of  the  scapular  region  with  the  pressure  of 
the  finger  or  the  blunt  end  of  a  pencil  will  reveal  one  or  two  or 
more  tender  points,  firm  pressure  on  which  produces  not  only  con- 
siderable pain  at  the  point  pressed  on,  but  also  radiating  pain, 
perhaps  into  the  neck  or  even  down  the  whole  of  the  upper 

S.T. — VOL.  n.  71 


1 122  Neuralgia. 

extremity  as  far  as  the  hand.  These  spots  must  be  carefully 
localised,  and  after  sterilisation  of  the  skin  and  freezing  with  ethyl 
chloride  should  be  injected  with  2  or  3  drops  of  2  per  cent, 
eucaine,  followed  by  from  5  to  10  min.  of  90  per  cent,  alcohol. 
Before  commencing  the  injection  care  must  be  taken  that  the 
limb  has  not  been  moved  since  the  tender  spot  was  localised,  and 
the  needle  must  be  pushed  down  to  the  bone  of  the  scapula  or  rib, 
as  the  case  may  be,  and  2  or  3  drops  of  the  alcohol  should  be 
injected  along  the  track  of  the  needle  as  it  is  withdrawn.  The 
immediate  result  is  usually  considerable  aggravation  of  the  pain 
around  the  shoulder,  lasting  for  several  hours  ;  but  on  the  following 
day  local  soreness  is  all  that  remains,  the  radiating  neuralgia  from 
the  injected  spots  having  disappeared. 

TOXIC    AND    DIATHETIC    NEURALGIAS    AFFECTING    THE 
HEAD    OR    LIMBS. 

These  forms  may  be  met  with  in  gout,  diabetes,  anaemia,  malaria, 
syphilis,  Bright's  disease  and  chronic  poisoning  by  lead  or  alcohol. 
The  possibility  of  such  various  causes  being  responsible  for  a 
case  of  obstinate  neuralgia  indicates  the  necessity  for  a  careful 
examination  of  the  patient  when  the  cause  is  not  immediately 
obvious,  and  its  discovery  when  made  will  indicate  the  treatment. 

VISCERAL    NEURALGIAS. 

These  occasionally  may  simulate  pleuritic  pain,  angina,  or  gastric 
crises,  and  will  have  to  be  distinguished  from  chronic  gastric  or  duo- 
denal ulcer,  gall-stones,  renal  calculus  or  appendicitis.  Neuralgia 
in  the  region  of  the  solar  plexus  and  ovary  may  be  periodic  in  women 
in  whom  there  is  no  sign  of  visceroptosis  ;  this  latter  condition  is  a 
common  cause  of  vague  abdominal  pains  and  general  neurasthenic 
symptoms.  Best,  hot  applications,  radiant  heat,  an  abdominal 
belt  and  one  of  the  coal-tar  analgesics  internally  should  be  tried 
for  these  visceral  neuralgias. 

POST-HERPETIC    NEURALGIA. 

This  is  sometimes  excessively  severe  and  prolonged  in  old  people 
over  sixty,  the  pain  bearing  no  proportion  to  the  severity  of  the 
scarring  of  the  skin.  This  is  a  most  difficult  pain  to  relieve, 
liniments,  blisters,  cataphoresis  and  injections  usually  failing  alike. 
I  have  known  alcohol  injection  down  to  the  inter-vertebral  foramen 
arrest  the  pain,  but  this  is  a  difficult  and  uncertain  operation. 
With  the  exception  of  keeping  the  patient  stupefied  with  morphia, 
laminectomy  and  division  of  the  posterior  roots  may  be  the  only 
remedy  to  give  relief. 


Neuralgia.  1123 

PAINFUL    HEEL. 

This,  causing  limping  from  inability  to  bear  the  weight  on  the 
heel,  after  excluding  such  causes  as  a  bony  spike  growing  from  the 
under  surface  of  the  calcaneum,  foreign  bodies,  inflamed  bursa 
under  the  tendo  Achillis,  etc.,  may  often  be  cured  at  once  by  an 
injection  of  eucaine  followed  by  1  cubic  centimetre  of  saline  at  the 
tender  spot. 

PSYCHALGIA. 

There  is  another  group  of  cases  in  which  the  pains  are  really 
mental  in  origin,  a  psychalgia,  in  which  the  pains  may  affect  any 
part  of  the  body,  scalp,  face,  trunk  or  limbs.  In  these  the  usual 
analgesic  remedies  are  of  no  use,  and  indeed  each  fresh  treatment 
seems  to  intensify  the  pain  ;  fortunately  these  cases  are  somewhat 
rare,  and  when  recognised  the  line  of  treatment  appropriate  for 
obsessions  must  be  employed.  Persistent  severe  neuralgic  pains, 
lasting  for  many  years,  in  which  no  cause  could  be  found  during  life, 
have  been  thought  to  be  functional,  but  have  been  proved  after  death 
to  be  due  to  sclerosis  of  a  posterior  root.  The  distribution  of  the 
area  of  the  pain  should  have  prevented  this  error  in  diagnosis. 
Neuralgia  of  a  definite  nerve  or  root  area  is  never  due  to  psychalgia 
or  neurosis.  Nevertheless,  undoubted  functional  pains  may  persist 
for  thirty  years  or  more,  as  I  have  seen  arise  from  lepraphobia  in 
one  case,  dread  of  hydrophobia  in  another,  and  other  neuroses. 
Such  pains  have  been  well  named  "  douleurs  d'habitude"  by 
Brissaud. 

SCIATICA. 

Acute  Sciatica,  or  inflammation  of  the  sheath  of  the  nerve  after 
its  exit  from  the  pelvis  at  the  great  sciatic  notch,  is  due  in  the 
majority  of  cases  to  the  spread  of  a  fibrositis  of  the  buttock  or 
lumbar  region,  either  of  rheumatic  origin,  or  the  result  of  a  fall  or 
sudden  muscular  strain.  Anti-rheumatic  remedies,  therefore,  will 
often  be  of  service,  such  as  aspirin,  salicylates  and  colchicum.  In 
the  acute  stage  when  the  pain  in  the  limb  is  constant  and  severe, 
extending  down  the  back  of  the  thigh  into  the  leg  and  ankle  and 
preventing  sleep,  complete  rest  of  the  limb  should  be  insisted  on. 
The  patient  should  remain  altogether  in  bed,  preferably  on  a  water 
or  air  mattress,  and  cataphoresis  with  salicylate  of  soda  and  lithia 
should  be  employed  twice  daily  for  twenty  minutes.  Using  a 
constant  current  battery  of  at  least  eighteen  cells,  the  negative  pole, 
a  flat  pad  of  about  7  inches  by  4,  is  soaked  in  hot  water  and 
moistened  with  saturated  solution  of  salicylate  of  soda,  and  then. 

71—2 


1 124  Neuralgia. 

applied  lengthwise  along  the  back  of  the  buttock  ;  the  positive  pad 
should  be  larger,  moistened  with  lithia  carbonate  solution,  and 
applied  across  the  under  surface  of  the  thigh,  just  above  the  knee. 
A  current  of  from  20  to  30  milliamperes  should  be  turned  on 
gradually,  without  any  sudden  breaks,  and  great  care  must  be  taken 
not  to  burn  the  skin,  the  patient's  sensations  of  stinging  pain 
being  usually  a  sufficient  index  that  the  strength  of  the  current 
ought  to  be  reduced.  After  ten  days  or  a  fortnight  of  this  treat- 
ment massage  and  passive  movements  may  be  commenced, 
especially  flexion  of  the  hip,  keeping  the  knee  straight.  This  is 
somewhat  painful  at  first,  but  is  necessary  to  prevent  adhesions 
being  formed  between  the  sheath  and  surrounding  muscles.  Other 
forms  of  treatment  that  are  frequently  used,  besides  rest  in  bed  for 
several  weeks,  are  blisters  to  the  back  of  the  thigh  along  the  course 
of  the  nerve,  frequently  repeated,  radiant  heat,  arc-lamp  rays,  and 
liniments  such  as  A.B.C.  and  methyl  salicylate,with  iodide  and  soap 
liniment.  Tincture  of  iodine  may  be  used  daily  to  paint  along  the 
course  of  the  nerve,  and  the  iodine  may  be  advantageously 
combined  with  the  cataphoresis  treatment  by  painting  the  skin  of 
the  buttock  under  the  kathode.  If  the  pain  at  night  is  preventing 
sleep,  10  gr.  of  aspirin  with  5  gr.  of  pyramidon  may  be  given,  and, 
if  that  fails,  an  injection  of  morphia. 

In  the  worst  and  most  obstinate  cases  of  sciatica,  in  which  almost 
every  movement  is  painful,  extraordinary  relief  and  rapid  cure  can 
often  be  brought  about  by  injection  of  the  nerve  near  the  great 
sciatic  notch  with  jiij  to  §iv  of  normal  saline  solution,  combined 
with  weak  eucaine.  This  is  known  as  Lange's  method  of  infil- 
tration of  the  nerve  sheath,  who  recommended  a  solution  of 
eucaine  (1  in  1,000  of  normal  saline).  In  my  own  practice  I  have 
found  it  best  to  inject  the  nerve  with  2  cubic  centimetres  of  2  per 
cent,  eucaine  solution,  following  it  up  at  the  same  point  immediately 
with  100  cubic  centimetres  of  '9  per  cent,  saline.  If  eucaine  is  not 
injected  first  into  the  nerve,  the  subsequent  injection  of  saline  is 
very  painful.  This  may  be  done  either  at  the  great  sciatic  notch, 
which  is  vertically  under  a  point  3^  to  4  inches  horizontally  out- 
wards from  the  top  of  the  inter-gluteal  fold,  or  else  where  the  nerve 
passes  between  the  tuber  ischii  and  the  lesser  trochanter,  according 
as  to  which  site  is  the  more  tender.  The  depth  at  which  the  nerve 
is  struck  by  the  needle  will  vary  from  2|  to  4  inches  or  more, 
according  to  the  size  of  the  patient.  None  but  local  anaesthetics 
must  be  employed,  as  the  only  certain  indication  that  the  nerve  has 
been  reached  is  the  sensation  felt  by  the  patient  of  a  sudden  twinge 
like  electricity  felt  in  the  foot.  The  injection  with  eucaine  is  then 


Neuralgia.  1125 

made  into  the  nerve,  taking  great  care  to  hold  the  needle  quite  still, 
and  this  is  followed  within  half  a  minute  by  the  warm  sterilised 
saline,  using  a  large  syringe  for  the  latter.  The  effect  is  to  inflate 
the  nerve  locally  at  the  point  of  injection,  separating  the  nerve 
bundles  and  breaking  down  adhesions.  The  immediate  result  is  a 
warm  swollen  sensation  of  the  whole  limb,  and  often  the  disappear- 
ance of  the  sciatic  pain  is  immediate.  The  patient  should  remain 
in  bed  for  twelve  hours  after  the  injection.  Usually  a  certain 
amount  of  pain  reappears  after  three  or  four  days,  and  a  second 
injection  is  often  necessary  at  the  end  of  a  week.  Ostwalt  has 
recommended  injecting  strong  carbolic-acid  solution  into  the  nerve  ; 
Schlosser  similarly  advocates  strong  alcohol,  and  sulphuric  ether 
and  chloroform  have  also  been  recommended,  but  immediate 
paralysis  of  the  leg  will  certainly  follow  if  any  one  of  these  drugs 
is  actually  injected  into  the  nerve.  However,  if  proper  care  is 
taken,  injections  of  strong  alcohol  may  be  used  with  much  advan- 
tage in  those  cases  of  sciatica  in  which  there  is  great  tenderness  on 
local  pressure  on  certain  spots  in  the  buttock,  often  at  some  little 
distance  from  the  nerve,  though  pain  may  radiate  from  them  over 
the  distribution  of  the  nerve,  as  in  the  case  of  the  shoulder 
neuralgia  already  described.  Just  as  in  that  case,  these  tender  spots 
should  be  injected  with  strong  alcohol  down  to  the  bone  of  the 
ilium,  taking  care,  however,  not  to  inject  the  alcohol  if  the  needle 
strikes  the  sciatic  nerve,  as  indicated  by  a  sudden  pain  in  the  foot. 
Injection  of  the  sciatic  nerve  is  not  an  easy  operation,  and  often 
great  patience  is  required  before  the  needle  is  correctly  placed.  So- 
called  acupuncture  of  the  nerve  is  of  no  value,  and  the  operation  of 
nerve-stretching  is  worse  than  useless,  considerable  harm  often 
being  done.  In  the  convalescent  stage,  bath  treatment  at  one  of  the 
spas,  such  as  Bath,  Buxton,  Harrogate  or  Aix-les-Bains,  will  assist 
the  improvement  of  the  general  health.  It  is  important  to  warn  a 
patient,  who  has  just  recovered  from  sciatica,  never  to  lift  heavy 
weights,  move  heavy  furniture,  or  exert  similar  strain  on  the  back 
muscles,  or  a  relapse  may  occur. 

In  old-standing  chronic  cases  of  sciatic  neuritis,  which  have 
existed  from  six  months  to  a  year  or  more,  the  progress  of  interstitial 
neuritis  may  lead  to  actual  damage  of  the  nerve-fibres,  producing 
numbness  and  even  anaesthesia  of  the  foot,  loss  of  the  Achilles  jerk 
and  muscular  wasting.  In  these  cases  there  is  generally,  though 
not  always,  severe  pain,  and  the  patient  hobbles  painfully  in  a 
crouched  position,  leaning  upon  a  stick.  Even  in  this  late  stage 
two  or  three  large  saline  injections  may  bring  about  a  cure  ;  but  if 
they  are  unsuccessful,  it  may  be  necessary  to  cut  down  upon  the 


1 1 26  Neuralgia. 

nerve  under  an  anaesthetic,  and  scarify  it  longitudinally  for  several 
inches,  as  the  nerve  may  be  found  shrunken  into  a  round  firm  cord 
from  scar  tissue. 

WILFRED  HARRIS. 

EEFEEENCES. 

Schlosser,  Verhand.  des  Congress  fur  Innere  Medizin,  1907,  XXIY.,  p.  49. 
Lange,  ibid.     Levy  and  Baudouin,  "  Les  N6vralgies  et  leur  Traitement,"  Paris, 

1909.  Sicard,  Presse  M&licale,  May  6th,  1908.     Harris,  W.,  Brit.  Med.  Journ., 

1910,  I.,  p.  1404  ;  also  Brit.  Med.  Journ.,  1910,  II. ,  p.  1051. 


1127 


THE  SURGICAL  TREATMENT  OF  NEURALGIA. 

THE  term  "  neuralgia  "  is  used  to  signify  pain  in  the  course  of  a 
nerve.  It  is  not  a  disease,  but  a  symptom,  and  in  every  case  the 
diagnosis  of  its  cause  is  of  the  utmost  importance  to  successful 
treatment.  In  every  case  of  "neuralgia"  the  cause  must  be 
carefully  sought  and  the  investigation  carried  out  to  discover  if  the 
pain  is  "  referred  "  from  irritation  of  the  nerve  in  its  course  by  the 
pressure  of  growth,  simple  or  malignant,  or  inflammatory  con- 
ditions or  by  the  pressure  of  a  cervical  rib  in  brachial  neuralgia, 
or  as  the  effect  of  scoliosis  in  intercostal  neuralgia,  or  one  of  its 
branches,  e.g.,  facial  neuralgia  due  to  irritation  of  a  branch  of  fifth 
nerve  in  connection  with  a  tooth.  Treatment  consists  in  removing 
the  cause  if  this  is  possible.  If  the  cause  cannot  be  discovered 
symptomatic  treatment  must  be  given  a  fair  trial ;  if  this  fails, 
destruction  of  the  nerve  supplying  the  painful  territory  must  be 
discussed.  This  may  be  done  by  the  injection  of  alcohol ;  if  this  is 
impossible  or  is  not  successful,  intradural  division  of  posterior 
roots  may  be  advisable. 

Facial  Neuralgia. — Under  this  heading  are  included  two  groups  : 
(1)  Minor  neuralgia ;  (2)  epileptiform  neuralgia,  tic  douloureux, 
major  neuralgia. 

(1)  The   pain  is  usually  referred  and  due  to  dental  irritation; 
other  causes  are  disease  of  maxillary  antrum  and  frontal  sinus, 
errors  of  refraction,  glaucoma,  etc.     Treatment  is  directed  to  the 
cause. 

(2)  Before  concluding  that  the  case  belongs  to  this  group  the 
most    careful    examination    is    necessary    to   exclude   peripheral 
irritation.     In  most   patients,  all  the  teeth  on  the  affected  side 
have   been   removed   before  a   surgeon   is  consulted.     The  gums, 
however,  must   be   carefully   examined    for    areas    of   tenderness 
marking  the  site  of  a  stump  giving  rise  to  irritation  or  a  small 
infected  cavity  left  after  extraction.     If  a  painful  spot  is  found,  a 
tiny   sinus  will  often  be  discovered  into  which  a  probe  may  be 
passed.     Under  an  anaesthetic  this  should  be  followed  down  and 
the  irritating  focus  dealt  with.     Even  if  no  sinus  is  discovered,  the 
gum  should  be  reflected  from  any  painful  spot,  when  an  opening  is 
often  seen  leading  into  the  bone ;  this  should  be  opened  up. 

Sensation  should  always  be  tested.  In  true  epileptiform 
neuralgia  there  is  no  alteration  in  sensibility  between  the  attacks. 


1 1 28     The  Surgical  Treatment  of  Neuralgia. 

If  this  is  present,  the  pain  is  due  to  pressure  or  involvement  in 
growth  in  the  course  of  the  division  or  intracranially. 

Until  recently  intracranial  operation  upon  the  primary  division 
of  the  nerve  or  upon  the  ganglion  was  the  treatment  of  choice  in 
all  undoubted  cases.  Since  the  introduction,  four  years  ago,  by 
Schlosser,  of  Munich,  of  the  method  of  alcohol  injections  into  the 
branches  as  they  leave  their  foramen  in  the  skull,  operation  is 
reserved  for  exceptional  cases.  The  injection  of  alcohol  into  a 
nerve  trunk  causes  destruction  of  the  nerve  fibres  at  the  seat  of 
injection  and  consequent  degeneration.  It  therefore  takes  the 
place  of  a  peripheral  neurectomy.  Operative  treatment  must  not 
be  considered  until  injections  fail  to  relieve,  or  pain  recurs  at  a 
short  interval  (see  p.  1117).  The  operative  treatment  of  this 
condition  is  not  yet  finally  settled.  Theoretically,  in  cases  in  which 
two  or  more  divisions  are  affected,  the  ideal  procedure  is  division 
of  the  sensory  root  of  the  ganglion,  leaving  the  motor  root  intact, 
as  recommended  by  Spiller,  in  1901,  and  first  performed  by  Frazier. 

If  operation  is  decided  upon,  it  should  be  intracranial.  Time 
should  not  be  wasted  in  performing  peripheral  neurectomies.  If 
the  pain  is  limited  to  one  division,  intracranial  resection  of  that 
division  with  the  interposition  of  rubber  tissue  at  its  foramen  of 
exit  should  be  performed.  If  two  divisions  are  involved,  the 
operation  consists  of  resection  of  these  with  the  portion  of  the 
ganglion  from  which  they  spring,  leaving  the  upper  part  with  the 
ophthalmic  nerve  (Hutchinson's  operation)  intact.  In  this  way 
the  risk  of  ocular  complications  is  avoided,  and  there  is  less  shock 
as  less  retraction  and  consequent  pressure  on  the  temporo- 
sphenoidal  lobe  is  necessary,  and  there  is  less  liability  to  damage 
to  the  cavernous  sinus  and  nerves  in  its  wall.  Only  when  the  pain 
involves  the  whole  territory  of  the  nerve  should  removal  of  the 
whole  ganglion  be  carried  out. 

The  easiest  access  to  the  ganglion  is  obtained  through  the 
temporal  region.  Cushing's  direct  temporal,  infra-arterial  method, 
I  consider  superior  to  the  high  temporal  route  of  Hartley-Krause  ; 
it  gives  the  most  convenient  access  with  the  least  disturbance  of 
the  part.  A  portion  of  the  temporal  bone  immediately  above  the 
zygoma  is  removed  through  a  sickle-shaped  incision  extending 
posteriorly  over  the  zygoma;  anteriorly  it  must  not  extend  low 
enough  to  injure  the  branches  of  the  facial  nerve  supplying  the 
frontalis.  The  dura  mater  is  stripped  up  from  the  middle  fossa 
and  the  foramen  ovale  found,  and  then  the  foramen  rotendum.  It 
must  be  remembered  that  the  ganglion  lies  in  the  cavum  Meckelii 
between  two  layers  of  dura  mater. 


The  Surgical  Treatment  of  Neuralgia.     1129 

The  results  of  the  removal  of  part  or  the  whole  of  the  ganglion, 
both  immediate  and  remotely,  are  extremely  good.  Mr.  Hutchinson 
has  performed  his  operation  twenty-six  times  without  a  death  and 
has  operated  on  the  ganglion  thirty-one  times  without  a  death. 
Sir  Victor  Horsley  has  removed  the  ganglion  in  149  patients  with 
a  death  rate  of  7  per  cent.,  but  has  had  no  deaths  among  the 
patients  below  the  age  of  fifty.  In  no  case  has  the  disease  recurred 
when  the  whole  ganglion  has  been  removed  or  in  Mr.  Hutchinson's 
cases. 

Sciatica. — No  case  must  be  treated  as  sciatica  until  a  thorough 
examination  has  shown  the  absence  of  disease  of  the  spinal  cord, 
cauda  equina,  bodies  of  vertebrae,  sacro-iliac  joint,  hip  joint,  rectum, 
etc.  An  X-ray  examination  should  always  be  made.  If  no  obvious 
cause  is  found,  or  if  the  pain  is  in  association  with  osteo-arthritis 
of  the  hip,  absolute  rest  should  be  the  first  treatment.  The  patient 
must  be  confined  to  bed  and  a  long  Listen  splint  with  weight 
extension  is  applied.  When  all  pain  has  ceased  the  splint  may  be 
removed,  and  massage  and  passive  movements  employed  before  the 
patient  is  allowed  to  get  up.  This  treatment  is  usually  successful. 
In  those  cases  in  which  it  fails  to  relieve  or  relapse  occurs,  Lange's 
infiltration  should  be  tried.  As  a  last  resort,  the  nerve  should 
be  exposed  and  carefully  examined  for  adhesions,  the  finger  being 
passed  up  into  the  sciatic  notch.  If  any  are  present,  they  should 
be  divided,  and  finally  the  nerve  should  be  stretched,  sufficient 
force  being  used  to  lift  the  limb  off  the  table  (see  also  Sciatica, 
p.  1123). 

JAMES  SHERREN. 


1 130 


NEURITIS. 

NEURITIS  may  be  limited  to  a  single  nerve  or  portion  of  a  nerve 
—local  neuritis,  or  may  involve  many  or  all  the  peripheral  nerves- 
multiple  neuritis. 

LOCAL  NEURITIS. 

Local  neuritis  may  arise  from:  (1)  Exposure  to  cold ;  (2) injury 
to  the  nerve  ;  (3)  the  involvement  of  the  nerves  in  local  affections 
of  the  surrounding  parts — traumatic,  inflammatory,  arthritic ; 
(4)  pressure  on  the  nerve  from  crutches,  cervical  rib,  callus  or  new 
growth  ;  (5)  local  affection  of  the  nerve,  as  in  syphilis,  leprosy  and 
new  growth ;  (6)  the  local  action  of  a  general  condition,  as  in 
rheumatism,  typhoid  fever,  gonorrhoea,  gout,  diabetes  and  malaria. 

The  treatment  of  local  neuritis  must  be  carried  out  on  the  fol- 
lowing general  principles  :  (1)  The  removal  or  treatment  of  the 
exciting  cause  ;  (2)  the  provision  of  absolute  rest  to  the  affected 
portion  of  the  nerve  and  the  alleviation  of  the  local  condition ; 
(3)  the  prevention  of  the  development  of  deformity  which  may 
result  from  the  paralysis ;  (4)  the  maintenance  or  improvement  of 
the  trophic  condition  of  the  parts  supplied  by  the  affected  nerve. 

The  Removal  or  Treatment  of  the  Cause. 

Rheumatic  Neuritis. — In  addition  to  the  local  treatment  which  is 
detailed  below,  the  patient  should  be  given  10  to  15  gr.  of  sodium 
salicylate,  combined  with  20  to  30  gr.  of  sodium  bicarbonate,  every 
six  hours  until  the  acute  stage  has  passed  off.  In  subacute  cases 
15-gr.  doses  of  aspirin  often  prove  successful.  The  bowels  should 
be  kept  freely  opened  and  alcohol  and  sweet  foods  forbidden. 

Gouty  Neuritis. — Treatment  should  be  directed  towards  removing 
the  gout.  The  bowels  should  be  kept  free  by  means  of  a  pill,  and 
Vichy  water  should  be  drunk  in  the  morning.  The  internal 
administration  of  colchicum  or  of  potassium  iodide  and  salicylate  of 
soda  should  be  persevered  with. 

Syphilitic  Neuritis. — Active  treatment  with  iodide  and  mercury  is 
essential.  The  iodide  should  be  given  in  fairly  large  doses 
(10  to  20  gr.)  three  times  a  day,  and  if  necessary  3  min.  of  liquor 
arsenicalis  [U.S.P.  liquor  potassii  arsenitis]  may  be  added  to  it. 
Mercurial  treatment  is  best  given  by  inunction,  and  should  be 
persevered  with  until  the  physiological  effect  of  the  drug  is  pro- 
duced. Sulphur  baths  should  be  given  daily  before  the  inunction. 


Neuritis.  .     1131 

It  is  yet  too  early  to  speak  definitely  of  the  result  of  treatment 
with  Ehrlich'snew  preparation  of  arsenic,  dioxydiamidoarsenobenzol, 
commonly  spoken  of  as  "  606."  It  has  certainly  proved  itself  to  he 
the  most  effective  drug  in  the  treatment  of  syphilis,  judging  by  the 
rapidity  of  its  action,  but  time  alone  can  show  whether  the  results 
so  obtained  are  permanent  or  not.  So  far  the  drug  has  only  been 
given  by  a  limited  number  of  skilled  persons,  and  how  far  its 
administration  is  possible  in  the  hands  of  the  general  practitioner 
remains  to  be  seen.  "  606  "  may  be  given  by  intra-muscular  or 
intra-venous  injection,  the  latter  method  being  practically  pain- 
less in  its  application  and  more  rapid  in  its  effect.  As  in  syphilitic 
neuritis  the  lesion  is  primarily  syphilitic,  the  nerve  elements  being 
involved  secondarily.  The  early  administration  of  "  606  "  should 
prevent  the  occurrence  of  degeneration  in  the  nervous  tissues. 

Diabetic  Neuritis. — Treatment  of  the  causal  condition  is  essen- 
tial. Alkaline  remedies  have  a  specially  good  influence  on  the 
neuritis.  The  prognosis  as  regards  the  neuritis  is  not  unfavourable, 
but  many  of  these  cases  tend  to  develop  chronic  muscular  atrophy, 
which  remains  long  after  all  traces  of  neuritis  have  disappeared. 

Malarial  Neuritis. — Neuritis  may  sometimes  develop  in  associa- 
tion with,  or  as  a  sequel  to  malaria.  In  the  former  the  treatment 
of  the  malaria  by  quinine  will  usually  remove  the  neuritis,  in  the 
latter  a  combination  of  iron  and  quinine  will  be  found  more 
useful. 

Compression  Neuritis. — The  removal  of  the  compressing  agent  is 
essential,  callus,  cervical  rib,  new  growth,  or  inflammatory  thicken- 
ings being  appropriately  dealt  with. 

The  Provision  of  Absolute  Rest  to  the  affected  Portion  of 
the  Nerve  and  the  Alleviation  of  the  Local  Condition.- — Rest  is 
secured  by  supporting  the  limb  and  preventing  movement  of  the 
affected  portion  of  the  nerve.  Where  there  is  an  acute  condition 
local  applications  may  be  applied — hot  compresses,  dry  heat,  anti- 
phlogistine  or  blisters  ;  in  more  chronic  cases  the  application  of 
the  actual  cautery  is  more  effective.  Iodide  may  be  given  in  the 
early  stages  of  most  cases,  and  may  be  combined  with  potassium 
salicylate,  potassium  bromide  and  phenazonum,  which  serve  to 
relieve  the  pain  as  well  as  to  help  in  removing  the  local  inflamma- 
tion. Should  the  pain  persist,  it  may  be  necessary  to  administer 
codeine  or  morphia  hypodermically ;  but  these  drugs  must  in  all 
cases  be  given  only  by  the  physician.  The  tenderness  over  the 
nerve  area  associated  with  neuritis  may  sometimes  be  relieved  by 
the  application  of  a  liniment  composed  of  equal  parts  of  tincture  of 
aconite,  belladonna  and  chloroform,  or  by  painting  the  arm  every 


1132  Neuritis. 

third  day  with  a  solution  composed  of  1  part  of  methyl  salicylate 
added  to  3  parts  of  olive  oil. 

The  Prevention  of  the  Development  of  Deformity  which 
tends  to  follow  upon  the  Paralysis. — Deformity  may  arise  from 
(a)  weakness  of  the  paralysed  muscles  associated  with  the  over- 
action  of  the  non-paralysed  muscles  ;  (6)  the  continual  adoption  by 
the  patient  of  a  posture  in  which  the  nerve  is  relaxed  and  freed 
from  the  pressure  exerted  by  muscular  contraction.  The  paralysed 
muscles  should  be  supported  so  as  to  prevent  over-stretching,  and 
where  possible  the  limb  should  be  placed  in  such  a  position  as  to 
prevent  over-action  of  the  non-paralysed  muscle  :  thus,  in  the  case 
of  a  dropped  wrist,  the  hand  and  fingers  should  be  bound  up  in  the 
hyper-extended  position.  In  the  case  of  dropped  feet,  the  feet 
should  be  kept  dorsi-flexed  at  the  ankle.  This  may  not  be 
possible  in  the  early  stages  owing  to  the  pain  produced  by  the 
stretching  of  the  muscles,  but  in  every  case  the  weight  of  the  bed- 
clothes should  be  removed  from  the  feet,  and  passive  movement 
should  be  carried  out  two  or  three  times  a  day  as  soon  as  the  acute 
stage  passes  off. 

The  Maintenance  or  Improvement  of  the  Trophic  Condi- 
tion of  the  Parts  supplied  by  the  Affected  Nerve. — The  trophic 
condition  of  the  paralysed  parts  may  be  maintained  by  keeping  the 
affected  part  wrapped  in  cotton-wool ;  this  will  keep  the  parts  warm 
and  prevent  the  occurrence  of  local  injury.  As  the  acute  stage 
passes  off  more  active  treatment  is  required ;  passive  movements, 
galvanism  and  mild  faradism  should  be  given.  Later,  massage, 
resistance  exercises  and  graduated  voluntary  movements  must 
be  carried  out  as  soon  as  all  tenderness  has  passed  off.  In 
many  cases  there  is  a  tendency  for  arthritic  changes  to  develop  in 
the  neighbouring  joints ;  this  may  be  counteracted  by  the  early 
employment  of  passive  movements  and  the  application  of  dry 
heat. 

T.  GRAINGER  STEWART. 


133 


DIVISION  OF  POSTERIOR  ROOTS. 

THIS  operation  may  be  necessary  for  the  relief  of  pain  due  to 
ascending  neuritis  from  the  irritation  of  terminal  branches  of 
nerves  or  the  bulbs  left  on  trunk  nerves  after  limb  amputations. 
It  is  also  occasionally  performed  for  the  relief  of  pain  in  involve- 
ment of  the  brachial  plexus  in  malignant  disease  of  axillary  glands 
secondary  to  carcinoma  of  the  breast.  It  has  been  carried  out  with 
success,  first  on  the  suggestion  of  Forster,  in  June,  1907,  for 
the  relief  of  spastic  paraplegia  and  also  to  relieve  pain  in  the 
gastric  crises  of  tabes. 

The  posterior  roots  supplying  the  affected  area  are  divided 
intradurally  after  removal  of  the  laminae.  When  possible  uni- 
lateral laminectomy  (Taylor)  should  be  performed. 

JAMES  SHERREN. 


134 


MULTIPLE    NEURITIS. 

IN  this  condition  there  is  a  widespread  involvement  of  the  peri- 
pheral nervous  system.  The  following  are  the  chief  varieties  : 
(1)  Cases  due  to  the  action  of  poisons  derived  from  outside  the  body- 
alcohol,  the  coal-tar  products,  lead,  arsenic,  mercury,  copper  and 
phosphorus  ;  (2)  cases  due  to  the  action  of  poisons  developed  in  the 
body  as  the  result  of  infective  disorders — diphtheria,  influenza, 
malaria,  typhoid  fever,  scarlatina,  puerperal  fever,  gonorrhoea, 
septicaemia  and  beri-beri ;  (3)  cases  arising  in  association  with  general 
disorders — diabetes,  gout,  rheumatism,  anaemia,  mal-nutrition, 
tuberculosis  and  carcinoma ;  (4)  cases  due  to  the  local  action  of 
organisms — leprosy  and  syphilis. 

Alcoholic  Neuritis.— The  first  essential  is  to  prevent  the  patient 
from  obtaining  any  more  alcohol ;  this  is  by  no  means  easy  in  the 
early  stages  of  the  disease,  as  the  patient  is  in  most  cases  a  secret 
drinker,  and  the  cause  of  the  illness  quite  unsuspected  by  the 
relatives.  The  loss  of  moral  sense  in  these  cases  is  so  great  that 
the  patient,  who  often  exercises  a  quite  extraordinary  degree  of 
cunning  in  obtaining  supplies  of  alcohol,  cannot  be  trusted  in  any 
way.  The  patient  should,  therefore,  be  removed  to  a  nursing  home 
or  institution,  or,  failing  that,  be  placed  under  the  direct  and 
constant  supervision  of  trusted  attendants. 

Having  removed  the  cause  of  the  illness  and  placed  the  patient 
in  favourable  surroundings,  the  next  care  must  be  to  improve  his 
general  health  and  mental  condition.  The  most  urgent  symptoms 
calling  for  relief  are  pain,  insomnia,  disordered  digestion,  and 
occasionally  cardiac  or  renal  complications.  The  patient  must 
have  absolute  rest  and  should  be  confined  to  bed,  when  possible 
on  a  water-bed.  Great  care  must  be  taken  to  prevent  bed-sores 
and  to  keep  the  patient  clean  and  dry.  Where  vaso-motor 
changes  are  pronounced  the  limbs  should  be  kept  warm  by 
wrapping  them  in  cotton-wool. 

Disorders  of  the  digestive  system  are  almost  invariably  present ; 
the  tongue  is  furred  and  foul,  and  the  patient  suffers  from  nausea 
and  a  distaste  for  sweetened  foods  ;  in  some  cases  there  is  persistent 
vomiting,  and  not  infrequently  the  patient  suffers  from  congestion  of 
the  liver  and  painful  and  bleeding  haemorrhoids.  In  the  minor 
cases  cutting  off  the  alcohol  and  proper  dieting  will  cause  a  rapid 


• 

Multiple  Neuritis.  H35 

improvement  in  the  digestive  functions.  In  more  severe  cases  the 
bowels  must  be  regulated  and  the  gastric  irritation  allayed  by  a 
bismuth  and  soda  mixture.  The  diet  should  be  light  and  nutritious, 
any  excess  of  nitrogenous  food  being  avoided.  The  appetite  may  be 
stimulated  by  giving  a  bitter  tonic  containing  cinchona  and  capsicum, 
especially  when  there  is  much  craving  for  drink.  If  cardiac  weak- 
ness is  present,  strychnine  should  be  given  by  mouth,  or  5  min. 
[U.S.P.  strychnine  hydrochloride,  gr.  ^]  of  the  solution  may 
be  injected  hypodermically  two  or  three  times  each  day.  The 
patient  should  be  allowed  plenty  of  fluid,  and  this  may  be  given  in 
the  shape  of  home  made  lemonade  or  imperial  drink.  The  pain  and 
insomnia  are  best  relieved  by  placing  the  patient  in  a  comfortable 
position,  applying  hot  compresses  or  sponging  alternately  with  hot 
and  cold  water,  and  administering  a  mixture  containing  15  gr.  of 
potassium  bromide,  10  gr.  of  potassium  salicylate,  and  5  gr.  of  phena- 
zonum.  Where  there  is  much  depression,  potassium  iodide  and 
digitalis  may  be  substituted  for  the  salicylate.  If  these  measures 
fail  to  procure  sleep,  10  gr.  of  trional  or  7  gr.  of  veronal  maybe  given 
at  night  for  two  or  three  nights  in  succession. 

During  the  early  stages  of  a  severe  case  no  active  local  treatment 
can  be  employed,  but  much  may  be  done  to  prevent  the  development 
of  contractures  and  deformity.  These  contractures  develop  mainly 
in  the  stronger  groups  of  muscles,  and  unless  attention  is  devoted 
to  their  prevention,  deformities  result  which  will  retard  recovery, 
and  even  cripple  the  patient  permanently,  although  all  traces  of  the 
neuritis  have  disappeared.  The  flexor  and  adductor  groups  of 
muscles  being  the  stronger,  the  deformities  which  result  are  :  Drop- 
foot,  with  drawing  up  of  the  heel ;  flexion  at  the  knees ;  adduction 
and  flexion  at  the  hips  ;  flexion  of  the  wrists,  fingers  and  elbows ;  and 
stiffness  and  adduction  at  the  shoulder.  A  most  important  practical 
point  which  must  not  be  lost  sight  of,  is  that  the  mere  overstretching 
of  the  extensor  muscles  is  of  itself  sufficient  to  retard  recovery  and 
therefore  measures  must  be  adopted  which  will  prevent  this. 

So  long  as  there  is  acute  tenderness  the  patient  lies  in  the  position 
of  greatest  relaxation,  the  legs  are  drawn  up  at  the  hips,  the  knees 
flexed  and  the  feet  pointed,  while  the  arms  are  folded  across  the 
chest,  flexed  at  the  elbow,  wrist  and  finger  joints.  No  attempt  to 
straighten  the  limbs  can  be  made,  owing  to  the  pain  which  the  least 
stretching  of  the  nerves  and  muscles  entails.  Care  must  be  taken  to 
prevent  the  weight  of  the  bedclothes  from  aggravating  the  drop-foot, 
by  placing  a  cradle  under  the  upper  sheet,  and  by  not  allowing  the 
hands  to  remain  in  a  position  which  accentuates  the  drop-wrist. 
When  the  tenderness  lessens,  gentle  passive  movements  should  be 


1136  Multiple  Neuritis. 

given  at  all  joints,  and,  as  soon  as  possible,  apparatus  should  be 
employed  to  .counteract  the  contracture,  which  can  be  done  only 
when  moderate  pressure  on  the  muscles  no  longer  causes  pain.  In 
testing  for  muscular  tenderness  it  is  necessary  to  divert  the  patient's 
attention,  as  he  will  often  scream  at  the  mere  idea  of  being  touched, 
when,  as  a  matter  of  fact,  all  true  hyperaesthesia  has  passed  off.  The 
most  suitable  appliances  for  the  lower  extremities  are  made  on  the 
principle  of  a  "  Gowers  boot,"  which  consists  of  a  slightly  flexible 
leather  splint  extending  from  well  up  the  thigh  to  the  heel,  and 
being  continued  from  the  heel  as  a  foot-piece.  The  splint,  having 
been  well  padded  with  cotton-wool,  is  applied  to  the  posterior  aspect 
of  the  limb,  and  the  foot-piece  is  made  to  exert  pressure  upon  the 
sole  of  the  foot,  so  as  to  approximate  the  position  of  the  foot  to  a 
right  angle  by  means  of  rubber  bands  or  tubes,  which  are  fitted  to 
either  side  and  attached  to  the  splint  at  the  level  of  the  knee,  the 
rubber  bands  being  crossed  so  that  the  one  which  is  fixed  to  the 
inner  side  of  the  foot-piece  is  attached  to  the  outer  side  of  the  knee, 
and  vice  versa.  The  flexor  contracture  at  the  knee  is  overcome  by 
broad,  crossed  elastic  bands,  which  stretch  diagonally  across  the 
front  of  the  knee  from  one  side  of  the  splint  to  the  other.  Similar 
apparatus  can  be  applied  to  the  arms  and  hands,  the  wrists  and 
fingers  being  straightened  gradually  by  means  of  elastic  tension. 
The  great  advantage  of  such  appliances  over  splints  is  that  they  can 
be  borne  more  continuously  and  be  adjusted  more  easily,  the 
elastic  bands  being  tightened  as  the  patient  gradually  improves 
and  becomes  able  to  bear  greater  pressure.  The  continuous  pull  of 
the  elastic  is  better  than  the  pressure  of  a  bandage,  which  does 
not  adapt  itself  to  changing  conditions.  At  first  it  may  be 
impossible  to  apply  the  apparatus  continually,  but  perseverance  is 
necessary  and.  will  be  amply  rewarded.  Massage  must  be  gentle  at 
first,  and  commenced  only  when  the  acute  stage  has  passed  off; 
later,  more  active  treatment  becomes  imperative,  and  galvanism  and 
faradism  will  be  found  useful,  especially  when  combined  with 
massage  and  passive  movements.  The  patient  must  be  encouraged 
in  every  way  to  make  use  of  returning  power,  and  every  improve- 
ment should  be  pointed  out  to  him.  Not  infrequently  progress  is 
arrested  by  the  deformities  and  contractures ;  when  this  occurs,  hot- 
air  baths  or,  failing  that,  an  ordinary  hot-water  bath  may  prove  of 
service  in  reducing  the  contracture  and  making  passive  movements 
more  easy.  If  this  does  not  suffice,  an  anaesthetic  should  be  given 
and  the  joints  moved,  hot  applications  being  applied  afterwards  to 
reduce  the  reaction  and  pain.  In  other  cases  surgical  interference 
may  be  necessary. 


Multiple  Neuritis.  1137 

In  mild  cases,  and  in  a  certain  type  of  alcoholic  neuritis,  ataxia 
is  the  most  marked  feature.  This  is  best  treated  by  putting  the 
patient  through  a  modified  course  of  Frenkel's  exercises,  the  extent 
to  which  this  can  be  done  being  determined  by  the  degree  of  neuritis 
and  tenderness  which  is  present. 

Treatment  must  extend  over  several  months  in  severe  cases,  and 
although  at  the  outset  attended  by  pain,  this  should  not  be  allowred 
to  stand  in  the  way  of  its  continuance.  Where  necessary  bromide, 
analgesics  or  even  veronal  or  trional  may  be  given  until  the  patient 
becomes  more  accustomed  to  the  movements  and  the  apparatus. 
One  of  the  greatest  difficulties  which  the  physician  has  to  encounter 
is  the  obstinacy  and  mental  apathy  of  the  patient ;  firmness  and 
encouragement  are  essential  to  the  success  of  the  treatment.  As 
soon  as  recovery  renders  it  possible  the  patient  should  be  encouraged 
to  use  his  arms  and  legs  ;  fresh  air  and  outdoor  life  materially 
hasten  recovery. 

Lead  Neuritis. — Painters,  plumbers,  typesetters,  workers  in 
white  lead,  glaziers,  etc.,  are  liable  to  suffer  from  this  condition.  In 
all  such  occupations  prophylactic  measures  should  be  insisted  upon. 
Strict  attention  to  personal  hygiene  must  be  enforced  :  the  work- 
ing clothes  should  be  changed  and  the  hands  cleansed  before 
eating.  The  mouth  and  teeth  must  be  attended  to,  and  the  bowels 
should  be  kept  well  opened  by  means^  of  a  morning  dose  of  Epsom 
salts.  Drinking  sulphuric  acid  lemonade,  made  by  adding  5  drops 
of  aromatic  sulphuric  acid  to  a  wineglassful  of  water,  is  also  recom- 
mended, as  it  tends  to  prevent  the  absorption  of  lead  into  the 
system. 

If,  despite  these  precautions,  symptoms  of  lead  poisoning  develop, 
the  patient  must  relinquish  his  occupation,  at  any  rate  for  a  time. 

Lead  poisoning  may  result  from  the  drinking  of  soft  water, 
alcohol  or  beer  which  has  become  impregnated  with  lead  by  being 
stored  in  leaden  receptacles  or  passed  through  leaden  pipes.  All 
such  sources  of  intoxication  should  be  considered  and,  if  possible, 
removed.  In  any  case  of  lead  neuritis  steps  must  be  taken  to 
prevent  further  intoxication,  and  treatment  directed  towards  the 
elimination  of  the  lead  from  the  system.  Whether  this  can  be 
effected  by  drugs  or  not  is  a  moot  question,  but  by  keeping  the 
bowels  well  opened  and  encouraging  diuresis  and  a  free  action  of  the 
skin  the  natural  process  of  elimination  is  doubtless  increased. 
Baths  impregnated  with  sulphurated  potash  are  also  of  assist- 
ance, their  action  being  increased  if  the  patient  is  well  soaped 
and  rubbed  down  with  a  rough  towel  after  the  bath.  Iodide  of 
potassium  has  been  recommended  on  the  grounds  that  it  hastens 
S.T. — VOL.  n.  72 


1138  Multiple  Neuritis. 

the  elimination  of  the  lead,  but  the  experiments  of  Professor  Dixon 
Mann  failed  to  prove  that  it  has  any  appreciable  influence  in  this 
direction ;  on  the  other  hand,  its  efficacy  in  cases  of  acute  lead 
poisoning  is  undoubted,  and  its  use  should  not  be  discarded. 
Associated  conditions  such  as  anaemia,  renal  and  vascular  disease 
must  be  appropriately  treated.  Pain  and  hypersesthesia  are  not 
prominent  features  of  lead  neuritis,  and,  therefore,  active  local 
treatment,  massage,  passive  movements,  resistance  exercises  and 
electrical  treatment  should  be  commenced  early,  and  the  daily 
injection  of  5  min.  of  liquor  strychninae  hydrochloridi  [U.S.P. 
strychnin®  hydrochloridi  gr.  -£$]  is  of  special  value.  Most  cases  of 
lead  paralysis  come  under  treatment  early,  and,  therefore,  it  may 
be  necessary  to  confine  the  patient  to  bed.  Apparatus  for  keeping 
the  hands  and  fingers  hyper-extended,  for  assisting  in  the  dorsi- 
flexion  of  the  feet,  will  enable  the  patient  to  use  his  hands  and  feet, 
and  by  preventing  over-extension  of  the  paralysed  muscles  promote 
a  rapid  recovery. 

Arsenical  Neuritis. — Arsenical  neuritis  may  arise  from,  the 
prolonged  taking  of  small  quantities  of  arsenic,  from  intoxication 
with  arsenical  pigments,  or  from  a  single  large  dose  of  the  drug. 

This  condition  differs  from  that  of  alcoholic  neuritis  in  the  extreme 
degree  of  hyperaesthesia  which  is  present,  in  the  persistence  of  pain, 
in  the  greater  degree  of  ataxia,  and  in  the  more  extensive  and 
severe  muscular  wasting  which  is  liable  to  ensue. 

Treatment  for  the  relief  of  the  pains  and  hyperaesthesia  is  essential, 
and  in  some  cases  the  administration  of  morphia  or  codeine  may  be 
necessary.  The  inco-ordination  may  require  special  treatment  by 
means  of  Frenkel's  exercises.  In  other  respects  the  treatment  is 
similar  to  that  of  alcoholic  neuritis,  but  complete  recovery  is  often  a 
matter  of  many  months. 

Post-diphtheritic  Neuritis. — This  form  of  paralysis  has  cer- 
tainly become  less  frequent  and  less  severe  since  the  introduction  of 
the  anti-toxin  treatment.  The  early  administration  of  anti-toxin 
is,  therefore,  of  importance  as  a  prophylactic  measure,  as  well  as 
being  curative  of  the  primary  condition.  The  severity  of  the  neuritis 
bears  no  relation  to  that  of  the  attack  of  diphtheria ;  indeed,  the 
most  severe  -  cases  of  post-diphtheric  paralysis  occur  in  patients  in 
whom  the  diphtheria  has  been  so  mild  as  to  escape  notice.  Great 
care  is  necessary  in  the  treatment  of  cases  of  post-diphtheric  neuritis, 
as  extension  of  the  paralysis  may  take  place  very  insidiously,  and 
cases  in  which  mild  palatal  symptoms  alone  are  present  may  rapidly 
develop  signs  of  cardiac  and  respiratory  paralysis.  Complete  rest  is 
essential,  and  ample  nourishment  should  be  given.  Care  must  be 


Multiple  Neuritis.  1139 

taken  to  prevent  food  entering  the  larynx,  and  nasal  feeding  is 
necessary  in  some  cases.  The  condition  of  the  heart  and  respira- 
tory muscles  must  be  carefully  watched.  Strychnine,  should  be 
given  by  the  mouth  in  mild  cases,  or  by  hypodermic  injection  in 
severe  cases.  If  respiratory  paralysis  threatens,  repeated  inhalations 
of  oxygen  should  be  given.  If  cardiac  failure  is  not  averted  by  rest 
and  strychnine,  venesection'  should  be  performed  and  8  to  10  oz.  of 
blood  removed.  The  treatment  of  the  paralysis  of  the  limbs  is  that 
of  multiple  neuritis  in  general,  but  active  local  treatment  must  not 
be  commenced  too  soon  owing  to  the  subacute  onset  of  the  condition 
and  the  danger  of  cardiac  failure.  Very  frequently  the  patient 
passes  through  an  ataxic  stage  before  the  paralytic  stage  becomes 
manifest,  and  there  is  a  natural  temptation  to  start  the  patient  upon 
Frenkel's  exercises  at  once.  This  should  not  be  yielded  to  until  all 
chance  of  advancing  paralysis  is  passed.  The  patient  in  most  cases 
recovers  rapidly,  and  if  the  local  treatment  has  been  carried  out 
on  the  lines  suggested  for  Local  Neuritis  (see  p.  1130),  there  is  little 
chance  of  deformity  or  contractures  delaying  his  progress. 

Puerperal  Neuritis. — This  may  occur  as  a  local  condition  during 
pregnancy,  or  develop  as  a  general  condition  during  the  puerperium. 
The  treatment  is  that  of  a  multiple  neuritis,  but  any  complication 
or  possible  causal  condition  should  be  dealt  with  at  the  same  time. 
The  prognosis  is  good.  - 

Senile  Neuritis. — This  results  from  general  mal-nutrition  and 
changes  in  the  vessels  supplying  the  nerves.  General  tonic  treat- 
ment is  indicated,  the  local  treatment  being  determined  by  the 
extent  and  severity  of  the  disease. 

Multiple  Neuritis  arising  from  some  Unknown  Cause.— 
The  treatment  of  this  condition  as  regards  the  paralysis  is  the  same 
as  in  alcoholic  multiple  neuritis.  Nourishment  and  attention  to 
the  cardiac  condition  are  most  important.  The  prognosis  is  good. 
Beri-beri. — This  is  an  endemic  form  of  neuritis,  for  the  treat- 
ment of  which  the  reader  is  referred  to  the  article  on  Beri-beri 
(Vol.  III.). 

T.  GRAINGER  STEWART. 


72- 


1 140 


NYSTAGMUS. 

Horizontal  Nystagmus  may  be  physiological,  and  may  be  seen 
in  anyone  sitting  in  a  moving  train  and  watching  passing  objects. 
Its  association  with  variations  in  pressure  in  the  endolymph  of  the 
internal  ear  may  be  shown  by  rotating  the  individual  five  or  six 
times  rapidly,  and  then  telling  him  to  look  towards  the  opposite  direc- 
tion to  that  in  which  he  was  turned.    Syringing  out  the  middle  ear  in 
some  cases  of  otitis  media  may  produce  the  same  effect.     Many  ocular 
affections  give  rise  to  nystagmus,  especially  when  acquired  in  infancy. 
Thus  perforation  of  the  cornea  from  gonorrhceal  ophthalmia  may  lead 
to  a  central  opacity  on  the  lens,  and  as  a  result  proper  fixation  is 
never  acquired,  the  fovea  centralis  is  never  educated,  and  nystagmus 
is  the  result.     When  one  eye  is  much  more  damaged  than  the  other, 
covering  the   worse   eye  with  a  ground   glass   may  diminish  the 
nystagmus  very  much,  or  abolish  it  entirely  for  the  time.     Albinism 
is  almost  constantly  associated  with  nystagmus,  or  "  dancing  eyes." 
Lamellar  cataracts,  acquired  in   infancy  and    due    to   rickets,    if 
unoperated  on  will  lead  to  slow  rolling  movements  of  the  eyes,  and 
if  the  cataracts  are  needled  and  thus  cured  by  becoming  absorbed, 
nystagmus  will  develop  in  later  childhood,  unless  the  infant  is  made 
to  wear  constantly  the  strong  glasses  necessitated  by  the  loss  of  the 
lens.     This  is  owing  to  fixation  never  being  acquired,  the  extreme 
hypermetropia  caused  by  the  loss  of  the  lens  blurring  the  images  to 
such  a  degree  that  the  fovea  centralis  is  never  developed.    Nystagmus 
may  be  congenital,  and  is  then  often  hereditary,  several  members 
of  the  same  family  suffering.     There  may  be  no  trace  of  albinism  in 
these  eases  or  anything  demonstrably  wrong  with  the  eyes,  except 
slightly  diminished  acuity  of  vision.     Although  the  nystagmus  may 
be  very  pronounced,  the  patients  never  admit  that  objects  appear 
to  be  moving.     Miner's  nystagmus  is  a  well-known  variety  found 
in  the  workers  at  the  face  of  the  coal,  who  hole  the  coal  lying  on 
their  sides,  working  in  a  bad  light.     It  is  generally  associated  with 
other  signs  of  neurosis,  and  is  to  be  looked  on  as  an  occupation 
neurosis  or  fatigue  spasm.     The  same  form  of  nystagmus  may  be 
met  with  in  mountaineers,  and  in  violin  players  and  others  who 
may  beobliged  to  read  music  from  an  angle  constantly.     Nystagmus 
in  disease  of  the  central  nervous  system  is  a  valuable   sign, 
usually   indicating  that   there   is   a   lesion   of   the   cerebellum    or 


Nystagmus.  1141 

cerebellar  tracts,  as  in  Friedreich's  disease  and  disseminated  sclerosis. 
The  coarse  slow  movement  is  to  the  same  side  as  the  cerebellar 
disease.  Rotatory  nystagmus  is  sometimes  seen  in  disease  of  the 
pons,  especially  if  the  anterior  corpora  quadrigemina  are  involved, 
or  in  tumours  of  the  third  ventricle.  In  such  diseases  there  is  no 
indication  for  the  treatment  of  the  nystagmus  as  a  symptom,  but 
the  sign  may  be  a  valuable  one  for  the  recognition  and  consequent 
treatment  of  the  disease  itself.  Head-nodding  or  spasmus  nutans 
in  infants  during  the  dentition  period  may  be  associated  with 
nystagmus,  often  of  one  eye  only,  and  the  nystagmus  may  be 
rotatory.  It  is  likely  to  be  more  marked  when  the  head  is  held 
fixed.  Occasionally,  instead  of  a  nodding  movement,  there  is  a 
lateral  movement  of  the  head.  It  is  not  a  serious  condition,  though 
it  has  been  thought  to  be  an  evidence  of  rickets.  Careful  feeding, 
cod-liver  oil  and  iron  are  all  that  is  necessary. 

In  some  children  with  pronounced  nervous  heredity  the  nodding 
movements  of  the  head  may  occur  only  at  night,  "  tic  du  sommeil," 
which  has  been  known  to  persist  for  many  years. 

WILFRED  HARRIS. 


REFERENCES. 

Oppenheim,  H.,  "  Text-book  of  Nervous  Diseases,"  5th  ed.,  8vo,  Edinb.,  1911. 
Reid,  A.  C.,  "  Brain,"  1906,  XXIX.,  363.  Gowers,  Sir  W.  R.,  "  Manual  of 
Diseases  of  the  Nervous  System,"  Vol.  II.,  2nd  ed.,  8vo,  Lond.,  1893. 


1 142 


TUMOURS  OF  NERVES. 

TUMOURS  growing  in  connection  with  peripheral  nerves  are  called 
"neuromata."  They  are  divided  into  the  "true,"  in  which  the 
growth  is  composed  of  nerve  fibres  and  nerve  cells,  and  the  "false," 
in  which  the  connective  tissue  structures  of  the  nerve  are  involved. 
The  true  neuromata  are  of  great  rarity  and  are  never  diagnosed. 
False  neuromata  may  be  circumscribed  or  diffuse,  simple  or 
malignant. 

Circumscribed  "  Neuromata." — Simple. — The  affected  nerve 
should  be  exposed  well  above  and  below  the  tumour  and  an  incision 
carefully  made  in  the  nerve  parallel  to  the  course  of  its  fibres  down 
to  the  tumour,  which  can  usually  be  shelled  out  with  ease.  No 
damage  should  result  to  the  nerve  from  this  procedure.  If  enuclea- 
tion  is  impossible  resection  must  be  carried  out  and  nerve  continuity 
restored. 

Malignant. — Sarcomata  may  arise  in  the  nerve  sheath  and 
spread  rapidly  up  and  down  the  nerve.  If  seen  early,  wide  resection 
should  be  carried  out  and  portions  of  the  ends  removed  for  rapid 
microscopical  examination  to  be  certain  that  the  incisions  are  above 
the  infiltrated  areas.  This  should  be  done  before  the  wound  is 
closed.  If  the  growth  is  adherent  to  surrounding  parts,  amputation 
is  advisable. 

Diffuse  Neuroma. — Neuro-fibromatosis. — Many  conditions  are 
described  under  this  head ;  they  have  one  feature  in  common,  a 
diffuse  overgrowth  of  the  connective  tissue  of  a  nerve  or  nerves. 

Surgical  interference  should  be  limited  to  the  removal  of  tumours 
which  are  painful  or  interfering  with  the  well-being  of  the  patient. 
Sarcomatous  degeneration  may  occur  in  any  of  the  tumours.  This 
is  treated  as  are  sarcomata  elsewhere. 

JAMES   SHERREN. 


H3 


DISEASES  AND  AFFECTIONS   OF  THE  BRAIN. 

APHASIA    AND    OTHER    SPEECH    DEFECTS    OF 
CEREBRAL    ORIGIN. 

IN  the  management  of  patients  in  whom  defects  of  speech  have 
resulted  from  lesions  of  the  cerebral  hemispheres  there  are  two 
entirely  distinct  aims  to  which  treatment  must  be  directed.  The 
first  of  these  is  the  limitation,  arrest  and  resolution  of  the  cerebral 
lesion  that  is  responsible  for  the  defect  of  speech,  and  the  prophy- 
laxis against  the  occurrence  of  further  lesions  of  the  same  nature. 
The  second  is  the  restitution  by  re-education  and  training  of  the 
defective  speech  faculty,  which  may  be  brought  about  both  by  the 
raising  of  the  functional  capacity  of  a  partly  damaged  speech-centre 
or  by  the  compensatory  acquirement  of  speech  functions  by  cerebral 
centres  other  than  those  chiefly  and  usually  concerned  with 
speech. 

During  the  early  days  of  the  illness  measures  directed  towards 
the  limitation  and  resolution  of  the  lesion  are  all-important,  and 
since  vascular  lesions  are  responsible  for  the  cerebral  defect  in  all 
but  a  very  few  of  the  cases,  the  appropriate  treatment  will  be  found 
under  the  heading  Cerebral  Vascular  Lesions. 

It  is  all-important  to  bear  in  mind  that  lasting  defects  of  speech 
result  only  from  lesions  of  the  convolutions  as  opposed  to  lesions  of 
the  central  white  matter,  and  that  the  vascular  lesions  affecting  the 
convolutions  are  nearly  always  of  the  nature  of  thrombosis  and 
embolism  as  opposed  to  haemorrhage.  The  measures,  therefore,  for 
the  relief  of  thrombosis  and  embolism  will  be  appropriate  in  almost 
all  the  cases  now  under  consideration.  These  measures  may  be  sum- 
marised as  follows :  (1)  Those  directed  towards  the  lessening  of  the 
coagulability  of  the  blood,  and  which  therefore  lessen  the  tendency  of 
thrombosis  to  extend,  and  which  lessen  the  liability  to  the  occurrence 
of  secondary  thrombosis  after  embolism.  For  this  purpose  it  is 
usual  to  administer  the  alkaline  citrates  or  citric  acid  in  full  doses 
and  to  relieve  any  marked  degree  of  cyanosis  by  bleeding.  (2)  Those 
directed  towards  the  increase  of  the  blood-flow  in  the  smaller 
vessels,  and  which  tend  not  only  to  limit  the  thrombosis,  but  also  to 
lessen  the  amount  of  tissue-death  within  the  thrombosed  area  by 
favouring  the  occurrence  of  compensatory  circulation  and  the 


1 1 44      Aphasia  and  other  Speech  Defects. 

re-channelling  of  thrombosed  vessels.  In  this  connection  the 
remedies  which  increase  the  heart's  force  and  which  relieve  any 
embarrassment  to  the  circulation  which  may  be  present  are 
invariably  indicated.  Strychnine  (in  doses  of  gr.  ^  thrice  daily, 
and  for  preference  administered  hypoderrnically),  digitalis  and 
alcohol  are  the  best  drugs  to  employ ;  but  it  must  be  borne  in  mind 
that  one  of  the  most  valuable  means  of  cardiac  stimulation  at  our 
disposal  is  the  administration  of  an  easily  assimilable  diet  con- 
taining proteids  and  extractives,  and  to  this  end  a  simple  diet, 
reinforced  by  the  addition  of  Valentine's  meat  juice,  raw  meat 
juice,  Fairchild's  "  Panopepton,"  pounded  raw  meat  and  beef-tea, 
should  be  given,  and,  when  the  patient  is  able  to  take  an  ordinary 
diet,  the  meaty  part  of  the  diet,  and  especially  underdone  meat, 
must  on  no  account  be  left  out.  It  not  unfrequently  happens  that 
for  some  time  after  the  occurrence  of  the  lesion  the  patient  may 
be  unable  to  swallow,  and  when  this  is  the  case  nasal  feeding  should 
be  employed  in  good  time,  for  the  absence  of  assimilation  by 
lowering  the  heart's  force  and  the  blood-pressure  tends  to  favour 
the  extension  of  the  thrombotic  process.  If  embarrassment  of 
the  circulation  is  shown,  by  stertorous  breathing  and  cyanosis 
with  distension  of  the  superficial  veins,  venesection  is  a  most  useful 
measure,  and  the  letting  of  about  10  oz.  of  blood,  so  far  from  being 
a  depletive  measure,  will  act  as  a  cardiac  stimulant,  in  that  it  will 
relieve  the  congestion  of  the  right  heart.  (3)  All  those  events 
which  tend  to  produce  temporary  lowering  of  the  blood-pressure  or 
lessening  of  the  heart's  force  are  to  be  studiously  avoided,  for  if 
such  occur  in  the  early  days  of  the  illness  the  extension  of 
thrombosis  and  the  enlargement  of  the  lesion  is  highly  probable, 
while  at  any  subsequent  time  such  lowering  of  the  heart's  force  or 
of  the  blood-pressure  may  be  responsible  for  the  occurrence  of  fresh 
areas  of  thrombosis.  It  is  for  this  reason  that  free  purgation  must 
be  especially  avoided  from  the  onset,  mild  aperients  supplemented 
by  enemata  alone  being  appropriate.  The  use  of  remedies  which 
have  the  effect  of  lowering  the  blood-pressure  is  contra-indicated,  no 
matter  how  high  the  blood-pressure  may  be.  The  administration 
of  iodide  of  potassium  should  be  rigidly  restricted  to  cases  in  which 
the  thrombosis  is  undoubtedly  of  a  syphilitic  nature,  and  in  such 
syphilitic  patients  it  should  only  be  used  after  a  thorough  exhibition 
of  mercury,  and  then  only  in  combination  with  cardiac  stimulants, 
for  it  has,  in  the  absence  of  mercury,  an  especial  action  in 
rendering  the  blocking  of  a  vessel  permanent  and  irremediable. 

Cardiac    disease    with  embolism    being  excepted,  the   common 
cause  of  rapidly  oncoming  aphasia  in  the  first  half  of  adult  life  is 


Aphasia  and  other  Speech  Defects.      1145 

syphilitic  thrombosis  of  cerebral  vessels.  The  diagnosis  of  this 
condition  may  be  aided  and  confirmed  by  Wassermann's  reaction  and 
by  the  probable  presence  of  lymphocytes  in  the  cerebro-spinal  fluid 
obtained  by  lumbar  puncture.  In  such  cases  it  is  imperative  to 
attack  the  syphilitic  process  as  early  as  possible  and  with  the  most 
rapidly  acting  and  potent  remedies,  not  only  with  for  the  purpose  of 
preventing  the  thrombosis  of  other  diseased  cerebral  vessels  but 
also  with  the  object  of  securing  the  re-channelling  of  the  vessels 
actually  thrombosed.  For  this  purpose  Ehrlich's  Salvarsan  seems 
to  possess  a  decided  advantage  over  other  remedies.  It  should  be 
given  by  the  intravenous  method  in  two  doses  of  0*4 — 0'6  gr. 
at  an  interval  of  a  fortnight,  and  should  be  followed  by  a  course 
of  mercury  and  iodide  of  potassium.  In  the  writer's  experience 
the  use  of  Salvarsan  has  not  been  followed  by  any  ill  effect  and  the 
immediate  and  rapid  improvement  in  recent  cases  has  been  remark- 
able, while  in  cases  of  long  standing  the  results  of  this  treatment 
have  in  many  cases  exceeded  expectation. 

Fatigue  and  exposure  to  cold  are  often  the  immediate  exciting 
causes  of  cerebral  thrombosis,  and  the  subjects  of  aphasia  must  be 
\varned  against  such  events. 

Temporary  Aphasia. — In  the  subjects  of  cerebral  vascular 
disease,  and  more  especially  in  the  patients  of  advancing  years  with 
cerebral  arterial  sclerosis,  attacks  of  transient  aphasia  are  not 
uncommon.  These  attacks  are  the  expression  of  a  temporary 
slowing  of  the  blood-stream  or  of  a  temporary  stasis  of  the  blood  in 
diseased  vessels  of  the  speech-centres.  They  are  warnings  that  the 
patient  is  in  immediate  danger  of  the  occurrence  of  thrombosis 
within  these  centres,  and  they  should  be  energetically  treated  in 
accordance  with  the  scheme  above  laid  down. 

Patients  who  have  had  a  cerebral  lesion  upon  the  left  side,  and 
who  as  a  result  of  that  lesion  have  developed  a  right-sided  hemi- 
epilepsy,  may  become  speechless  after  each  attack,  the  aphasia 
passing  off  after  a  variable  time.  The  aphasia  is  here  the  expres- 
sion of  exhaustion  of  the  speech-centres  during  the  cerebral  com- 
motion which  is  responsible  for  the  convulsion.  Such  convulsions 
with  associated  aphasia  are  very  amenable  to  treatment  with  the 
bromides.  A  single  dose  of  20  gr.  of  sodium  bromide  each  night 
continued  indefinitely  generally  suffices  to  prevent  the  occurrence 
of  such  attacks. 

After  complete  or  partial  recovery  from  aphasia  transient 
relapses  or  transient  exacerbations  in  the  speech  defect  may  occur 
which  are  of  the  same  nature,  namely,  epileptic  seizures  initiated 
by  the  organic  lesion.  These  may  be  accompanied  by  general  or 


1146       Aphasia  and  other  Speech  Defects. 

local  convulsion,  but  more  often  by  slight  impairment  of  conscious- 
ness only.  The  regular  administration  of  bromide  brings  about 
the  complete  cessation  of  these  attacks. 

It  is  sometimes  very  difficult  when  dealing  with  an  exacerbation 
of  aphasia  in  a  patient  who  has  partly  or  completely  recovered  to 
determine  whether  one  is  dealing  with  an  attack  of  organic 
epilepsy,  as  described  above,  from  the  original  lesion,  or  whether 
the  condition  present  is  the  occurrence  of  a  fresh  thrombosis  near 
the  original  lesion,  for  the  symptoms  produced  by  these  two  con- 
ditions of  widely  different  import  and  seriousness  are  identical. 
Under  these  circumstances  there  is  every  advantage  in  combining 
the  treatment  for  the  prevention  and  limitation  of  possible  throm- 
bosis, as  given  above,  with  the  regular  administration  of  bromides. 

Temporary  loss  of  speech  sometimes  occurs  in  young  children, 
soon  after  they  have  acquired  facility  with  spoken  language,  as  the 
result  of  any  severe  illness,  and  may  give  rise  to  alarm.  With  the 
restoration  of  general  health,  however,  speech  returns,  but  in  some 
cases  so  slowly  as  to  make  it  obvious  that  the  child  is  not  utilising 
any  speech  memories  that  he  may  have  had  prior  to  the  illness,  but 
that  he  is  learning  to  speak  afresh. 

It  is  necessary  to  bear  in  mind  that  asphasia  may  be  an 
important  and  early  indication  of  certain  conditions  which  call  for 
surgical  procedures.  Injuries  to  the  head  which  have  caused 
fracture  of  the  left  temporal  bone  and  rupture  of  a  branch  of 
the  middle  meningeal  artery,  with  a  gradually  increasing  collection 
of  blood  between  the  skull  and  the  dura  mater,  give  rise  to  aphasia 
by  the  pressure  of  the  tumour  thus  formed  upon  Broca's  convolu- 
tion. Aphasia  following  a  cranial  injury  is  almost  invariably  the 
result  of  extra-meningeal  haemorrhage  and  it  is  worthy  of  note 
that  many  cases  are  upon  record  in  which  comparatively  slight 
injuries  of  the  temporal  region  have  sufficed  to  fracture  the  thin 
temporal  bone  and  to  cause  extra-dural  haemorrhage. 

In  a  few  cases  the  direct  pressure  of  a  depressed  area  of  bone  upon 
Broca's  area  or  upon  the  left  temporal  lobe,  has  resulted  in  aphasia. 
Under  either  circumstance  the  removal  of  the  cause  of  compression 
by  surgical  means  results  in  a  rapid  disappearance  of  the  aphasia. 

Abscess  of  the  left  temporal  lobe  not  uncommonly  causes  defects 
of  speech  which  may  be  "  word-blindness,"  "  word-deafness," 
aphasia,  or  a  combination  of  these  conditions.  When  in  a  case  of 
long  standing  disease  of  the  left  middle  ear,  cerebral  symptoms 
with  defect  of  speech  occur,  the  latter  are  of  sure  localising 
importance  and  call  for  immediate  exploration  of  the  temporal 
lobe.  That  many  cases  of  abscess  of  the  left  temporal  lobe  are 


Aphasia  and  other  Speech  Defects.         1147 

met  with  in  which  speech  defects  do  not  occur,  is  explained  by 
the  situation  of  the  abscess,  which  in  these  cases  is  deeply  placed 
in  the  white  matter  and  does  not  involve  the  convolutions. 

When  aphasia  is  due  to  the  presence  of  a  cerebral  tumour  in 
the  neighbourhood  of  the  speech  centres  considerable  temporary 
improvement  often  follows  the  removal  of  a  considerable  area  of 
bone  over  the  affected  region  with  free  openings  of  the  dura 
mater.  The  pressure  is  relieved  and  with  it  the  evascularisa- 
tion  which  pressure  always  produces ;  with  the  restoration  of  a 
sufficient  blood  supply  the  speech  centres  are  likely  to  resume 
their  function.  This  operation  has  a  further  important  recom- 
mendation that  it  may  reveal  a  tumour  either  of  the  bone  or  of 
the  meninges  that  can  be  extirpated  without  injury  to  the  cerebral 
hemisphere. 

Whatever  the  pathological  nature  of  a  cerebral  tumour  may 
be  the  effect  of  the  administration  of  mercury  and  of  iodide  of 
potassium  in  diminishing  its  size,  slowing  the  rate  of  its  growth 
and  alleviating  the  symptoms  is  remarkable,  and  in  no  case  should 
these  remedies  be  omitted.  The  effect  is  enhanced  by  combination 
with  diuretics. 

Hysterical  Aphasia,  or,  as  it  is  better  called,  "  Functional 
Aphonia  "  and  "  Functional  Mutism,"  must  be  treated  upon  the 
same  lines  as  other  functional  paralyses.  There  is,  however,  one 
very  valuable  method  for  the  treatment  of  these  conditions  which 
must  be  mentioned  in  this  place.  The  patient  suffering  from 
functional  aphonia  or  mutism  is  placed  lightly  under  the  influence 
of  ether  by  inhalation.  As  soon  as  the  excited  stage  of  the 
anaesthesia  is  reached  the  patient,  having  lost  control,  struggles, 
regains  the  voice  and  shouts.  The  ether  is  at  once  discontinued 
and  the  patient  is  encouraged  to  use  the  voice  as  the  effects  of  the 
partial  anaesthesia  pass  off,  and  regains  complete  consciousness  to 
find  that  the  voice  has  returned. 

TREATMENT  TO  FACILITATE  RESTORATION  OF  SPEECH 
FACULTIES  BY  FUNCTIONAL  COMPENSATION. 

Any  restoration  of  speech  that  occurs  after  a  destructive  lesion  of 
any  of  the  speech-centres  must  be  brought  about  by  the  develop- 
ment of  the  lost  speech  function  in  some  undamaged  part  of  the 
brain,  presumably  in  those  regions  of  the  right  hemisphere  which 
correspond  with  the  damaged  speech-centre  in  the  left  hemisphere, 
and  which  are  normally  supposed  to  have  a  subsidiary  function  in 
speech.  It  is  at  once  obvious  that  the  development  of  a  compen- 
satory speech  function  in  such  a  centre  must  take  place  by  training 


1148       Aphasia  and  other  Speech  Defects. 

and  imitation,  just  as  it  does  in  the  usual  speech-centres  when  a 
child  learns  to  speak,  and  therefore  the  essential  elements  of  any 
treatment  to  facilitate  the  establishment  of  compensatory  speech 
function  consist  in  the  slow  and  laborious  teaching  to  the  patient 
of  the  lost  elements  of  his  speech. 

The  degree  to  which  this  compensatory  restoration  of  speech  func- 
tion may  reach  varies  widely.  It  is  greatest,  in  children,  for  up  to  the 
sixth  year  of  life  uni-lateral  lesions  of  the  brain,  however  extensive, 
do  not  result  in  permanent  loss  of  speech,  but  complete  compensa- 
tory recovery  takes  place,  provided  that  no  great  defect  of  intelligence 
exists.  It  is  least  marked  in  old  age,  for  at  the  degenerative  time 
of  life  not  only  is  the  capacity  for  fresh  acquisitions  much  smaller 
than  at  other  periods,  but  also  the  general  lowering  of  cerebral 
functions,  which  invariably  results  from  the  cerebral  arterial 
sclerosis  which  is  responsible  for  conditions'of  aphasia  in  old  people, 
places  a  well-nigh  insuperable  obstacle  in  the  way  of  any  re-educa- 
tion. During  the  periods  from  childhood  to  the  end  of  middle-age 
the  capacity  for  re-education  after  destructive  lesions  in  the  region 
of  the  speech-centre  varies  so  much  in  different  individuals  as  to 
render  prognosis  in  an  individual  case  impossible. 

The  method  of  re-education  is  essentially  the  same  in  all  cases, 
and  it  is  based  upon  the  processes  by  which  a  child  first  learns  the 
elements  of  his  speech,  the  details  being  varied  according  to  the 
nature  of  the  speech-defect  in  each  patient.  For  success  much  time 
and  patience  are  necessary,  and  since  aphasic  patients  are  easily 
wearied  and  soon  become  inattentive,  the  frequent  repetition  of  short 
lessons  must  be  employed.  It  is  useless  to  attempt  re-education 
unless  good  general  intelligence  is  preserved,  and  it  must  be 
remembered  that  the  outlook  is  much  more  hopeful  when  a  defect 
of  the  executive  speech  mechanism  is  present,  such  as  aphasia  or 
agraphia,  than  when  a  defect  of  the  recipient  speech  mechanism 
exists,  such  as  word-deafness  or  word-blindness. 

Where  aphasia  alone  exists  the  patient  is  able  to  understand 
everything  that  is  said  to  him,  and  the  education  is  conducted  by  the 
oral  method ;  the  simple  vowel  and  consonantal  sounds  are  repeated 
before  the  patient,  and  he  is  urged  to  watch  intently  the  movements 
of  the  teacher's  lips  and  to  make  attempts  to  imitate  these  move- 
ments. In  this  way  the  patient  learns  to  repeat  and  afterwards  to 
utter  voluntarily  the  simple  sounds,  and  when  this  has  been  gained 
the  teaching  is  continued  with  simple  words  and  syllables  and  after- 
wards with  increasingly  more  complicated  parts  of  speech.  During 
this  process  of  learning  words  it  is  often  advantageous  to  present  to 
the  patient's  sight  the  object  to  which  the  word  belongs,  and  if  there 


Aphasia  and  other  Speech  Defects.        1149 

is  no  word-blindness  to  let  the  patient  see  at  the  same  time  the 
written  symbol  of  the  word  or  sound  that  is  being  taught. 

The  patient  suffering  from  agraphia  is  taught  to  write  just  as  a 
child  is  taught  to  write,  but  from  the  common  association  of  right 
hemiplegia  with  speech  defects  it  is  generally  the  left  hand  that  has 
to  be  educated.  He  must  first  learn  to  copy  letters,  syllables  and 
simple  words,  and  he  is  taught  to  connect  these  symbols  with  their 
corresponding  sounds  by  the  frequent  repetition  of  the  sound  as 
his  attention  is  directed  to  the  written  symbol,  and  he  becomes  able 
first  to  wrrite  the  letter  or  word  at  command  and  afterwards  to  do  so 
voluntarily  for  the  expression  of  his  thoughts.  A  patient  with 
word-blindness  is  first  taught  his  letters  by  pointing  out,  each  letter 
and  naming  it  aloud,  and  is  afterwards  taught  simple  combinations 
of  these  letters  and  then  the  meaning  of  words,  the  corresponding 
object  being  shown  to  him  as  the  word  he  is  being  taught. 

Word-deafness  is  much  less  amenable  to  re-education  than  are 
the  other  speech  defects,  except  in  young  children,  in  whom  the 
capacity  for  the  development  of  a  chief  speech-centre  upon  the  right 
side  of  the  brain  is  great.  Moreover,  word-deafness  necessarily 
entails  defective  intelligence,  since  it  results  from  damage  to  the 
chief  centre  in  which  the  function  of  speech  is  located,  and  since 
this  centre  plays  an  important  part  in  the  higher  mental  processes. 
Attempts  must  be  made  first  to  teach  the  patient  the  meaning  of 
words  by  showing  him  an  object  and  then  repeating  the  name  of  the 
object,  and  when  the  name  has  been  learnt,  to  apply  the  oral  method 
as  described  for  simple  aphasia  and  urge  the  patient  to  pronounce 
the  name. 

When  both  word-deafness  and  word-blindness  are  present  in 
severe  degree  the  patient  is  ineducable,  and  any  recovery  that  may 
in  rare  cases  take  place  is  referable  to  the  recovery  of  elements 
which  have  been  partially  damaged,  and  not  to  functional  compensa- 
tion. It  is  obvious,  however,  that  the  restitution  of  function  in 
damaged  elements  may  be  greatly  aided  by  the  applications  of  the 
above  methods. 

The  conditions  of  defective  articulation  that  not  infrequently 
result  from  cerebral  lesions,  anarthria  and  dysarthria,  are  to  be 
treated  by  the  oral  method  :  the  former  just  as  aphasia  is  treated, 
the  latter  by  the  slow  and  careful  articulation  of  words  under  the 
supervision  of  the  teacher. 

JAMES  COLLIER. 

KEFERENCES. 

Bastian,  H.    C.,    "  Aphasia   and  other   Defects  of  Speech,"   London,  1898. 
WyJlie,  J.,  "  The  Disorders  of  Speech,"  Edinburgh,  1895. 


1 150 


APRAXIA. 

THE  successful  treatment  of  apraxia  necessitates  an  exact  com- 
prehension of  the  nature  and  cause  of  this  condition.     Apraxia  is 
the  inability  to  perform  highly  specialised  subjectively  purposive 
movements,  while  the  common  movements  can  be  performed.     The 
patient,  though  he  is  perfectly  cognisant  of  the  details  of  the  act 
which  he  wishes  to  perform,  is  entirely  unable  to  execute  it.     The 
following  example  exactly  illustrates  the  condition  :  A  highly  skilled 
professional  violinist  was  seized  with  left  hemiplegia.     In  the  course 
of  a  few  weeks  he  completely  recovered  power  in  the  left  upper 
extremity  and  could  use  it  for  all  ordinary  purposes,  but  on  taking 
up  his  fiddle  he  found  that   he  could  not  play  the  simplest  air, 
for  he  could  not  execute  the  well-known  movements  of  his  left 
fingers,  though  these  were  powerful  and  supple  and  could  be  moved 
quickly.     So  complete  was  his  knowledge  of   the  technique  of  the 
violin  that  he  was  able  to  continue  his  avocation  in  teaching  the 
higher  branches  of  his  art,  but  he  was  never  able  to  play  again. 
Apraxia  bears  the  same  relation  to  the  movements  of  the  limbs 
as  does  motor  aphasia  to  the  movements  of  the  tongue  and  lips, 
for  in  the   latter  condition,  though  there  is  no  paralysis  of  the 
tongue  and  lips,  and  though  the  patient  knows  exactly  what  he 
wishes  to  say,  yet  the  execution  of  the  highly  specialised  move- 
ments of  speech  is  impossible ;   so  in  apraxia,  though  there  is  no 
paralysis,  yet  the  patient  is  unable  to  execute  the  specialised  acts 
which  formerly  he  performed  with  ease. 

The  cortical  centres  for  the  common  movements  of  the  tongue 
and  lips  and  also  for  the  common  movements  of  limbs  are  situated 
in  the  ascending  frontal  convolutions  of  both  hemispheres  (motor 
area  or  pyramidal  centres),  but  the  centre  for  the  highly  specialised 
movements  of  the  tongue  and  lips  is  placed  immediately  in  front  of 
the  corresponding  motor  area.  It  occupies  the  posterior  half  of  the 
third  frontal  gyrus,  and  it  is  developed  in  the  left  side  of  the  brain 
only.  In  the  same  way  the  centres  for  the  highly  specialised 
movements  of  the  limbs  are  situated  immediately  in  front  of  the 
corresponding  motor  area  in  the  posterior  parts  of  the  second  and 
first  frontal  gyri.  These  centres  are  developed  upon  the  left  side 
only,  and  are  concerned  with  the  highly  specialised  movements 
upon  both  sides  of  the  body.  It  is  from  lesions  of  the  frontal 


Apraxia.  1151 

convolutions  in  the  left  hemisphere  that  apraxia  more  commonly 
results,  and  from  the  proximity  of  the  centres  for  specialised 
movements  (eupraxic  centres)  to  the  motor  area  the  two  are 
usually  involved  together,  and  right-sided  hemiplegia  is  for  this 
reason  the  usual  clinical  associate  of  apraxia.  It  is  especially 
when  a  right-sided  hemiplegia  is  recovering  or  has  recovered  that 
apraxia  becomes  manifest.  The  rapid  recovery  of  power  has 
perhaps  given  rise  to  high  hopes  that  complete  usefulness  will  he 
re-estahlished  in  the  limb,  but  nevertheless  the  patient  remains 
unable  to  execute  specialised  acts  in  which  he  was  formerly  skilled. 
His  right  hand  has  lost  its  cunning,  since  the  centres  from  which 
those  skilful  acts  were  started  and  guided  have  been  damaged  by 
disease. 

From  the  nature  of  the  eupraxic  centres  it  follows  that  apraxia 
is  usually  bi-lateral,  but,  if  the  right  upper  limb  is  paralysed 
by  the  lesion,  the  limb  apraxia  is  manifest  in  the  left  upper  limb 
only.  In  rare  cases  small  and  isolated  lesions  have  caused  limb 
apraxia,  confined  to  the  left  side  or  to  the  right  side  as  the  sole 
symptom  of  the  lesion. 

Since  cerebral  vascular  lesions  are  responsible  for  the  production 

of  apraxia,  what  has  been  said  on  that  subject  in  the  article  upon 

aphasia  applies  equally  to  apraxia.     The  special  treatment  of  the 

condition   consists  in  the    slow  and    laborious    re-training  of  the 

limb   towards  those  acts  which  are  lost  or  which  are  defectively 

performed.    The  exercises  performed  must  be  simple  or  complicated 

according  to  the  severity  of  the  apraxia.     The  regular  taking  out 

and  replacing  of  the  pegs  of  a  cribbage  board  or  of  the  marbles  of 

a  solitaire  board  are  examples  of  useful  exercises  of  the  simple  order. 

The  tracing  over  of  figures  and  designs  faintly  marked  on  paper, 

the  use  of  the  copy-book  and  of  other  measures  by  which  a  child 

is  taught  to  write  are  examples  of  exercises  directed  to  the  cure  of 

a  particular  variety  of  apraxia,  namely,  agraphia.     The  performance 

of  lost  or  defective  acts  in  front  of  the  patient  by  the  teacher,  the 

patient  meanwhile  imitating  the  teacher  so  far  as  he  is  able,  any 

errors  that  he  makes  being  pointed  out  and  corrected,  constitutes 

the  chief  method   by  which  apraxia  may   be   benefited.     It  is  at 

once  obvious   that   the   exercises   must   be  modified   or  invented 

according  to  the  nature  of  the  defects  of  each  individual  patient. 

As  the  result  of  such  treatment  excellent  recovery  may  occur,  but 

some  cases  resist  all  treatment.     Where  rapid  recovery  occurs  it  is 

probable  that  the  eupraxic  centres  have  been  partly  damaged  only, 

and  that  functional  restitution  has  occurred  in  these  centres.    When 

recovery  occurs  but  tardily  it  is  possible  that  this  results  from  the 


1152  Apraxia. 

development  of  corresponding  regions  of  the  right  hemisphere  as 
the  result  of  education.  Where  no  recovery  occurs,  complete 
destruction  of  the  eupraxic  centres,  the  absence  of  any  capacity  for 
the  development  of  fresh  centres  or  the  severance  of  the  paths 
which  connect  the  several  nerve-centres  concerned  with  the  per- 
formance of  specialised  acts  are  the  probable  explanations. 


JAMES  COLLIER. 


KEFERENCES. 


Collier,  J.,  "  Apraxia,"  Allbutt  and  Eolleston's  "  System  of  Medicine,"  2nd  ed., 
VIII.,  p.  447.  Wilson,  S.  A.  K,  "  Study  of  Apraxia,"  "Brain,"  London,  1910, 
XXXI.,  p.  164. 


THE    CEREBRAL    PALSIES    OF    INFANCY. 

THE  cerebral  palsies  of  infancy  fall  into  several  groups,  according 
to  their  etiology,  pathology  and  clinical  symptoms ;  but  all  varieties 
are  characterised  by  a  spastic  paresis,  in  which,  as  a  rule,  compared 
with  the  cerebral  palsies  of  later  life,  the  degree  of  rigidity  is 
relatively  greater  than  the  loss  of  power.  Many  cases  also  present 
spontaneous  or  involutary  movements  of  the  affected  limbs,  generally 
of  that  type  known  as  athetosis;  and  there  is  often  considerable 
mental  impairment  or  lack  of  development.  Epileptic  seizures 
frequently  occur.  From  the  clinical  point  of  view  they  may  be 
divided  into  hemiplegia,  in  which  only  one  side  of  the  body  is 
affected,  and  di-plegia,  in  which  the  whole  of  the  body  is  involved, 
but  the  lower,  as  a  rule,  more  so  than  the  upper  extremities. 

Our  knowledge  of  the  pathological  bases  of  these  conditions  is 
very  incomplete,  and  cannot  be  considered  in  detail  here ;  but  a  short 
reference  to  it  is  necessary  as  a  guide  to  appropriate  treatment. 
Infantile  hemiplegia  may  develop  in  fetal  life,  during  birth  or  in 
early  infancy.  Congenital  cases  are  not  rare  ;  they  may  be  due  to 
mal-development  of  certain  regions  of  the  brain,  or  to  local  lesions 
that  occur  during  fostal  life.  In  the  later  cases  there  is  usually  a 
porencephaly  or  microgyria,  or  on  examination  of  the  brain  only  a 
focus  or  foci  of  sclerosis  may  be  found. 

The  lesions  that  develop  during  birth  are  usually  due  to  direct 
injury  to  the  head  owing  to  difficult  labour,  or  to  the  use  of  instru- 
ments, or  to  a  meningeal  or  even  mtra-cerebral  haemorrhage,  which 
is  most  often  caused  by  rupture  of  the  veins  at  their  entry  into  the 
sinuses.  This  is  by  no  means  infrequent.  Spencer  found  it  in 
fifty-three  out  of  the  hundred  and  thirty  newly  born  children  whose 
brains  he  examined.  In  other  cases  the  cerebral  lesions  seem  to 
result  from  the  vascular  disturbances  associated  with  asphyxia. 
Infantile  hemiplegia  of  post-natal  onset  may  be  due  to  the  same 
causes  as  this  condition  in  the  adult,  but  it  results  most  frequently 
from  a  non-purulent  encephalitis. 

Cerebral  diplegia,  which  is  usually  congenital,  though  its  symptoms 
may  be  noticed  only  some  months  after  birth,  may  be  also  due  to 
different  pathological  processes.  Those  already  considered  may,  if 
they  affect  both  hemispheres  of  the  brain,  produce  its  symptoms, 
but  it  is  more  commonly  the  result  of  a  cortical  agenesis.  Other 

S.T. — VOL.  n.  78 


1 154        The  Cerebral  Palsies  of  Infancy. 

cases  are  apparently  born  with  an  intact  cortex,  but  its  cells  soon 
degenerate  owing  to  a  hereditary  diminished  potentiality  of  life,  or 
from  the  action  of  toxins  or  infections  to  which  they  are  unduly 
susceptible. 

The  treatment  of  these  different  conditions  may  be  considered 
together,  for  as  we  can  rarely  remove  or  repair  the  cerebral  lesion, 
it  must  be  mainly  symptomatic,  and  the  symptoms  are  essentially 
the  same  whatever  be  the  cause.  They  are  due  to  the  diminished 
power  of  movement  owing  to  the  paresis  and  rigidity,  to  disturbance 
of  co-ordination,  and  the  presence  of  involuntary  movements. 

Many  cases  improve  considerably  under  treatment  by  massage, 
and  by  passive  movements  directed  to  overcome  or  obviate  the 
development  of  contractures,  but  both  must  be  persisted  in  for  long 
periods.  If  the  rigidity  is  great,  the  massage  may  with  advantage  be 
preceded  by  warm  baths.  Electrical  treatment,  on  the  other  hand, 
is,  as  a  rule,  inadvisable,  as  all  peripheral  stimulation  tends  to 
increase  the  rigidity.  In  the  slighter  cases,  whether  one  or  both 
sides  of  the  body  are  affected,  careful  training  by  exercises  and 
gymnastic  movements,  and  encouragement  to  the  child  to  attempt 
simpler  movements  and  to  use  the  limbs  as  much  as  possible,  are 
most  important,  and  if  persisted  in  may  have  unexpectedly  favour- 
able results. 

Drugs  are  rarely  indicated  in  the  treatment  of  the  main  symptoms, 
but  as  it  is  important,  especially  in  cases  with  a  progressive 
tendency,  to  maintain  the  general  health  at  as  high  a  level  as 
possible,  cod-liver  oil  and  other  tonics  may  be  administered.  Many 
organic  extracts  have  been  tried  but  without  benefit ;  but  improve- 
ment has  followed  the  use  of  thyroid  extract  in  some  cases,  and  con- 
sequently this  should  always  be  given  a  trial  in  the  comparatively 
rare  cases  in  which  diplegia  is  associated  with  the  signs  of  cretinism. 

A  large  number  of  patients  suffering  from  the  cerebral  palsies  of 
infancy  are  subject  to  epileptic  seizures,  for  the  relief  of  which  drugs 
must  be  employed,  though  it  must  be  admitted  that  their  treatment 
is  generally  unsatisfactory.  Bromides  are  the  most  efficient  drugs, 
but  large  doses  and  frequent  administration  are  frequently  necessary 
to  produce  any  effect.  Biborate  of  soda  (in  doses  of  from  5  to  10  gr. 
for  a  child)  may  with  advantage  be  combined  with  the  bromides. 
Relatively  large  doses  of  belladonna  are  often  useful,  especially  in 
cases  with  minor  epileptic  attacks.  The  calcium  salts  seem  to 
diminish  the  excitability  of  the  cortex,  and  consequently  have  been 
given  in  these  conditions,  generally  in  the  form  of  calcium  lactate, 
alone  or  combined  with  bromides,  but  I  have  failed  to  obtain  any 
promising  results  from  their  use. 


The  Cerebral  Palsies  of  Infancy.         1155 

In  conditions  so  little  amenable  to  medical  treatment  the  aid  of 
surgery  has  been  frequently  invoked,  but,  on  the  whole,  with  equally 
disappointing  results.  In  certain  cases  of  hemiplegia  developing 
afterbirth  injuries,  Gushing1  has  trephined  and  removed  menin- 
geal  haemorrhages  with  favourable  results.  Surgical  exploration  of  the 
brain  has  been  proposed  in  cases  with  frequent  local  or  uni-lateral 
epileptiforni  seizures,  for  removal  of  the  irritating  lesion,  if  this  is 
possible  ;  the  results  of  these  operations  have  been,  however,  on  the 
whole,  far  from  satisfactory. 

Tenotomy  becomes  necessary  when  contractures  have  developed, 
and  frequently  restores  the  mobility  of  the  limbs  considerably ;  it  is, 
of  course,  useless  unless  there  is  a  certain  amount  of  power  in  the 
muscles. 

The  muscles  of  the  affected  limbs  are  generally  unequally 
paralysed  ;  for  instance,  the  extensors  of  the  hand  and  fingers  and 
the  dorsi-flexors  of  the  foot  are,  as  a  rule,  weaker  than  their 
antagonists.  Spiller 2  recognised  this,  and  suggested  the  relief  of  the 
weaker  muscles  by  the  transplantation  or  anastomosis  of  the  nerves 
that  innervate  them  into  nerves  of  less  affected  muscles.  On  the 
same  argument  he  suggests  the  same  operation  in  cases  of  athetosis 
in  which  there  is  disproportion  between  the  innervation  of  the 
flexors  and  extensors  of  the  arm  and  fingers.  In  one  such  case 
Frazier  3  transplanted  the  ulnar  and  median  nerves  into  the 
musculo-spiral  with  a  good  result. 

It  is  not  infrequent  to  find  in  infantile  hemiplegia,  and  even 
more  so  in  diplegia,  that  the  rigidity  of  the  limbs  is  so  great  as  to 
prevent  or  seriously  interfere  with  their  use,  though  there  may  be 
considerable  power  of  movement.  This  rigidity  is  due  to  a  reflex 
over-activity  of  the  subcortical  and  spinal  centres  which  results  from 
the  loss  of  cortical  inhibition,  but  it  is  directly  excited  by  peripheral 
stimulation,  and  would  disappear  if  this  could  be  completely  obviated, 
as  it  would  be  by  section  of  the  posterior  spinal  roots.  Forster 4 
has  consequently  recommended  this  procedure,  and  has  obtained 
remarkably  favourable  results.  It  would  be,  of  course,  dangerous  or 
inadvisable  to  cut  all  roots  that  carry  afferent  impulses  from  a  limb  ; 
but  as  all  peripheral  structures  are  innervated  by  the  overlapping 
of  the  fibres  of  two  or  three  adjacent  roots,  section  of  alternate  roots 
may  suffice  to  diminish  the  rigidity  considerably,  and  thus  permit 
the  exercise  of  the  power  that  remains  in  the  limb.  Forster  has 
advised  section  of  the  second,  third  and  fifth  lumbar,  and  of  the 
second  sacral  roots,  as  a  routine  operation  in  cases  where  the  lower 
limbs  as  a  whole  are  spastic,  but  the  muscle  groups  which  are 
chiefly  affected  by  the  spasticity  should  be  carefully  determined  in 

78—2 


1156        The  Cerebral  Palsies  of  Infancy. 

each  case  and  the  operation  modified  accordingly.  The  operation 
is  less  satisfactory  in  the  relief  of  spastic  paresis  of  the  arms  ;  the 
fourth,  fifth,  seventh  and  eighth  posterior  roots  may,  however, 
safely  be  cut.  Sufficient  experience  has  not  yet  accumulated  to 
pass  a  definite  opinion  on  Forster's  operation,  but  the  procedure 
is  rational,  and  his  results  on  suitable  cases  have  been  promising. 

The  majority  of  children  subject  to  cerebral  palsies  are  either 
backward  or  mentally  deficient,  and  consequently  require  special 
mental  training  and  education  adapted  to  their  capabilities. 


GORDON  HOLMES. 


REFERENCES. 


1  Amer.  Journ.  of  the  Med.  Sciences,  Phila.,  1905,  CXXX.,  p.  563. 

2  Journ.  Ment.  and  Nerv.  Diseases,  1905,  XXXII.,  p.  310. 

3  Amer.  Journ.  of  the  Med.  Sciences,  1906,  CXXXL,  p.  430. 

4  Forster,  0.,  Mitteil.  aus  d.  Grenzgeb.  d.  Med.  und  Chir.,  1909,  XX.,  p.  493. 


THE    SURGICAL   TREATMENT    OF   CEREBRAL 
PALSIES    OF    INFANCY. 

THE  treatment  of  cerebral  palsies  of  infants  on  surgical  lines  has 
been  greatly  developed  in  recent  years.  The  cause  of  the  paralysis 
is  in  every  case  an  interference  in  the  control  normally  exercised 
by  the  cortical  centres  over  the  motor  cells  in  the  anterior  horns  of 
the  cord.  The  originating  cause  may  be  an  error  in  development 
of  the  upper  neuron,  a  vertical  haemorrhage  occurring  at  birth 
producing  pressure  on  cortical  motor  areas,  some  form  of  polio- 
encephalitis  of  toxic  origin,  or  some  interference  with  the  pyramidal 
tracts. 

Apart  from  the  characteristic  spastic  condition  of  the  muscles  of 
the  limbs  there  may  be  more  or  less  pronounced  mental  defect. 
In  some  cases  there  may  be  no  obvious  signs  of  mental  impair- 
ment, but  when  these  are  present  two  clinical  types  can  be 
recognised.  In  one  the  child  seems  placid  and  contented,  in  the 
other  the  child  is  irritable,  perhaps  subject  to  fits,  and  often 
is  wantonly  mischievous.  The  latter  type  is  less  amenable  to 
treatment  than  the  former.  Deficient  control  of  the  sphincters 
of  the  bladder  and  rectum  is  a  prominent  symptom  in  some  cases. 
In  deciding  whether  a  case  is  suitable  for  treatment  on  the  lines 
about  to  be  described,  incontinence  of  urine  and  faeces  and  frequent 
convulsions  may  be  taken  as  a  general  centra-indication.  A  history 
of  convulsive  fits  decreasing  in  frequency  is  not  necessarily  a 
centra-indication  for  treatment,  for  in  some  of  these  cases  the  fits 
may  cease  or  become  much  less  frequent  after  operative  treatment. 

An  absolute  imbecile  who  cannot  help  the  work  of  education  by 
making  an  effort  to  use  his  limbs  is  not  suitable  for  treatment. 
Great  judgment  is  required,  however,  in  estimating  the  mental 
condition  of  a  patient,  for  many  cases  are  apparently  imbecile  who 
have  not  a  serious  brain  defect ;  their  trouble  is  that  they  have 
never  educated  their  brains  by  touching,  feeling  and  tasting  things 
as  a  normal  infant  does.  A  child  whose  limbs  are  spastic  and  are 
the  seat  of  sudden  uncontrolled  spasmodic  movements  has  never 
come  into  proper  relation  with  its  environment.  Treatment  directed 
to  abolish  the  muscular  spasm  and  rest  the  over-excited  spinal 
centres  gives  such  a  child  peace  and  leisure  to  pay  attention  to  its 


1158     Surgical  Treatment  of  Cerebral  Palsies. 

surroundings,  and  a  rapid  improvement  in  intelligence  may  some- 
times be  noted  within  a  week  of  operation. 

Clinically  cases  may  be  classed  as:  (1)  Hemiplegia;  (2)  para- 
plegia; (3)  diplegia. 

Most  cases  of  hemiplegia  are  post-natal  and  are  due  to  an  ence- 
phalitis, usually  in  the  first  two  years  of  life,  though  some  cases 
occur  later.  The  upper  limb  is  usually  more  severely  affected  than 
the  lower. 

Most  cases  of  paraplegia  and  some  cases  of  diplegia  are  due  to 
haemorrhage  at  birth,  generally  over  the  vertex  and  therefore  com- 
pressing the  leg  areas  more  than  the  arm  areas.  There  is  not  space 
in  an  article  such  as  this  to  discuss  the  many  other  causes  which 
have  been  advanced  as  originating  diplegia  and  paraplegia. 

In  the  upper  limb  the  following  characteristic  features  may 
be  noted:  the  elbow  is  kept  close  to  the  side  and  flexed,  the 
wrist  is  pronated  and  flexed,  the  fingers  are  flexed,  and  the 
thumb  is  flexed  and  adducted,  being  tucked  into  the  palm  of  the 
hand.  If  the  child  initiates  a  voluntary  extensor  movement  of  the 
fingers,  it  is  often  interrupted  by  a  sudden  uncontrolled  spasm  of 
the  strong  flexors.  The  great  disability  in  such  a  case  is  (a)  the 
absence  of  balance  between  opposing  muscles,  (b)  the  lack  of 
co-ordination.  Therefore  treatment  must  aim  (1)  at  restoring 
muscular  balance,  (2)  at  educating  the  powers  of  co-ordination. 
In  cases  of  hemiplegia  the  patient  has  great  difficulty  in  dissociating 
the  movements  of  the  two  hands.  He  always  performs  the  same 
movements  with  both  hands  at  once ;  to  educate  him  out  of  this 
habit  is  one  of  the  most  difficult  parts  of  the  treatment. 

In  the  lower  limbs  the  most  constant  features  are  spasm  and 
contracture  of  the  adductors,  so  that  the  patient  cannot  abduct  the 
limbs.  The  hamstrings  are  frequently  contracted,  the  calf  muscles 
are  often  short,  so  that  the  foot  is  in  an  equinus  position,  usually 
with  some  varus  deformity,  and  very  rarely  with  a  valgoid  defor- 
mity. In  addition  to  these  there  may  be  spasm  of  the  flexors  of 
the  hip  with  shortening  of  the  fasciae  in  the  groin,  producing 
flexion  deformity  of  the  hip  and  lordosis  of  the  lumbar  spine. 

Finally,  there  is  often  spasm  and  shortening  of  the  tensor  fasciae 
femoris  and  gluteus  medius,  producing  internal  rotation  of  the  whole 
limb.  Adduction  may  be  so  great  that  the  knees  are  crossed.  Even 
in  cases  where  the  patient  can  walk  his  gait  is  shambling  and 
unsteady,  he  is  insecurely  balanced  on  his  toes  on  account  of  his 
spastic  equinus  deformity,  he  cannot  separate  his  thighs  on  account 
of  the  spasm  of  his  adductors,  and  therefore  cannot  take  a  broad 
base  of  support  either  when  standing  or  when  walking.  If  in  doubt 


Surgical  Treatment  of  Cerebral  Palsies.      1159 


about  spasm  of  the  adductors  in  a  mild  case  it  at  once  becomes 
more  marked  if  the  child  is  lifted  by  the  shoulders. 

Treatment  of  the  upper  and  lower  extremities  respectively  is  in 
the  first  place  guided  by  these  features. 

In  addition  to  the  above  there  may  be  other  phenomena,  such  as 
irregular  movements   of  the  muscles  of  the  head  and  face  and 
nystagmus.     In  cases  of  paraplegia  the  hands  are  often  the  seat  of 
irregular   movements   of   an   athetoid   type,    though   not   directly 
affected  by  spastic  paraly- 
sis.     Finally,    there  is  a 
strong  tendency  for  simul- 
taneous associated  move- 
ments   to   take   place   in 
both    limbs.      Thus    the 
patient  often  cannot  open 
one    hand    without    per- 
forming a  similar  move- 
ment with  the  other,  and 
a      paraplegic     generally 
tries  to  advance  both  feet 
at    once    and    has   to   be 
taught  to  walk  advancing 
one  foot  at  a  time. 

The  real  difficulties  in 
treatment  begin  after  the 
operations  to  correct  de- 
formity, relieve  spasm 
and  restore  muscular 
balance  are  completed. 
The  child  must  then  be 
educated  to  use  his  limbs 
independently,  a  process 
which  is  always  slow  and  requires  patience  and  perseverance. 

Treatment  of  the  lower  limbs,  as  in  a  case  of  paraplegia, 
the  upper  limbs  not  being  affected. 

Abolish  the  spasm  of  the  adductors  by  fixing  the  patient 
with  the  thighs  fully  abducted.  We  use  a  double  Thomas'  frame 
with  abduction  (Fig.  1).  In  the  mildest  cases  the  adductors  may 
be  stretched,  in  mild  cases  they  may  be  divided  subcutaneously  ; 
in  the  majority  of  cases  of  any  severity  the  only  satisfactory 
procedure  is  to  make  an  incision  along  the  prominent  tendon 
of  the  adductor  longus,  and  boldly  excise  about  1  inch  of 
the  adductors  longus  and  brevis  at  their  origin  and  the  upper 


FIG.  1. — Thomas'  abduction  frame.  In  the  figure 
the  right  limb  only  is  abducted.  In  treating 
spastic  paraplegia  both  are  abducted. 


1160     Surgical  Treatment  of  Cerebral  Palsies. 

transverse  fibres  of  the  adductor  magnus.  Unless  this  is  done 
freely  the  adduction  deformity  is  very  liable  to  recur.  The  skin 
wounds  must  be  carefully  closed  and  sealed  to  protect  them 
from  contamination  by  excreta.  The  patient  is  then  at  once  put 
into  the  abduction  frame  and  kept  in  that  position  for  six  weeks. 
If  all  these  structures  have  been  divided  or  ruptured  or  fully 
over-stretched,  the  child  does  not  complain  of  pain  after  the  first 
twelve  hours,  but  any  muscle  which  is  tense  and  still  capable 
of  resistance  will  be  the  seat  of  severe  pain. 

Flexion  Deformity  and  Internal  Rotation  of  the  hip  may  require 
correction  by  operation.  A  vertical  incision  (8  inches  long)  is 
made  a  little  below  the  anterior  superior  spine  of  the  ilium.  The 
iliac  fascia,  tensor  fasciae  femoris  and  anterior  fibres  of  the  gluteus 
medius  are  then  divided.  To  prevent  recurrence  of  internal  rota- 
tion we  turn  back  and  fix  the  cut  ends  of  the  tensor  fasciae  and 
gluteus  muscles  to  prevent  them  from  reuniting,  and  have  found 
the  results  very  satisfactory.  Spasm  and  contracture  of  the  ham- 
strings is  dealt  with  by  stretching  or  lengthening  the  tendons  of 
these  muscles.  In  some  cases  it  is  better  to  transplant  one 
or  more  of  them  into  the  quadriceps  to  reinforce  the  extensor 
muscle. 

Spasm  of  the  Calf  Muscles. — We  must  enter  a  warning  against 
the  performance  of  tenotomy  of  the  tendo  Achillis  with  a  view  to 
correcting  equinus  deformity.  The  extensor  group  of  muscles  is 
not  paralysed,  and  contracts  as  soon  as  it  is  relieved  of  the  resist- 
ance of  the  tendo  Achillis,  the  spastic  muscles  of  the  calf  retract 
and  the  tendon  may  not  reunite.  We  made  this  mistake  in  several 
of  our  early  cases,  and  though  the  spasm  was  completely  relieved 
the  patients  afterwards  developed  a  calcaneus  deformity  and  walked 
on  their  heels. 

Now  we  always  perform  an  open  operation  and  lengthen  the 
tendon.  It  is  sufficient  to  divide  the  tendon  and  moor  the  two  ends 
together  with  a  few  strands  of  strong  catgut.  We  expose  the 
tendon,  pass  two  strong  strands  through  it  and  tie  each  firmly.  The 
tendon  is  then  divided  between  the  two  sutures ;  an  assistant 
places  the  foot  exactly  at  a  right  angle,  and  the  upper  and  lower 
ligatures  are  tied  together.  The  foot  is  then  fixed  at  right  angles. 

Such  of  these  operations  as  may  be  necessary  are  performed  at 
one  time  or  at  short  intervals,  while  the  child  is  lying  in  the 
abduction  frame. 

It  will  be  noted  that  the  aim  and  object  of  these  procedures 
is  not  merely  to  correct  deformity,  but  still  more  to  abolish  for 
a  time  the  action  of  the  spastic  muscles,  so  as  to  allow  their 


Surgical  Treatment  of  Cerebral  Palsies.      1161 

opponents  to  recover  power  and  so  restore  the  muscular  balance  of 
the  limb. 

It  is  always  better  to  divide  or  rupture  a  spastic  muscle  rather 
than  simply  to  stretch  it,  for  a  muscle  kept  on  the  stretch  is  always 
the  seat  of  pain.  Simple  stretching  is  therefore  only  applicable  to 
those  cases  in  which  the  muscle  can  be  so  completely  over- stretched 
that  it  is  virtually  paralysed  for  the  time  and  ceases  to  resist. 

If  spasm  has  been  entirely  abolished  by  these  means  the  child 
no  longer  complains  of  pain,  and  after  the  second  daj7  a  remarkable 
and  noteworthy  change  in  its  appearance  may  often  be  observed.  The 
child  no  longer  starts  awake  at  night  but  sleeps  quietly.  Irregular 
grimaces  and  movements  of  the  head  and  hands  become  less  pro- 
nounced and  less  frequent.  The  child's  whole  motor  system  seems 
to  come  to  rest.  This  we  explain  in  the  following  way :  athetoid 
movements  of  the  hands,  irregular  twitchings  of  the  face,  and 
sudden  starting  at  night  are  indications  of  an  irritable  spinal  motor 
system  which  is  not  properly  under  the  inhibitory  control  of  the 
cortex.  The  spastic  groups  of  muscles  are  the  groups  which  are 
actually  or  mechanically  stronger  than  their  opponents ;  they  have 
overpowered  their  opponents  and  become  short,  and  the  over- 
stretched antagonists  cannot  hold  them  properly  in  check.  The 
motor  cells  in  the  anterior  cornua  are  not  under  the  proper  inhibi- 
tory control  of  the  cortex  and  are  liable  to  send  out  irregular  reflex 
impulses.  Spastic  muscles  are  always  in  a  state  of  partial  con- 
traction and  are  continually  giving  rise  to  reflexes  which  keep  the 
spinal  motor  cells  in  a  state  of  constant  irritability.  "When  the 
spasm  is  abolished  the  spinal  cord  ceases  to  be  irritated  by  a  con- 
stant stream  of  irregular  reflex  stimuli  and  comes  to  rest,  and  the 
motor  manifestations  of  its  irritability  disappear  and  the  child 
begins  to  take  an  interest  in  its  surroundings.  For  example,  a 
child  of  five  with  spastic  paraplegia  could  only  speak  two  or  three 
words  very  indistinctly,  and  was  constantly  on  the  move  when 
admitted  to  hospital.  A  week  after  operation  she  slept  quietly  all 
through  the  night,  and  six  weeks  after  operation  suddenly  began  to 
talk  and  continued  to  learn  rapidly.  This  case  illustrates  the  fact 
that  apparent  mental  defect  may  be  due  not  to  brain  defect, 
but  to  the  fact  that  muscular  spasm  occupies  a  child's  attention  and 
prevents  it  from  coming  into  proper  relation  with  its  surroundings. 

The  next  stage  in  treatment  is  the  education  of  muscles.  At  first 
the  legs  are  freed  from  the  splint  for  a  few  minutes  several  times 
a  day  while  abduction,  flexion  and  extension  movements  are  prac- 
tised. All  movements  must  be  made  to  word  of  command  to  train 
brain  and  muscle  to  work  together.  Splints  are  next  applied  to 


1162     Surgical  Treatment  of  Cerebral  Palsies. 

keep  the  knees  fully  extended  and  prevent  the  hamstrings  from 
shortening  before  the  quadriceps  is  strong  enough  to  resist  them. 
In  these  splints  the  child  is  taught  to  walk,  keeping  the  feet  wide 
apart.  He  must  never  be  allowed  to  move  both  legs  forward 
together;  hence  crutches  cannot  be  permitted.  In  teaching  a  child 
to  walk  the  following  points  must  be  observed :  (1)  He  must  learn 
to  balance  himself ;  (2)  the  legs  must  be  kept  wide  apart :  when 
put  back  to  bed  his  feet  are  tied  to  the  sides  of  his  cot  to  maintain 
abduction ;  (3)  he  must  learn  to  put  forward  one  foot  at  a  time, 
no  matter  how  short  the  stride ;  (4)  he  must  not  be  allowed  to  look 
at  the  ground,  but  must  keep  his  eyes  fixed  on  some  distant  object 
as  high  as  or  slightly  above  the  level  of  his  eyes ;  (5)  he  must  never 
be  allowed  to  stoop  forward  or  walk  with  his  hips  flexed,  for  flexion 
at  the  hip  and  consequent  lordosis  of  the  lumbar  spine  is  one  of  the 
troubles  to  be  'guarded  against.  He  should  be  helped  by  two  people 
walking  one  on  either  side  during  his  lesson.  A  rope  stretched 
across  the  room  is  a  help,  for  the  child  can  hold  on  to  this  and 
practise  walking.  The  teacher  should  make  the  child  practise  all 
movements  of  the  legs  to  word  of  command. 

In  the  case  of  a  child  which  has  never  walked  it  will  be  six  months  or 
a  year  before  the  child  can  stand  alone.  He  should  then  be  taught 
to  walk  with  two  sticks,  later  these  may  be  discarded  one  at  a  time. 

Treatment  of  the  Upper  Limbs.— In  cases  of  spastic  hemiplegia 
the  upper  limb  is  generally  more  severely  affected  than  the  lower. 
A  description  of  the  treatment  appropriate  to  such  a  case  will 
therefore  suffice. 

As  has  been  already  stated,  the  fingers,  thumb,  elbow  and  wrist 
are  all  flexed.  The  object  of  treatment  is  to  restore  the  power  of 
co-ordinate  movement  to  the  wrist  and  fingers.  All  our  attention 
is  therefore  concentrated  on  the  hand.  The  hand  is  put  on  to 
a  splint  with  the  wrist  dorsi-flexed  and  the  fingers  extended : 
a  thumb-piece  keeps  the  thumb  well  abducted.  As  soon  as  possible 
the  wrist  is  dorsi-flexed  to  a  right  angle.  The  flexors  are  then 
thoroughly  stretched  and  we  wait  for  the  extensors  to  recover  power. 
The  elbow  is  acutely  flexed  and  the  wrist  fixed  in  a  halter  close 
to  the  neck,  with  the  hand  in  the  supinated  position.  This  position 
is  maintained  night  and  day  without  a  moment's  relaxation.  It  is 
desirable  to  have  the  extensor  muscles  in  the  forearm  regularly 
massaged,  and  this  is  done  without  changing  the  position  of  the 
limb.  When  the  patient  can  hyper-extend  the  fingers  away 
from  the  splint  the  latter  may  be  shortened  so  as  to  allow  move- 
ment of  the  fingers,  but  a  short  splint  extending  to  the  tips  of 
the  fingers  is  worn  at  night. 


Surgical  Treatment  of  Cerebral  Palsies.      1163 

At  this  stage  education  of  the  fingers  is  commenced,  the  patient 
flexing  and  extending  them  one  at  a  time  to  word  of  command. 
He  is  encouraged  to  use  his  fingers  in  every  possible  way. 

Adduction  of  the  thumb  is  the  most  difficult  part  of  the  deformity 
to  correct.  The  adductor  obliquus  and  transversus  are  shortened, 
and  act  at  much  greater  mechanical  advantage  than  their  oppo- 
nents, the  abductor  pollicis  and  extensor  ossis  metacarpi  pollicis. 
When  the  thumb  is  abducted  and  fixed  on  the  splint  there  is  a 
tendency  to  produce  a  luxation  of  the  metacarpo-phalangeal  joint. 
To  meet  this  difficulty  we  have  a  leather  pad  fixed  in  the  palm 
of  the  splint  to  push  the  metacarpal  outwards,  and  find  it  very 
effective  in  some  cases. 

Operative  Treatment. — (1)  Obstinate  pronation  can  be  overcome 
by  converting  the  pronator  radii  teres  into  a  supinator  (Tubby). 
The  position  of  the  muscle  is  first  noted  by  making  it  tense.  An 
incision  (3  inches  long)  is  then  made  at  the  inner  border  of  the 
supinator  longus  over  the  pronator  teres.  The  supinator  longus  is 
drawn  outwards  and  the  radial  nerve  and  artery  inwards.  The 
upper  and  lower  margins  of  the  pronator  radii  teres  are  defined, 
and  the  insertion  of  the  muscle  is  dissected  off  the  radius  along 
with  the  periosteum.  A  silk  suture  is  now  passed  through  the 
tendon.  The  interosseous  membrane  is  next  separated  from  the 
radius  for  1£  inches,  an  aneurysm  needle  is  passed  round  the 
bone  and  the  silk  suture  threaded  in  the  eye  of  the  needle. 
The  tendon  is  then  pulled  through  the  gap  in  the  membrane  and 
fixed  to  the  back  of  the  radius,  or  if  possible  to  the  point  from 
which  it  was  removed. 

We  have  so  often  found  the  muscle  too  short  for  this  that  we 
prefer  to  stitch  the  separated  pronator  radii  teres  to  the  flexor  carpi 
radialis.  The  tendon  of  the  flexor  carpi  radialis  can  then  be 
divided  low  down  in  the  forearm,  and  will  be  found  long  enough  to 
be  wrapped  well  round  the  radius. 

(2)  In  some  instances  the  extensors  of  the  wrist  may  be  rein- 
forced with  great  advantage  by  transplanting  the  flexor  carpi 
radialis  into  the  extensor  carpi  radialis  longior  and  the  flexor  carpi 
ulnaris  into  the  corresponding  extensor.  Each  tendon  is  exposed 
by  a  separate  longitudinal  incision. 

(8)  The  flexor  tendons  at  the  wrist  are  sometimes  lengthened. 
This  operation  is  tedious  and  is  seldom  necessary. 

(4)  Spitzy,  of  Gratz,  has  recently  published  his  .results  of  the 
treatment  of  these  cases  by  transplantation  of  part  of  the  median 
nerve  into  the  musculo-spiral  nerve  just  above  the  elbow.  The 
after-treatment  is  similar  to  that  which  we  have  described.  It  is 


1164     Surgical  Treatment  of  Cerebral  Palsies. 

still  too  early  to  estimate  how  much  of  his  success  is  due  to  the 
operation  and  how  much  to  the  after-treatment  by  splints  and 
massage.  He  encounters  the  same  difficulties  as  we  do  in  the 
treatment  of  the  thumb. 

Summary. — The  treatment  described  above  is  an  outline  of  the 
routine  we  adopt.  Its  application  is  beset  with  difficulties  which 
must  be  met  by  the  ingenuity  of  the  surgeon  as  they  arise.  We 
mention  here  some  of  the  chief  points  to  be  considered  before 
undertaking  the  treatment  of  a  case. 

(1)  Absolute  imbeciles  and  cases  with  incontinence  of  faeces  do 
not,  as  a  rule,  live  long,  and  are  not  suitable  for  surgical  treatment. 

(2)  In  severe  cases   of   diplegia  it  is  not  much  use   trying  to 
improve  the  condition  of  the  lower  limbs  unless  the  surgeon  is  sure 
he  can  so  far  improve  the  condition  of  the  upper  limbs  that  the 
child  will  be  able  to  handle  sticks. 

(3)  This  difficulty  often  arises  in  cases  of  hemiplegia,  for  the 
arm  is  often  more  severely  affected  than  the  leg.     The  difficulty  of 
teaching  the  child  to  walk  is  greatly  increased  if  he  cannot  hold  a 
stick  to  steady  himself. 

Even  excluding  these  more  severe  cases  there  are  still  a  host  of 
children  left  untreated  whose  condition  could  be  vastly  improved, 
if  a  systematic  method  of  attack  were  more  generally  understood. 

ROBERT  JONES  and  D.  McCRAE  AITKEN. 


CEREBELLAR    CONDITIONS    IN    CHILDREN. 

THE  cerebellum  has  connections,  both  afferent  and  efferent,  with 
the  cerebral  hemispheres  and  the  spinal  cord.  The  symptoms, 
produced  by  cerebellar  disease,  are  due  to  interruptions  in  these 
connections.  Very  frequently,  especially  in  young  subjects,  com- 
pensation may  take  place  for  the  cerebellar  defect,  provided  that  the 
cerebral  hemispheres  are  intact,  so  that  the  symptoms  of  cerebellar 
disease  may  materially  diminish,  and  indeed  almost  disappear,  with- 
out any  improvement  in  the  local  lesion.  The  interruption  probably 
in  all  cases  affects  both  the  afferent  and  efferent  connections,  the 
typical  symptoms  being  vertigo,  inco.-ordination  of  muscular  action, 
and  loss  of  muscle  power,  together  with  some  loss  of  muscle  tone. 
Cutaneous  sensibility  is  unaltered  and  the  tendon  jerks,  instead  of 
being  diminished,  are  usually  increased ;  nystagmus  is  generally 
present,  and  in  cases  of  tumour,  optic  neuritis  and  consecutive 
atrophy  are  the  rule ;  the  speech  is  often  scanning.  Since  the  con- 
nections of  the  cerebellum  are  with  the  opposite  side  of  the  cerebrum 
and  the  same  side  of  the  spinal  cord,  in  uni-lateral  lesions  the  ataxia, 
muscular  weakness  and  hypotonia  are  on  the  same  side  as  the 
cerebellar  defect. 

The  abnormal  conditions  of  the  cerebellum  may  be  congenital  or 
acquired.  Of  the  congenital,  one  type  shows  itself  at  birth  or 
shortly  after,  and  then  gradually  improves.  Here  the  cerebellum  is 
congenitally  deficient,  and  the  improvement  is  due  to  the  compen- 
sation which  results  from  the  cerebrum  taking  on  the  functions  of 
the  cerebellum.  The  improvement  can  probably  be  hastened  by 
educating  the  child  in  the  co-ordination  of  movements  by  means  of 
carefully  chosen  exercises,  such  as  picking  up  small  objects,  putting 
pegs  into  holes,  etc.,  care  being  taken  to  avoid  causing  fatigue  to 
the  patient. 

Another  type  of  congenital  abnormality  is  definitely  inherited,  but 
the  symptoms  do  not  appear  until  the  affected  individual  arrives  at  the 
age  of  from  ten  to  thirty  years,  after  which  the  course  is  surely 
but  slowly  progressive.  The  morbid  changes  are  found  either  in  the 
cerebellum,  when  the  affection  has  been  called  Marie's  disease,  or  in 
the  spinal  cord,  when  it  is  known  as  Friedreich's  ataxia,  but  there 
are  a  number  of  intermediate  cases.  Treatment  seems  to  have 
little  or  no  influence  in  arresting  or  delaying  the  progress  of  the 
disorder,  and  the  most  that  can  be  done  is  that  attention  should  be 
given  to  the  patient's  general  health. 

After   certain    acute  infectious    disorders,    such    as   measles   or 


ii66       Cerebellar   Conditions  in  Children. 

influenza,  an  encephalitis  may  develop,  which  specially  attacks 
the  cerebellum.  As  a  result  of  this  the  child  becomes  ataxic,  and 
has  a  scanning  speech  and  nystagmus.  Generally  these  cases 
gradually  recover,  compensation  taking  place  for  the  damage  done 
to  the  small  brain.  Here,  as  in  cases  of  congenital  ataxia,  improve- 
ment may  be  accelerated  by  exercises  calculated  to  train  the  child 
in  the  performance  of  skilled  movements. 

Tumour  or  abscess  are  the  commonest  causes  of  ataxia  in  child- 
hood. Of  these,  abscess,  which  is  generally  secondary  to  disease  of 
the  middle  ear,  is  found  in  the  temporo-sphenoidal  lobe  much  more 
frequently  than  in  the  cerebellum.  The  general  symptoms  of  fever 
and  cerebral  pressure  may  render  it  difficult  to  obtain  definitely  the 
signs  of  local  mischief,  but  with  care  these  may  often  be  found. 
Exact  diagnosis  is  of  great  importance,  as  the  only  treatment  is 
surgical :  trephining  over  the  abscess  and  letting  out  the  pus. 

Cerebral  tumour  is  more  frequent  in  children  than  in  adults,  and 
especially  tends  to  affect  the  cerebellum.  In  the  early  stages  we 
meet  with  the  typical  picture  of  cerebellar  ataxia  with  optic 
neuritis,  but  as  the  case  drags  on  compensation  takes  place,  so 
that  the  localising  symptoms  improve  while  the  general  signs 
of  intra-cranial  pressure  may  become  more  severe.  Severity, 
too,  of  the  general  symptoms  may  conceal  the  local  signs.  Severe 
headache  may  be  relieved  by  icebags,  opium,  phenazone  (5  gr.), 
or  phenacetin  (2  to  4  gr.),  and  vomiting  may  be  allayed  by  ice 
and  rest.  Beyond  this  there  is  little  to  be  done  for  the  patient 
short  of  surgical  removal  of  the  tumour.  Before  deciding  on  opera- 
tion one  has  to  consider  that  the  tumour  is  most  frequently  tuber- 
culous, and  as  such  is  probably  associated  with  tuberculosis  elsewhere ; 
that  solitary  tuberculous  tumours  sometimes,  though  very  rarely, 
become  quiescent,  allowing  of  the  patient's  recovery  ;  and  that  there 
is  always  difficulty  in  the  exact  localisation  of  the  lesion  and  danger 
in  the  operation.  On  the  other  hand,  several  tumours  have  been 
successfully  removed,  and  if  the  tumour  proves  irremovable  the 
opening  of  the  dura  may  relieve  headache  and  to  some  extent  blind- 
ness by  lessening  the  intra-cranial  pressure.  Trephining  is  often 
advisable  on  this  account  alone  when  nothing  further  is  possible. 
It  is  true  that  pressure  may  be  relieved  temporarily  by  lumbar 
puncture,  but  trephining  and  opening  the  dura  are  much  more 
satisfactory  in  cases  of  tumour  of  the  brain. 

ALFRED  M.  GOSSAGE. 

REFERENCES. 

Batten,  F.  E.,  "Brain,"  1905,  XXVIII.,  p.  484.  Russell,  Risien,  Brit.  Med. 
Joui-n.,  1910,  L,  pp.  425,  497,  626. 


n6y 


CEREBRAL    EMBOLISM. 

IN  cerebral  embolism  the  embolus  originates  in  some  part 
of  that  portion  of  the  circulatory  system  which  conveys  the  blood 
from  the  heart  to  the  brain.  Most  commonly  emboli  originate 
from  the  heart,  either  in  consequence  of  an  endo-cardial  lesion  or  of 
the  detachment  of  a  portion  of  an  intra-cardiac  clot ;  they  may, 
however,  be  formed  by  the  breaking  off  of  a  portion  of  a  cerebral 
thrombosis  which  becomes  lodged  in  some  more  distal  vessel,  or  may 
result  from  a  septic  focus,  in  which  case  they  are  usually 
multiple. 

Cerebral  embolism  should  be  looked  upon  as  a  complication 
arising  in  the  course  of  the  above-mentioned  diseases,  and  as  such 
every  precaution  should  be  taken  to  prevent  its  recurrence. 

Every  patient  suffering  from  cerebral  embolism  must  be  kept 
absolutely  quiet  and  still,  and  treated  on  the  same  general  lines  as 
cases  of  cerebral  thrombosis.  Stimulants  must  not  be  given  unless 
the  general  condition  of  the  patient  renders  their  employment 
imperative.  In  cases  where  the  heart's  action  is  too  forcible, 
sedative  treatment  should  be  employed,  but  in  the  large  majority 
of  cases  rest  alone  is  necessary. 

T.  GRAINGER  STEWART. 


u68 


CEREBRAL  HEMORRHAGE. 

THE  terms  apoplexy  or  "  stroke "  have  been  applied  in  their 
widest  sense  to  a  clinical  condition  characterised  by  the  sudden,  or 
relatively  sudden,  onset  of  paralysis  on  one  side  of  the  body,  with 
or  without  loss  of  consciousness,  arising  from  some  local  interference 
with  the  cerebral  blood  supply.  The  vascular  lesion  may  arise  in 
two  ways  :  (1)  From  rupture  of  a  cerebral  vessel  (cerebral  haemor- 
rhage) ;  (2)  from  occlusion  of  a  cerebral  vessel,  either  by  the 
formation  of  a  clot  within  it  (cerebral  thrombosis)  or  by  a  clot 
carried  to  it  from  some  distant  part  (cerebral  embolism). 

It  is  often  impossible  to  decide  as  to  which  of  these  causes  the 
stroke  is  due,  and  it  is  only  by  obtaining  an  accurate  account  of  the 
previous  history  of  the  patient  and  by  a  careful  investigation  of  his 
physical  condition  that  a  definite  diagnosis  can  be  arrived  at. 

There  is  a  general  tendency  to  regard  cases  of  apoplexy  as  being 
due  to  cerebral  haemorrhage  rather  than  to  cerebral  thrombosis,  and 
yet  if  the  statistics  of  cases  of  apoplexy  are  carefully  examined  it 
becomes  quite  clear  that  cases  of  cerebral  thrombosis  are  more 
numerous  than  cases  of  cerebral  haemorrhage. 

When  it  is  possible,  a  careful  history  of  the  patient  should  be 
obtained  as  regards  his  previous  health,  and  the  presence  or 
absence  of  premonitory  symptoms  as  well  as  a  full  account  of  the 
mode  of  onset  of  the  stroke.  Having  learned  as  much  as  possible 
of  the  history  of  the  case,  the  physical  condition  of  the  patient  must 
be  then  examined.  This  examination,  important  as  it  is  from  the 
point  of  view  of  localising  the  position  of  the  lesion,  is  of  still 
greater  importance  from  the  point  of  view  of  determining  its  actual 
cause.  Thus  we  have  to  consider  the  age  of  the  patient,  his 
general  condition,  the  state  of  the  blood-vessels,  the  condition  of  the 
circulation,  of  the  heart,  and  of  the  kidneys.  By  such  examination 
it  may  be  possible  to  arrive  at  the  immediate  exciting  cause  of  the 
condition,  either  by  obtaining  positive  evidence  or  by  a  process  of 
exclusion. 

CEREBRAL    H/EMORRHAGE. 

Before  discussing  the  treatment  of  cerebral  haemorrhage  it  is 
necessary  to  describe  briefly  the  factors  which  underlie  its  production, 
and  to  review  shortly  the  effect  of  cerebral  haemorrhage  on  the 
functions  of  the  brain.  Unless  these  facts  are  appreciated,  the 


Cerebral  Haemorrhage.  1169 

treatment  of  any  given  case  of  cerebral  haemorrhage  must  be  purely 
empirical. 

(1)  Factors  Underlying  the  Production  of  Cerebral  Haemor- 
rhage.— The  two  conditions  accessory  to  the  production  of  cerebral 
haemorrhage  are  (a)    a   weakening  of  the   blood-vessel,  and  (b)  a 
blood-pressure  sufficiently  high  to  cause  rupture  of  the  weakened 
vessel.     In  the  great  majority  of  cases  the  latter  is  the  determinant 
factor,  though  a  high  blood-pressure  is  not  of  itself  sufficient  to 
cause   rupture   of   a   healthy  vessel.     Capillary  haemorrhage,  it  is 
true,  may  result,  as   in   whooping   cough,    from   an  acute  rise  in 
blood-pressure,  but  such  cases  are  rare. 

In  most  conditions  in  which  there  is  a  constant  high  blood- 
pressure,  definite  pathological  changes  occur  in  the  vascular  system. 
It  is  obvious  that  the  degree  of  blood-pressure  necessary  to  cause 
rupture  of  a  blood-vessel  will  vary  in  inverse  proportion  to  the 
amount  of  weakening  of  the  vessel.  Thus  in  some  cases  of  severe 
vascular  disease  a  slight  rise  in  blood-pressure,  if  sudden,  is 
sufficient  to  cause  rupture.  It  is  important  to  realise,  however,  that 
in  a  large  number  of  cases  of  vascular  degeneration  a  high  blood- 
pressure  may  exist  for  a  long  time  without  rupture  taking  place.  It 
may  happen  that,  owing  to  some  temporary  or  permanent  failure 
of  cardiac  power,  thrombosis  occurs,  with  resultant  softening  of  the 
surrounding  supporting  cerebral  tissues.  In  consequence  of  this 
there  is  a  further  local  weakening  of  the  vessel,  which  renders  any 
subsequent  rise  in  blood-pressure  dangerous  to  the  patient,  because 
of  the  increased  risk  of  rupture  at  that  point. 

Primary  cerebral  haemorrhage  rarely  occurs  as  the  result  of 
vascular  degeneration  in  the  absence  of  high  blood-pressure,  except 
in  cases  of  aneurysm,  traumatism,  or  septic  softening.  In  cases  of 
aneurysm  and  septic  softening  the  onset  is,  as  a  rule,  sudden  and 
without  warning.  In  traumatic  cases,  on  the  other  hand,  although 
the  onset  of  the  haemorrhage  may  be  immediate  and  sudden,  it  is 
not  infrequently  gradual.  The  history  of  such  cases  records  a  blow, 
recovery  from  the  effects  of  the  blow,  and  some  short  time  after, 
hours  or  days,  a  rather  rapid  but  gradual  onset  of  paralytic 
symptoms,  culminating  in  coma  and  death,  due  to  the  haemorrhage 
bursting  into  the  ventricle  or  spreading  over  the  base  of  the  brain. 
In  most  of  these  cases,  however,  there  is  slight  but  definite  clinical 
evidence  of  damage  to  the  cerebral  structures,  and  if  a  daily 
routine  examination  were  made,  the  discovery  of  a  gradual  increase 
in  the  paralytic  signs  would  enable  exploratory  surgical  methods  to 
be  successfully  undertaken. 

(2)  The     Effects     of     Cerebral     Haemorrhage.  —  Cerebral 
S.T. — VOL.  ii.  74 


1 1 70  Cerebral  Haemorrhage. 

haemorrhage  produces,  in  addition  to  the  paralysis  which  may  result 
from  the  local  destruction  of  the  nervous  elements,  certain  general 
effects.  These  must  be  considered,  as  they  have  some  bearing  on 
the  treatment  of  the  condition. 

A  severe  cerebral  haemorrhage  increases  the  intra-cranial 
pressure.  This  causes  (a)  a  rise  in  the  general  arterial  blood- 
pressure  ;  (b)  cerebral  compression ;  (c)  coma,  and  ultimately  death 
from  respiratory  paralysis,  owing  to  anaemia  of  the  respiratory 
centres  in  the  bulb.  Thus  a  cerebral  haemorrhage  does  not  of  itself 
cause  death,  unless  the  intra-cranial  pressure  becomes  so  high  as 
to  cause  anaemia  of  the  respiratory  centres  in  the  medulla. 

In  cases  of  pontine  or  cerebellar  haemorrhage  the  amount  of 
haemorrhage  necessary  to  increase  the  intra-cranial  pressure  to 
such  a  degree  as  to  cause  anaemia  of  the  respiratory  centres  is  much 
less,  because  in  the  first  place  the  subtentorial  chamber  is  small,  and 
its  walls  firm  and  resistant,  except  for  the  relatively  large  opening 
of  the  foramen  magnum.  Thus  the  intra-cranial  pressure  rises 
rapidly,  causing  the  formation  of  a  pressure  cone  at  the  foramen 
magnum,  portions  of  the  cerebellum  being  forced  down  through  the 
opening  and  compressing  the  medulla.  In  the  second  place,  in  all 
cases  of  haemorrhage,  even  where  the  actual  haemorrhage  is  small, 
there  is  developed  in  the  area  of  brain  substance  surrounding  the 
clot  a  condition  of  anaemia.  Therefore,  if  a  small  haemorrhage 
occurs  in  the  neighbourhood  of  the  respiratory  centres,  death  from 
respiratory  paralysis  may  ensue  on  account  of  the  centres  being 
implicated  in  the  local  anaemia. 

Cerebral  haemorrhage  may  be  of  sudden  or  gradual  onset.  When 
the  onset  is  gradual,  no  difficulty  will  be  experienced  in  diagnosing 
the  situation  of  the  lesion  from  the  history  of  onset  and  the 
presence  of  physical  signs  indicating  preponderant  paralysis  of  one 
side  of  the  body.  In  most  cases  it  should  be  possible  to  diagnose 
whether  the  haemorrhage  is  superficial,  i.e.,  extra-dural  or  on  the 
surface  of  the  brain,  or  deep,  i.e.,  into  the  brain  substance, 
intra-cerebral. 

If  the  haemorrhage  is  superficial  and  progressive,  and  especially 
in  traumatic  cases,  surgical  interference  should  not  be  delayed,  as 
in  many  instances  the  actual  seat  of  the  haemorrhage  can  be 
exposed,  the  clot  removed  and  the  bleeding  arrested. 

TREATMENT  OF  SUPERFICIAL,  MENINGEAL  AND  TRAUMATIC 

HAEMORRHAGE. 

The  bone  above  the  seat  of  lesion  should  be  trephined,  or 
preferably  a  large  bone-flap  should  be  made,  the  bleeding  vessel 


Cerebral   Haemorrhage.  1171 

ligatured,  and  the  blood-clot  removed.  Whether  the  bone  should 
be  at  once  replaced  or  a  drain  left  in  depends  upon  the  circumstances 
present  in  each  case. 


GENERAL    TREATMENT    OF    INTRA-CEREBRAL 
HAEMORRHAGE. 

Treatment  is  directed  to  stopping  the  haemorrhage.  Rest  is 
essential,  and  the  patient  must  not  be  moved  more  than  is 
necessary.  The  neck  must  be  freed  from  all  tight  clothing,  the 
patient  placed  in  the  horizontal  position  with  the  head  and 
shoulders  slightly  raised,  and  the  face  turned  to  one  side  to  prevent 
the  tongue  falling  back  in  the  mouth  and  obstructing  the  breathing. 
Hot-water  bottles  covered  with  flannel  should  be  applied  to  the 
lower  limbs. 

When  practicable,  a  bed  or  mattress  should  be  made  up  for 
the  patient  in  the  room  where  the  stroke  has  occurred.  If,  however, 
this  is  impossible,  the  patient  should  not  be  disturbed  more  than  is 
necessary ;  his  removal  to  another  room  should  be  delayed  until 
everything  has  been  prepared  for  his  reception.  Great  care  must 
be  taken  to  prevent  bed-sores,  and  for  this  purpose  a  water-bed  is 
best,  and  careful  nursing  is  essential.  The  bladder  must  be  attended 
to  and  distension  avoided,  catheterisation  being  carried  out  as 
required.  Absolute  cleanliness  is  only  assured  by  assiduous  care, 
and  the  patient  must  be  kept  dry  and  clean,  the  limbs  and  body 
being  washed,  dried,  and  the  points  of  pressure  afterwards  rubbed 
with  spirit  and  then  powdered. 

At  a  later  stage,  when  all  risk  of  a  fresh  haemorrhage  is  over,  the 
patient  may  be  moved  from  side  to  side  to  avoid  undue  pressure  on 
one  spot,  and  to  lessen  the  chances  of  hypostatic  congestion  of  the 
lungs.  The  mouth  must  be  kept  clean  and  sweet  by  sponging  with 
antiseptic  washes,  and  much  trouble  will  be  avoided  if  the  patient's 
mouth  and  tongue  are  coated  with  vaseline  or  glycerine  to  prevent 
them  becoming  dry  and  cracked.  Light  nourishment  in  the  shape 
of  fluids  may  be  administered  by  rectal  feeding,  or  the  patient  may 
be  able  to  swallow  small  quantities  of  fluid  placed  on  the  back  of 
the  tongue,  care  being  taken  to  prevent  the  entrance  of  food  into 
the  lungs. 

Purgation. — In  all  cases  where  there  is  a  high  pulse-tension 
without  signs  of  cerebral  compression,  active  purgation  is  indicated. 
This  is  obtained  most  easily  by  placing  1  to  2  minims  of  croton 
oil  mixed  with  olive  oil  on  the  back  of  the  tongue.  In  every  case 
movement  of  the  bowels  should  be  obtained. 

74—2 


1172  Cerebral  Haemorrhage. 

Venesection. — Opinions  differ  as  to  the  wisdom  of  venesection 
in  cases  of  cerebral  haemorrhage.  It  is  well  known  that  a  rise  of 
intra-cranial  pressure  will  cause  a  rise  in  the  general  arterial 
pressure.  This  rise  in  arterial  tension  may  be  regarded  as  Nature's 
attempt  to  maintain  the  supply  of  blood  to  the  respiratory  centres. 
Death  ensues  in  most  cases  of  cerebral  haemorrhage  from  anaemia  of 
respiratory  centres  due  to  the  rise  of  intra-cranial  pressure.  Those 
who  hold  that  venesection  should  not  be  performed  consider  that 
the  lowering  of  the  blood-pressure  is  dangerous,  because  it  further 
diminishes  the  blood  supply  to  the  already  embarrassed  respiratory 
centres.  On  the  other  hand,  we  must  not  lose  sight  of  the  fact  that 
the  rise  in  intra-cranial  pressure  is  due  to  the  intra-cranial 
haemorrhage,  and  that  the  anaemia  of  the  respiratory  centres  is 
primarily  due  to  the  rise  in  the  intra-cranial  pressure  and  not  to 
any  lowering  of  the  arterial  blood-pressure.  It  seems  obvious, 
therefore,  that  cases  of  cerebral  haemorrhage  can  be  divided  into  two 
classes :  (1)  Cases  in  which  there  is  evidence  of  a  high  intra- 
cranial  pressure — coma  and  respiratory  failure ;  and  (2)  cases  in 
which  there  is  little  or  no  evidence  of  cerebral  compression.  In  the 
first  class  of  case,  those  with  cerebral  compression,  a  lowering  of  the 
blood-pressure  by  venesection  may  quite  conceivably  cause  death  by 
upsetting  the  compensatory  increase  in  arterial  pressure  which  has 
resulted  from  the  high  intra-cranial  pressure,  but  it  is  obvious  that 
to  save  the  patient's  life  in  such  cases  the  first  step  to  be  taken  is 
to  reduce  the  intra-cranial  pressure.  This  can  only  be  done 
effectively  by  removing  the  bone  and  evacuating  the  blood  clot, 
or  by  making  the  cranial  opening  of  sufficient  size  to  afford 
complete  relief  of  pressure.  If  either  of  these  measures  is  employed, 
the  lowering  of  the  intra-cranial  pressure  will  be  followed  by  the 
lowering  of  the  arterial  pressure.  In  the  second  class  of  case,  where 
there  is  no  obvious  cerebral  compression,  the  respiratory  centres 
are  not  in  any  immediate  danger,  and,  therefore,  venesection  can  be 
quite  safely  performed,  and  the  lowering  of  the  blood-pressure  so 
brought  about  may  suffice  to  stop  the  haemorrhage.  Should  it  fail 
to  do  so,  the  intra-cranial  pressure  will  continue  to  rise,  and  with  it 
the  arterial  blood-pressure.  There  does  not,  therefore,  appear  to  be 
any  reason  against  venesection  being  employed  in  those  cases  in 
which  symptoms  of  compression  are  absent.  It  must  not  be 
forgotten  that,  although  a  rise  in  intra-cranial  pressure  would 
cause  a  rise  in  arterial  blood-pressure,  there  are  many  cases  in 
which  the  arterial  pressure  is  above  normal,  because  of  other 
conditions  quite  distinct  from  the  intra-cranial  pressure. 

If  the  treatment  by  rest,  purgation,  or  venesection  has  failed  to 


Cerebral  Haemorrhage.  1173 

arrest  the  haemorrhage,  the  employment  of  further  measures  must 
be  considered.  So  many  people  die  from  cerebral  haemorrhage, 
despite  the  efforts  made  to  save  them,  that  it  appears  to  be 
justifiable,  at  any  rate,  to  consider  the  adoption  of  surgical 
measures. 


SURGICAL  TREATMENT  OF  INTRA  CEREBRAL   HAEMORRHAGE. 

The  question  of  surgical  interference  where  the  haemorrhage  is 
presumably  deep-seated  is  a  point  of  much  difficulty. 

It  may  be  urged  that  in  cases  of  small  haemorrhage  surgical 
interference,  even  if  successful,  would  cause  a  greater  amount  of 
permanent  damage.  In  our  present  state  of  knowledge,  therefore, 
surgical  measures  should  be  confined  to  the  more  severe  cases  of 
intra-cranial  haemorrhage.  It  is  obvious  that  when  a  patient  is 
dying  from  cerebral  compression,  decompression  is  indicated,  this 
alone  offering  any  hope  of  recovery.  Decompression  may  be 
obtained  by  removing  a  large  amount  of  bone  and  freely  opening 
the  dura,  or  by  making  a  small  opening  in  the  dura  and  by  tapping 
the  clot,  and  thus  relieving  the  pressure  by  removing  its  cause. 
As  regards  the  first  procedure,  where  the  dura  is  freely  opened,  the 
blood  clot  will  almost  certainly  burst  through  the  brain ;  this  may 
cause  very  extensive  laceration  of  the  brain  substance,  with  sub- 
sequent paralysis,  or  even  the  sudden  death  of  the  patient.  To 
make  such  an  operation  successful  the  bone  should  be  removed  for 
a  sub-temporal  decompression,  and  at  the  same  time  as  the  dura 
is  opened  lumbar  puncture  should  be  performed.  This  will,  by 
lowering  the  intra-ventricular  pressure,  lessen  the  tendency  of  the 
clot  to  burst  through  the  brain  at  the  moment  when  the  dura  is 
freely  incised.  If  the  clot  does  happen  to  burst  through  the  brain 
substance,  the  area  destroyed  is  more  or  less  silent,  and  its 
destruction  unattended  by  any  serious  paralysis. 

Concerning  the  second  surgical  measure,  namely,  tapping  of  the 
clot  and  draining  it  through  the  opening,  Gushing  advises  that 
the  attempt  should  be  made  from  a  sub-temporal  opening,  a  small 
incision  being  made  in  the  upper  portion  of  the  exposed  area 
corresponding  to  the  lower  portions  of  the  central  convolutions. 
A  blunt  aspirator  or  curved  director  should  be  introduced  directly 
towards  the  internal  capsule,  care  being  taken  to  pass  the  instru- 
ment through  the  summit  of  one  of  the  exposed  convolutions  far 
enough  above  the  Sylvian  fissure  to  avoid  the  insula.  In  the  case 
of  severe  hemorrhage,  where  the  clot  is  large,  it  is  quite  probable 
that  the  aspirator  will  reach  the  effused  blood,  and,  if  so,  the 


1 1 74  Cerebral  Haemorrhage. 

external  opening  can  be  enlarged,  and  through  it  the  altered  blood 
and  clot  will  escape.  Drainage  from  the  cavity  will  be  maintained 
naturally.  If  the  clot  is  large  enough  and  a  direct  opening 
has  been  made  into  it,  it  is  quite  probable  that  the  patient's  life 
will  be  preserved  by  the  decompression,  and  that  the  ultimate 
paralysis  will  be  less  because  of  the  removal  of  the  clot.  It  is  not 
to  be  expected  that  the  paralysis  due  to  the  destruction  of  the 
fibres  will  be  affected  in  any  way ;  but,  on  the  other  hand,  all 
pressure  paralysis  will  be  recovered  from. 

Ligation  of  the  carotid  artery  on  the  same  side  as  the 
haemorrhage  has  been  advocated  and  carried  out  in  some  cases. 
Theoretically  it  should  stop  the  haemorrhage  and  prevent  any 
further  increase  in  the  intra-cranial  pressure,  and  should  not  have 
the  effect  of  causing  any  diminution  of  the  blood  supply  of  the 
respiratory  centres,  which  would  be  carried  on  by  the  vertebral 
arteries.  The  results  of  ligature  of  the  carotid  on  one  side  are 
extremely  variable ;  death  or  permanent  softening  of  the  brain  has 
ensued  in  about  a  third  of  such  cases.  It  is,  therefore,  not  justifi- 
able to  advise  this  operation  in  minor  cases  of  cerebral  haemorrhage. 
In  severe  cases,  on  the  other  hand,  although  the  haemorrhage  would 
be  stopped,  the  cerebral  compression  would  not  be  relieved,  and 
a  decompressive  operation  or  an  operation  for  evacuation  of  the  clot 
would  have  to  be  performed  subsequently.  It  would  appear  wiser, 
therefore,  to  attempt  to  combine  the  checking  of  the  haemorrhage 
and  the  relieving  of  the  cerebral  compression  by  an  operation  at 
the  site  of  the  haemorrhage,  rather  than  run  the  risk  of  causing 
widespread  paralysis  from  cerebral  softening,  and  yet  not  avoid 
the  necessity  for  decompressive  operation  in  addition. 

CEREBELLAR    HAEMORRHAGE. 

Haemorrhage  into  the  cerebellum  is  uncommon,  and,  if  extensive, 
usually  causes  death  very  rapidly.  In  some  cases,  however,  its 
development  may  be  more  or  less  gradual.  If,  despite  the  usual 
measures,  respiratory  paralysis  sets  in,  no  time  should  be  lost  in 
opening  the  skull  oh  both  sides  below  the  tentorium  in  order  to 
attempt  to  stop  the  bleeding. 

Where  operation  is  impossible,  lumbar  puncture  may  be  per- 
formed in  the  hope  of  relieving  the  intra-cranial  tension.  This 
procedure,  however,  is  attended  with  a  certain  amount  of  risk.  If 
no  fluid  escapes  from  the  sub-tentorial  chamber,  the  withdrawal  of 
the  spinal  fluid  alone  may  cause  the  immediate  formation  of  a 
"  pressure  cone "  and  the  sudden  death  of  the  patient.  The 
pressure  must  be  relieved  as  soon  as  possible,  for  any  considerable 


Cerebral  Haemorrhage.  1 1 75 

rise  in  intra-cranial  pressure  is  attended  with  the  greatest  danger, 
owing  to  the  small  size  of  the  infra-tentorial  chamber  and  the 
proximity  of  the  respiratory  centres. 

PONTINE    H/EMORRHAGE. 

The  treatment  of  haemorrhage  into  the  pons  must  be  carried  out 
on  the  general  lines  of  treatment  for  cerebral  haemorrhage.  If  the 
bleeding  is  severe,  all  treatment  will  be  unavailing ;  but  if,  as 
sometimes  happens,  the  haemorrhage  is  small,  although  giving  rise 
at  the  time  to  widespread  paralysis,  recovery  is  possible,  provided 
that  the  patient  can  be  kept  absolutely  still.  As  in  most  cases  the 
patient  is  very  restless,  he  should  be  kept  under  the  influence  of 
morphia.  Venesection,  active  purgation  and  surgical  intervention 
are  strongly  contra-indicated. 

SUBSEQUENT     TREATMENT    OF     CASES     OF    INTRA-CRANIAL 

HAEMORRHAGE. 

Patients  who  recover  from  the  initial  attack  and  regain  con- 
sciousness require  constant  attention.  The  sick  room  should  be 
well  ventilated  and  the  patient  protected  from  the  glare  of  light. 
In  many  instances  the  patient  is  restless  and  uneasy,  and  to  quiet 
him  20  to  30  gr.  of  potassium  bromide  should  be  given  once,  twice 
or  thrice  daily,  as  required  ;  in  some  cases  it  may  be  necessary  to 
give  morphia.  If  cold  applications  to  the  head  annoy  the  patient, 
they  should  be  discontinued.  The  bowels  must  be  kept  freely 
opened.  During  the  early  stages  rectal  feeding  may  be  necessary ; 
but  if  the  patient  is  able  to  swallow,  he  may  be  given  a  little  milk 
or  water,  2  to  3  teaspoonfuls  every  two  hours.  In  four  or  five 
days  the  patient  may  be  given  4  or  5  oz.  of  milk  or  chicken-broth 
every  two  hours.  The  diet  is  then  gradually  increased  by  the 
addition  of  eggs  and  farinaceous  food,  and  still  later  of  fish  and 
white  meat.  It  is  wise  to  be  on  the  side  of  safety,  and  all  stimulat- 
ing foods  must  be  avoided.  The  patient  should  not  be  excited,  and 
it  is  best  at  this  stage  to  forbid  the  entrance  of  relatives  to  the  sick 
room  ;  on  the  other  hand,  it  should  not  be  forgotten  that  an  aphasic  or 
partially  aphasic  patient  may  be  worrying  to  see  someone  and  unable 
to  signify  his  desire.  Therefore,  in  some  instances,  it  does  the  patient 
good  merely  to  be  allowed  to  see  his  relatives.  As  recovery  takes 
place,  treatment  of  the  paralysis  must  be  undertaken  (see  Hemiplegia, 
p.  1181).  The  after-life  of  the  patient  must  be  regulated  so  as 
to  avoid  any  sudden  or  excessive  mental  or  physical  strain.  He 
should  be  guarded  against  emotional  excitement  of  all  kinds,  and  as 
far  as  possible  his  life  should  be  quiet  and  peaceful.  When  the 


1176  Cerebral  Haemorrhage. 

paralysis  permits,  gentle  exercise  on  the  flat  is  not  contra-indicated. 
The  diet  must  be  light  and  spare,  and  fluids  should  be  restricted 
and  alcohol  prohibited.  The  patient  should  never  be  allowed  to 
become  constipated.  If  the  blood-pressure  tends  to  rise,  steps  must 
be  taken  to  lower  it.  If  syphilitic  vascular  disease  is  present,  a 
course  of  anti-syphilitic  treatment  should  be  carried  out  each  year. 
For  the  treatment  of  Aphasia,  see  p.  1045. 

T.  GRAINGER  STEWART. 


1 177 


CEREBRAL    THROMBOSIS. 

THE  patient  should  be  kept  absolutely  still,  the  same  precautions 
being  taken  as  in  a  case  of  cerebral  haemorrhage.  He  should  be 
placed  in  the  horizontal  position,  with  his  shoulders  and  head 
slightly  raised  and  all  tight  clothing  removed  from  the  neck.  If  the 
tongue  is  obstructing  his  breathing  his  head  should  be  turned  gently 
to  one  side.  Having  seen  to  his  immediate  needs  the  patient  must 
be  examined  with  a  view  to  finding  out  the  factors  underlying  the 
production  of  the  thrombosis. 

The  factors  which  underlie  the  production  of  cerebral  thrombosis 
are :  (1)  Vascular  degeneration — syphilitic  or  atheromatous ; 
(2)  circulatory  enfeeblement — cardiac  or  general ;  (3)  combinations 
of  the  above ;  (4)  abnormal  blood  states  ;  (5)  intra-cranial  neoplasms 
or  abscess  formations,  which  by  pressing  on  the  vessels  obstruct  the 
flow  of  the  blood  within  them. 


TREATMENT   OF   THROMBOSIS   DUE  TO  VASCULAR 
DISEASE   OR   DEGENERATION. 

(1)  Syphilitic  Vascular  Disease. —  Syphilis  is  the  commonest 
cause  of  vascular  disease  up  to  the  age  of  forty,  and  it  may  be  the  sole 
cause  of  cerebral  thrombosis,  some  patients  showing  no  evidence  of 
circulatory  or  renal  disease.  The  actual  extent  of  the  syphilitic 
vascular  disease  may  vary  widely  ;  in  many  cases  the  disease  though 
intense  is  extremely  local  in  distribution.  In  other  cases  the 
affection  of  the  vascular  system  is  more  widespread,  and  in  not  a 
few  the  vascular  changes  are  associated  with  more  obvious  syphilitic 
or  parasyphilitic  affections.  In  all  such  cases,  whatever  the  degree 
of  severity  of  the  paralysis  present,  the  patient  should  be  put  to  rest, 
a  mild  aperient  should  be  given,  and  a  vigorous  course  of  anti- 
syphilitic  treatment  by  inunction  with  mercury  should  be  carried  out 
until  the  full  physiological  effect  of  the  drug  has  been  induced ;  this 
should  be  accompanied  by  the  administration  of  large  doses  of 
potassium  iodide  (gr.  15  to  40)  three  times  a  day.  The  question  as  to 
whether  any  stimulant  should  be  given  may  be  answered  on  general 
lines  in  the  negative.  It  certainly  must  not  be  given  in  cases  in 
which  there  is  a  previous  history  of  thrombosis,  or  in  cases  of 


1178  Cerebral  Thrombosis. 

syphilis,  where  the  vascular  disease  is  complicated  by  the  presence 
of  chronic  renal  disease.  If,  on  the  other  hand,  cardiac  weakness  is 
present  and  is  not  recovered  from  as  a  result  of  rest,  the  judicious 
administration  of  stimulants  should  not  be  prohibited. 

(2)  Senile  Arterial  Changes. — In  these  cases  rest  is  essential ; 
purgation  or  anything  which  will  tend  to  depress  the  circulation  must 
be  avoided  ;  warmth  should  be  applied  to  the  feet  and  extremities. 
The  question  of  the  administration  of  cardiac  stimulants  must  be 
decided  by  the  state  of  the  patient  and  by  his  previous  health.     If 
there  is  a  history  of  previous  thrombotic  attacks,  or  if  there  is 
evidence  of  cardiac  hypertrophy,  although  associated  with  temporary 
dilatation,  stimulants  must  not  be  given.     On  the  other  hand,  if 
there  is  acute  cardiac  failure,  or  if  in  a  chronic  case  the  heart  fails 
to  respond  to  rest,  stimulants  should  be  given.     There  can  be  no 
doubt  that  in  these  cases  iron  is  one  of  the  most  satisfactory  drugs ; 
it  may  be  given  in  combination  with  arsenic. 

(3)  Vascular   Disease    associated  with  Renal  Disease. — It 
occasionally   happens,   more  often   than   is  fully  recognised,  that 
patients  suffering  from  chronic  renal  disease  with  hypertrophy  of 
the  heart  and  general  arterial  sclerosis  suffer  from  cerebral  throm- 
bosis, owing  to  some  temporary  or  more  permanent  enfeeblement 
of  the  circulation :  thus,  for  example,  a  patient  with  chronic  renal 
disease  and  hypertrophy  may  have  an  attack  of  influenza,  as  a  result 
of  which  his  heart's  action  becomes  depressed  and  cerebral  throm- 
bosis ensues.     All  that  is  necessary  in  such  cases,  indeed  all  that  is 
justifiable,  is  to  keep  the  patient  at  rest,  and  to  employ  only  the  mini- 
mal amount  of  stimulant  necessary  to  restore  the  heart  to  its  normal 
condition,  for  it  must  always  be  remembered  that,  whereas  previous  to 
the  thrombosis  the  condition  of  the  vascular  system  and  of  the  blood 
pressure  were  more  or  less  relative  to  each  other,  the  fact  of  throm- 
bosis having  occurred  weakens  the  vascular  system  locally,  and  may 
render  it  incapable  of  withstanding    a    blood-pressure   which  has 
become  raised  to  compensate  for  the  vascular  changes.     In  such  cases, 
therefore,  it  n^ay  be  necessary,  when  the  patient  recovers  from  the 
thrombosis,  to   take   means   to   ensure  that  the  blood-pressure   is 
prevented  from  returning  to  its  former  level. 

TREATMENT   OF   THROMBOSIS   DUE   TO   CIRCULATORY 
ENFEEBLEMENT. 

Pure  cases  of  this  condition  are  rare.  As  a  general  rule,  the 
cardiac  cases  are  due  either  to  acute  cardiac  disease  or  to  some 
acute  affection  which  depresses  the  heart's  action.  In  these  cases 
rest  and  treatment  of  the  causal  condition  are  indicated. 


Cerebral  Thrombosis.  I!79 

TREATMENT   OF   THROMBOSIS   DUE   TO   COMBINATIONS 
OF    THE    ABOVE   CAUSES. 

In  a  large  number  of  cases,  although  cardiac  disability  may  un- 
doubtedly be  the  preponderant  factor  in  the  production  of  the  throm- 
bosis, vascular  changes  in  varying  degree  are  associated  with  it.  It 
follows,  therefore,  that  the  line  of  treatment  must  be  determined 
by  a  consideration  of  the  amount  of  cardiac  weakness  in  relation  to 
the  degree  of  vascular  change  which  is  present  in  each  individual 
case,  stimulation  being  given  in  inverse  proportion  to  the  degree  of 
vascular  change. 

TREATMENT   OF   THROMBOSIS   DUE   TO   ABNORMAL 
BLOOD   STATES. 

Cerebral  thrombosis  may  occur  as  a  complication  of  chlorosis, 
leukaemia,  polycythsemia  and  pernicious  anaemia.  In  certain  other 
conditions — pregnancy,  typhoid  fever,  pulmonary  tuberculosis,  dia- 
betes, septicaemia  and  pyaemia — the  occurrence  of  apoplexy  has  been 
attributed  to  cerebral  thrombosis,  due  chiefly  to  changes  in  the  blood 
state.  The  treatment  of  all  such  cases  is  essentially  that  of  the  causal 
factor. 

TREATMENT    OF     THROMBOSIS    DUE     TO    LOCAL 
OBSTRUCTION  BY  PRESSURE  FROM  WITHOUT. 

It  occasionally  happens  that  a  cerebral  vessel  may  become 
obstructed  as  the  result  of  pressure  exerted  upon  it  from  without  by 
new  growth,  abscess  or  chronic  inflammatory  disease  of  the  mem- 
branes, such  as  gummatous  meningitis.  Signs  of  the  obstructing 
cause  are  usually  present  for  some  considerable  period  prior  to 
the  onset  of  the  thrombosis.  The  advent  of  thrombosis  is  shown  by 
the  more  or  less  sudden  development  of  paralysis  owing  to  the  loss 
of  function  in  the  parts  supplied  by  the  vessel.  In  these  cases, 
should  the  onset  of  thrombosis  be  suspected,  the  skull  should  be 
opened,  the  pressure  relieved,  and,  if  practicable,  the  obstruction 
removed. 

SUBSEQUENT    TREATMENT    OF   CASES   OF   CEREBRAL 
THROMBOSIS. 

In  addition  to  the  treatment  of  the  paralysis  which  has  resulted 
from  the  stroke  (see  Hemiplegia,  p.  1181),  it  is  necessary  to  see  that 
the  after-life  of  the  patient  is  ordered  so  as  to  avoid  excitement  or 
sudden  physical  or  emotional  strain. 

In  the  syphilitic  cases  regular  courses  of  iodide  and  mercury 
should  be  prescribed  each  year,  and  if  this  is  done  the  risk  of 


1180  Cerebral  Thrombosis. 

recurrence   may  be    much   diminished.     As    a   number    of    these 
cases  recover  completely  from  the  stroke,  the  prognosis  is  good. 

In  atheromatous  cases  care  must  be  taken  to  prevent  the  blood- 
pressure  either  falling  too  low  or  rising  too  high,  as  there  is  the 
double  risk  of  thrombosis  or  haemorrhage  should  the  limit  of 
safety  be  overs.tepped.  In  the  cardiac  cases  the  treatment  is 
practically  that  of  the  cardiac  condition. 

T.  GRAINGER  STEWART. 


HEMIPLEGIA. 

[EXCLUDING  HEMIPLEGIA  OF   CHILDREN.] 

HEMIPLEGIA  is  not  a  disease  ;  it  is  either  a  symptom  indicating 
the  existence  of  an  active  morbid  process  affecting  some  part  of  the 
upper  motor  neuronic  system  within  the  brain  or  the  more  or  less 
permanent  result  of  some  such  process  which  has  ceased  to  be  active. 

When  it  is  a  symptom,  therapeutic  measures  must  be  primarily 
directed  to  the  arrest  or  eradication  of  the  responsible  disease, 
whether  it  is  vascular,  neoplastic,  inflammatory,  toxic  or  hysterical 
in  origin.  For  guidance  in  these  matters  the  reader  is  referred  to 
the  articles  on  Cerebral  Vascular  Disease,  Cerebral  Tumour, 
Cerebral  Abscess,  Encephalitis,  Uraemia,  Hysteria,  etc. 

This  article  is  concerned  with  the  hemiplegia  remaining  after  the 
storm  of  disease  has  passed,  the  object  of  treatment  being  to 
promote,  as  far  as  is  possible,  the  recovery  of  natural  motor  function, 
and  to  minimise  the  effect  of  attendant  disabilities  and  discomforts. 
At  the  same  time  it  must  not  be  forgotten  that  all  measures  under- 
taken for  this  purpose  must  be  free  from  the  danger  of  exciting  a 
recurrence  of  the  primary  disease  and  be  subordinated  to  considera- 
tions for  the  patient's  general  health.  For  example,  the  amount  of 
physical  exercise  prescribed  for  a  man  who  is  already  hemiplegic, 
as  the  result  of  a  cerebral  haemorrhage  and  who  has  a  high  blood 
pressure,  must  be  regulated  by  the  fear  of  provoking  a  second 
apoplexy.  Owing  to  the  frequency  of  vascular  lesions  of  the  brain 
and  to  their  fleeting  character,  it  will  be  obvious  that  cases  of  hemi- 
plegia suitable  for  treatment  will  be  largely  drawn  from  the 
victims  of  cerebral  haemorrhage,  thrombosis  or  embolism.  What  is 
applicable  to  them  will  be  equally  applicable  to  patients  who  are 
left  hemiplegic  after  the  removal  of  a  cerebral  tumour,  after  the 
evacuation  of  a  cerebral  abscess,  or  after  an  attack  of  encephalitis. 

General  Considerations. — In  order  to  appreciate  both  the  possi- 
bilities and  the  limitations  in  the  treatment  of  hemiplegia  the  recog- 
nition of  certain  well-established  facts  is  essential.  It  is  very  rarely 
possible  to  judge  what  proportion  of  paralysis,  at  an  early  stage, 
is  dependent  on  actual  destruction  of  the  fibres  of  the  cortico- spinal 
motor  tract  and  what  proportion  is  due  to  temporary  disturbance 
of  their  function.  Ignorance  on  this  point  obtains  equally  in  cases 
of  haemorrhage,  when  it  is  impossible  to  discriminate  between  the 


1 1 82  Hemiplegia. 

direct  effects  of  blood  extravasation  and  the  indirect  effects  of  pressure 
exerted  by  a  clot ;  in  cases  of  thrombosis,  when  the  size  of  the 
blocked  vessel  is  unknown  and  the  opportunities  for  the  establish- 
ment of  compensatory  circulation  therefore  undeterminable ;  in 
cases  of  tumour  or  abscess,  when  the  relief  of  pressure  is  often 
followed  by  intense  but  transient  local  oedema  ;  and  finally  in  cases 
of  encephalitis,  when  the  degree  to  which  the  nervous  elements 
have  suffered  from  inanition  or  intoxication  can  only  be  gauged  by 
careful  observation  over  a  lengthy  period  of  time.  Our  inability 
to  decide  these  questions  on  the  spot  requires  the  adoption  of  a 
reasonably  hopeful  attitude  in  the  majority  of  cases  and  makes  it 
imperative  that  every  available  method  for  facilitating  recovery 
should  be  utilised,  lest  subsequent  improvement  be  hampered  by 
the  neglect  of  this  precaution.  The  correctness  of  this  attitude  is 
constantly  being  illustrated  by  the  gratifying  and  often  unexpectedly 
favourable  results  of  early  and  persevering  treatment  on  appropriate 
lines. 

The  disablement  of  the  limb  in  hemiplegia  is  dependent  partly 
upon  a  diminished  power  of  initiating  voluntary  movements  and 
partly  upon  the  resistance  to  their  being  carried  out  afforded  by  the 
strong  tendency  of  the  different  parts  of  the  limb  to  assume  fixed 
positions.  The  relative  preponderance  of  these  two  factors  varies 
considerably  in  each  case,  and  our  knowledge  of  the  exact  anatomical 
changes  upon  which  this  variation  depends  is  still  incomplete. 
There  is  good  reason,  however,  to  believe  that  the  intelligent  antici- 
pation of  the  tendency  to  rigidity  and  the  adoption  of  methods  to 
prevent  its  supervention  or  modify  its  strength  may  be  attended 
with  a  certain  amount  of  success.  In  the  upper  limb  the  natural 
inclination  towards  adduction  at  the  shoulder,  flexion  and  pronation 
at  the  elbow,  and  flexion  at  the  wrist  and  metacarpo-phalangeal 
joints,  may  be  fought  with  determination  from  the  very  beginning 
by  manipulations  having  an  antagonistic  influence.  Similarly,  in 
the  lower  limb,  flexion  and  adduction  at  the  hip,  extension  at  the 
knee  and  extended  inversion  of  the  ankle  may  be  more  or  less 
effectually  controlled.  Even  if  the  tendency  to  the  hemiplegic 
postures  is  not  completely  overcome,  fixation  by  permanent  con- 
tractures  can  certainly  be  avoided.  The  responsibility  for  avoiding 
contractures,  for  preserving  the  motility  of  joints  and  for  keeping 
up  the  nutrition  of  the  paralysed  muscles,  lies  with  the  medical 
attendant,  who  will  probably  depute  the  actual  manipulation  and 
massage  to  the  nurse.  The  medical  attendant  must  not,  however, 
be  content  with  having  ordered  the  adoption  of  these  methods  for 
overcoming  or  preventing  arthritic  and  muscular  obstructions.  He 


Hemiplegia.  1183 

must  remember  that  a  diminished  power  of  initiating  voluntary 
movements,  due  to  interference  with  the  nervous  tracts  between  the 
cerebral  cortex  and  the  spinal  cord,  is  much  more  serious  than  the 
condition  of  the  muscles  or  joints,  and  that  his  responsibility  for 
dealing  with  this  part  of  the  trouble  is  just  as  weighty  and  infinitely 
more  difficult  to  carry  out  than  ordinary  massage  and  passive 
movements.  In  the  fashionable  desire  to  enlist  the  aid  of  massage 
and  electricity,  the  value  of  which  is  largely  limited  to  their  local 
effects,  the  co-operation  of  the  patient  in  his  own  treatment  is  apt 
to  be  neglected.  A  medical  attendant  on  a  case  of  hemiplegia 
should  not  rest  until  he  has  convinced  his  patient  that  no  amount 
of  massage  or  electricity  or  passive  movements  will  accomplish  much 
unless  they  are  supplemented  by  constant  personal  attempts  to  carry 
out  voluntary  movements.  He  should  point  out  that  there  is 
nothing  wrong  with  the  arm  or  leg,  that  their  paralysis  is  due  to 
blockage  in  the  nervous  paths  leading  to  them,  and  that  the 
patient's  participation  in  treatment  is  needed  for  re-establishing 
communication  between  the  brain  and  the  limb  by  forcing 
impulses  either  through  the  obstruction  or  along  alternative  paths 
which  avoid  it. 

The  neglect  of  taking  the  trouble  to  enlighten  the  patient  on 
this  point  may  have  serious  consequences.  In  his  ignorance  the 
patient  waits,  and  waits  in  vain,  for  massage  to  restore  movement 
to  his  arm,  and  finally,  in  disgust,  seeks  help  in  other  directions. 
Sooner  or  later  he  will  be  induced  to  take  up  physical  exercises  on 
the  ridiculous  plea  that  the  muscles  need  development.  To  his 
gratification  the  power  of  carrying  out  voluntary  movements  now 
begins  to  return,  not  because  the  muscles  become  larger,  but 
because,  unconsciously,  he  has  been  persuaded  to  make  great  efforts 
at  producing  movements  himself  and  has  ceased  to  expect  others 
to  produce  them  for  him.  The  medical  man  is  discredited ;  the 
advertiser  of  some  curative  system  of  exercise  gains  kudos  and 
other  advantages  which  he  has  done  little  to  deserve. 

The  rapidity  with  which  anaesthesia  may  clear  up  under  favour- 
able circumstances,  as  compared  with  the  rate  of  recovery  of 
movement  is  probably  to  be  explained,  in  part  at  least,  by  the  fact 
that  afferent  impulses  originate  in  the  skin,  joints  and  muscles, 
irrespective  of  the  patient's  will,  whereas  efferent  impulses  for 
the  carrying  out  of  movements  must  be  started  voluntarily,  each  one 
involving  a  conscious  effort  on  the  part  of  the  higher  centres. 

Finally,  if  cases  of  hemiplegia  are  studied  with  intelligence  and 
not  all  relegated  without  consideration  into  the  same  category,  the 
observer  will  soon  realise  that  there  are  subtle  differences,  the 


1184  Hemiplegia. 

appreciation  of  which  may  be  turned  to  useful  account  in  treat- 
ment. For  instance,  some  patients  suffer  more  from  spasticity  than 
from  actual  loss  of  power ;  others  remain  flaccid  and  yet  make 
little  use  of  their  apparently  mobile  limbs.  Some  of  the  latter 
patients  undoubtedly  combine  functional  with  organic  disability, 
the  association  being  due  to  concomitant  injury  of  higher  psychic 
centres  and  motor  paths.  In  such  a  case  methods  of  treatment 
must  not  exclude  persuasion,  suggestion  and  other  stimulating 
measures  which  we  are  accustomed  to  employ  in  hysterical  palsies. 
At  the  same  time  it  must  be  remembered  that  flaccid  hemiplegia  is 
not  necessarily  functional  in  character;  the  flaccidity  often  depends 
upon  mid-brain  lesions  of  particular  localisation.  Similarly  the 
power  of  moving  a  limb  and  the  ability  to  apply  the  power  to  some 
useful  purpose  are  not  always  combined.  In  the  condition  known 
as  apraxia  a  patient  may  see  and  feel  and  handle  an  object  and 
yet  may  be  unable  to  use  it  for  the  purpose  for  which  it  was  given 
him.  This  must  not  be  mistaken  for  hysteria. 


SYMPTOMATIC    TREATMENT. 

Paralysis. — Keference  has  already  been  made  to  the  fact  that  it 
is  always  difficult  and  generally  impossible  to  determine  in  the 
early  days  of  hemiplegia  how  far  the  damage  to  tissues  is  temporary 
or  permanent.  In  the  majority  of  cases  nature's  process  of  repair 
will  permit  of  some  return  of  voluntary  power,  and  if  nature  is 
assisted  the  amount  of  recovery  may  be  very  considerable.  As 
soon  as  the  patient's  general  condition  allows  of  attention  to  this 
part  of  his  malady  the  re-education  of  movement  must  be 
started.  It  will  generally  be  advisable  to  pay  most  attention  at 
first  to  those  movements  which  are  least  affected,  that  is  to  say,  to 
movements  which  are  more  automatic  and  less  specialised  than 
others.  The  attendant  must  engage  the  patient's  collaboration  by 
explaining  to  him  the  principles  which  have  already  been  detailed. 
While  passive  movement  is  being  performed  at  each  joint  the 
patient  should  make  every  effort  to  assist  in  the  performance,  and 
special  attention  should  be  given  to  those  movements  which  the 
medical  man  knows  to  be  most  important  in  counteracting  the 
tendency  to  rigidity.  While  in  bed  the  inclination  for  the  leg  to 
assume  a  position  of  internal  rotation  and  adduction,  with  inversion 
of  the  foot,  must  be  pointed  out,  and  movements  of  external 
rotation,  abduction,  etc.,  be  carried  out  daily  in  the  manner 
described.  In  the  same  way  flexion  and  pronation  of  the  forearm 
at  the  elbow  should  be  particularly  counteracted  by  active  and 


Hemiplegia.  1185 

passive  movements  of  an  antagonistic  character.  Thus  the  patient 
will  not  only  be  re-educating  his  power  of  movement  but  will  at 
the  same  time  be  taking  active  measures  against  the  supervention 
of  contractures.  When  the  first  attempts  to  walk  are  being  made 
intelligent  instructions  on  the  part  of  the  attendant  will  prevent 
the  acquisition  of  bad  habits.  If  left  to  himself  the  patient  will 
tend  to  walk  with  an  extended  leg,  which  he  circurnducts  or  swings 
in  order  to  prevent  the  toes  catching  the  ground.  Under  guidance 
he  will  persevere  in  endeavouring  to  acquire  the  power  of  flexion  at 
the  hip  and  ankle  joints,  and  he  will  resist  the  tendency  to  sit  with 
his  affected  leg  adducted  and  internally  rotated,  and  with  his  toes 
pointing  inwards.  Just  as  a  schoolmaster  successfully  anticipates 
wrong  tendencies  and  harmful  influences  in  the  child  committed  to 
his  care,  so  must  the  doctor  be  forewarned  and  forearmed  against 
the  disabling  habits  to  which  every  hemiplegic  patient  is  liable  if 
he  is  allowed  to  proceed  along  the  path  of  least  resistance.  It  is 
unnecessary  to  multiply  instructions  under  this  heading;  if  the 
principles  are  understood  the  details  can  easily  be  supplied,  and 
hemiplegia  is  too  common  a  condition  for  any  medical  man  to  plead 
ignorance  of  its  special  features.  The  chief  difficulties  present  them- 
selves when  the  attempt  is  made  to  re-educate  the  hand  to  perform 
delicate  actions.  Unless  the  patient  is  thoroughly  convinced  of  the 
necessity  for  perseverance  he  will  easily  become  resigned  to  the 
habitual  use  of  the  sound  hand  for  all  finer  manipulations.  This 
resignation  should  not  be  permitted  unless  the  lapse  of  time  and 
the  failure  of  prolonged  and  genuine  efforts  have  demonstrated 
the  hopelessness  of  looking  for  further  recovery.  Ingenuity  on 
the  part  of  the  medical  attendant  in  devising  occupations  and 
games  which  necessitate  or  encourage  the  use  of  the  clumsy  fingers 
will  go  far  towards  attaining  success,  if  success  is  attainable.  A 
game  of  draughts  or  even  of  solitaire  may  have  uses  of  which  the 
inventor  never  dreamed,  and  knitting  may  add  to  its  many  virtues 
as  a  recreation. 

Having  once  regained  a  movement  efforts  must  be  directed 
towards  increasing  the  power  and  precision  with  which  it  can  be 
made,  both  by  daily  repetition  and  by  its  performance  against 
graduated  resistance  offered  by  the  attendant  or  nurse.  Dumb 
piano  keys  and  miniature  staircases  are  among  the  mechanical 
contrivances  which  may  help  and  amuse  the  patient  without  causing 
annoyance  to  his  neighbours.  In  learning  to  walk  the  support  of 
a  companion  is  to  be  preferred  to  that  of  a  stick  or  crutch,  because 
the  former  can  inspire  more  confidence  while  rendering  less 
assistance. 

S.T. — VOL.  ii.  75 


1 1 86  Hemiplegia. 

When  loss  of  power  is  largely  of  a  functional  nature  much  can 
be  done  by  encouragement  and  suggestion,  and  the  latter  method  of 
treatment  is  often  facilitated  by  the  employment  of  some  form 
of  electricity,  especially  faradism,  through  the  medium  of  the 
wire  brush. 

Spasticity. — It  is  unfortunate  that  authoritative  text-books  are 
to  be  found  which  suggest  that  faradism,  massage  and  exercises, 
should  be  begun  several  weeks  after  the  onset  of  hemiplegia  and 
which  omit  to  mention  the  most  important  prophylactic  measures 
belonging  to  the  intervening  period.  Whatever  the  proper 
scientific  explanation  of  this  spasticity  may  be  there  is  ample  proof, 
both  from  clinical  and  experimental  experience,  that  it  is  promoted 
by  prolonged  immobility  and  retarded  by  passive  movements  of 
limbs  and  frequent  changes  of  position.  If  serious  spasticity  is  to 
be  avoided,  therefore,  the  early  days  of  the  disease  must  not  be 
wasted.  Granted  that  there  are  cases  in  which  the  practice  of 
faradism  and  attempts  at  active  movements  are  clearly  contra- 
indicated  by  other  considerations  for  some  weeks,  it  must  be  very 
rare  that  careful  attention  to  the  position  of  limbs  and  the  daily 
performance  of  passive  movements  with  perhaps  a  little  gentle 
massage  can  be  anything  but  beneficial  to  the  patient.  Even  the 
period  of  unconsciousness  which  so  often  follows  an  apoplectic 
attack  is  not  one  during  which  the  limbs  may  be  left  to  assume 
any  sort  of  attitude,  especially  as  that  attitude  is  almost  certain  to 
include  close  adduction  of  the  arm  to  the  side  of  the  trunk  and 
pronated  flexion  of  the  forearm  across  the  chest. 

Two  principles  are  of  paramount  importance ;  in  the  first  place, 
neither  the  arm  nor  the  leg  should  be  allowed  to  lie  undisturbed  for 
long  in  any  position.  In  the  second  place,  during  periods  of  sleep 
and  rest,  care  should  be  taken  that  the  position  of  the  limbs  is  the 
opposite  of  that  to  which  they  are  naturally  inclined.  A  pillow 
placed  in  the  axilla  will  prevent  extreme  adduction  ;  a  ball  placed 
in  the  hand  will  not  allow  the  latter  to  close ;  sand-bags  can 
correct  the  adduction  and  internal  rotation  of  the  leg ;  a  felt 
slipper  on  the  foot  with  stays  drawing  the  toes  towards  the  knee 
may  do  much  to  obviate  permanent  and  rigid  plantar  extension  at 
the  ankle. 

Such  precautions  combined  with  daily  passive  manipulation  of 
all  joints  will  do  much  to  counteract  the  spastic  tendency,  but 
there  are  cases  in  which  such  simple  measures  have  failed  or  in 
which  none  have  been  carried  out  in  the  early  months  after  the 
onset  of  hemiplegia.  Under  these  circumstances  it  may  become 
necessary  to  adopt  other  means  than  passive  movements,  massage, 


Hemiplegia.  1187 

etc.  Galvanism  is  often  recommended  but  is  of  little  assistance 
in  the  more  severe  cases.  Drugs,  such  as  belladonna,  ergot  and 
veronal,  are  sometimes  useful  in  modifying  the  involuntary  and 
painful  spasms  of  the  muscles,  but  cannot  be  said  to  effect  any 
marked  alteration  in  the  permanent  degree  of  spasticity.  Within 
recent  years  other  procedures  have  been  suggested,  some  of  which 
deserve  further  trial.  Based  on  the  theory  that  spasticity  is  to  some 
extent  maintained  by  peripheral  stimuli  originating  in  the  skin, 
joints  and  muscles,  division  of  the  posterior  spinal  roots  in  connec- 
tion with  the  spastic  limb  has  been  carried  out.  If  only  alternate 
roots  are  divided  the  actual  sensory  loss  is  not  great  and  the 
diminution  of  peripheral  stimuli  thus  brought  about  is  sufficient 
to  reduce  the  spasticity. 

Another  method  which  depends  upon  the  production  of  temporary 
paralysis  of  the  more  spastic  muscles,  being  simpler,  may  prove 
more  acceptable.  In  the  common  spastic  flexion  of  the  fingers 
which  completely  destroys  the  patient's  manual  dexterity  the 
flexors  of  the  fingers  may  be  temporarily  put  out  of  action  by 
exposing  the  median  nerve  and  injecting  alcohol  into  its  sheath. 
If  60  or  70  per  cent,  alcohol  is  used  the  paralysis  will  pass  off  in  a 
few  weeks  or  months,  and  in  the  meantime  every  effort  may  be 
made  to  re-establish  the  activity  of  the  extensors  so  that  they  may 
ultimately  be  able  to  hold  their  own  in  carrying  out  manual  move- 
ments. Sufficient  experience  of  these  more  modern  methods  has 
not  yet  been  collected,  but  the  alcoholic  injection  procedure  is  both 
promising  and  suggestive.  To  know  what  not  to  do  is  also 
important.  When  spasm  reigns  supreme,  energetic  massage  and 
strong  electric  currents  only  tend  to  make  matters  worse,  and  the 
administration  of  strychnine  is  not  likely  to  influence  favourably  a 
condition  which  is  partly  reflex  in  origin. 

Contractures. — Permanent  shortening  of  muscles  and  tendons 
ought  not  to  be  allowed  to  occur.  If  it  is  present  gradual  passive 
stretching  may  correct  a  moderate  degree  of  contracture,  but  in 
more  severe  cases  division  or  lengthening  of  certain  tendons  is 
clearly  indicated.  Subsequently  gentle  massage  and  faradism  of  the 
muscles  will  be  necessary  to  sustain  their  proper  function. 

Arthritic  Adhesions. — These  are  common  enough,  especially 
in  the  shoulders.  Early  precautions  on  the  lines  indicated  above 
should  prevent  their  occurrence.  They  must  be  broken  down  by 
daily  passive  movements  or  at  one  sitting  under  an  anaesthetic, 
when  they  are  found  to  be  limiting  the  mobility  of  a  joint. 

Muscular  Atrophy. — A  moderate  amount  of  wasting  is  frequent 
in  the  muscles  of  hemiplegic  limbs  when  the  condition  is  of  long 

75—2 


1 1 88  Hemiplegia. 

standing.  In  exceptional  cases  rapid  muscular  atrophy  supervenes 
in  the  early  stages.  This  is  difficult  to  explain,  although  it  has 
been  shown  that  secondary  degeneration  of  the  peripheral  neurones 
may  sometimes  take  place.  Massage  and  faradism  are  necessary 
for  the  restoration  of  the  muscular  nutrition  and  when  the  latter 
is  threatened  should  be  at  once  employed.  The  reaction  of 
degeneration  is  rarely  met  with  in  these  muscles ;  should  it  be 
present  galvanism  must  replace  the  faradic  current  in  treatment. 

Ataxia.— In  some  cases  of  herniplegia  the  recovery  of  voluntary 
movement  in  the  arm  may  be  remarkably  good  and  yet  the  useful- 
ness of  the  limb  be  diminished  by  a  considerable  degree  of  loss  of 
sense  of  position  and  of  the  power  of  recognising  objects  placed  in 
the  hand  (astereognosis) .  This  condition  may  be  present  when 
tactile  sensibility  is  perfectly  preserved.  It  is  important  not  to 
regard  this  as  a  sign  of  hysteria  and  it  is  equally  important  to  try 
and  restore  the  lost  sense  by  the  practice  of  exercises  on  the 
Fraenkel  system.  A  definite  period  of  time  should  be  allotted 
daily  to  carrying  out  manipulations  with  the  affected  hand  (under 
supervision  to  begin  with),  manipulations  which  are  carefully 
graduated  in  respect  to  their  delicacy  and  difficulty.  Thus,  a 
patient  may  commence  by  building  houses  with  bricks  and  end  by 
building  houses  with  cards,  by  which  time  he  will  be  ready  to  pass 
on  to  the  finer  arts  of  writing  and  sewing.  By  these  means  he  will 
be  doing  something  to  re-educate  his  sense  of  position,  of  shape 
and  of  size. 

Involuntary  Movements. — A  few  hemiplegic  patients  suffer 
from  involuntary  movements  of  the  affected  limbs,  movements 
which  are  sometimes  tremulous,  sometimes  choreiform  and  some- 
times athetotic.  In  all  probability  their  presence  indicates  a  lesion 
of  some  definite  structure  in  the  region  of  the  basal  ganglia  and 
has  little  or  nothing  to  do  with  involvement  of  the  pyramidal  tract. 
Such  movements  are  difficult  to  deal  with.  The  restoration  of 
complete  control  over  movement  by  the  motor  cortical  centres  is 
most  likely  to  bring  about  their  cessation,  and  the  means  of 
promoting  that  control  have  already  been  amply  described. 

Pain. — Hemiplegia  may  be  a  painless  condition  throughout  its 
course ;  more  commonly  it  is  associated  with  aches  and  pains  of 
different  degrees  of  severity  and  of  varying  origin.  They  may  be 
classified  under  three  heads  :  (1)  Pain  due  to  arthritic  adhesions 
especially  in  the  shoulder-joint.  This  pain  is  naturally  evolved 
by  movement  and  must  be  treated  by  breaking  or  stretching  the 
adhesions  and  the  application  of  local  heat.  (2)  Rheumatic  or 
osteo-arthritic  pain.  The  normal  resistance  to  morbid  processes 


Hemiplegia.  1189 

appears  to  be  lowered  on  the  hemiplegic  side  of  the  patient  and  he 
is  particularly  liable  to  suffer  from  chronic  muscular  rheumatism 
and  chronic  arthritis  in  the  affected  limbs.  These  must  be  treated 
on  ordinary  lines,  such  as  the  administration  of  salicylates,  iodides 
or  guaiacol,  gentle  massage  and  hot  air  baths.  (3)  Pain  of  central 
origin  :  In  some  cases  of  hemiplegia  in  which  there  is  an  extension 
of  the  lesion  into  the  optic  thalamus,  the  patient  is  liable  to  constant 
aching  pain  over  the  whole  of  the  paralysed  limbs  with  paroxysmal 
exacerbations  of  great  severity.  When  this  condition  is  present  it 
is  usual  to  find  that  ordinary  stimuli  of  heat,  cold,  scratching  and 
tickling  may  be  extraordinarily  disagreeable  to  the  sufferer  and  that 
the  pain  they  elicit  is  not  limited  to  the  site  of  stimulation  but 
spreads  widely  in  different  directions.  Therapeutic  measures  are 
peculiarly  ineffective  in  dealing  with  this  variety  of  pain  and  even 
morphia  is  often  powerless  to  control  the  more  severe  paroxysms. 
The  patient  must  be  guarded  against  exposure  to  the  offending 
stimuli,  must  avoid  draughts  and  direct  contact  with  cold  or  hot 
water.  He  soon  learns  to  abstain  from  touching  metal  or  other 
substances  which  give  rise  to  chilly  sensations.  The  continuous 
administration  of  bromides  may  diminish,  although  it  does  not 
abolish,  this  distressing  symptom. 

Vasomotor  Disturbance. — The  paralysed  limb  is  often  the  seat 
of  vasomotor  disturbance  in  the  form  of  cyanosis  or  oedema.  This 
liability  must  be  fought  by  taking  care  that  the  limb  is  warmly 
wrapped  up  in  cotton-wool  or  flannel  garments,  by  frequent  change 
of  position,  by  gentle  massage  and,  if  necessary,  by  the  local  appli- 
cation of  heat.  Such  precautions  are  necessary  not  only  for  the 
patient's  comfort  but  because  their  neglect  leads  to  malnutrition 
of  the  arm  or  leg  and  to  an  increase  in  their  spasticity.  It  is  well 
recognised  •  by  the  patient  that  rigidity  is  worse  in  cold  than  in 
warm  weather,  and  that  when  a  spastic  hand  or  foot  has  been  well 
warmed  in  a  hot  bath  more  movements  are  possible  than  at  other 
times. 

Length  of  Treatment. — Speaking  generally,  the  treatment  of 
hemiplegia  should  be  persevered  with  during  a  period  of  at  least 
eighteen  months,  and  in  cases  in  which  improvement  is  still  taking 
place  for  as  long  as  this  continues.  When  no  movement  is 
possible  in  a  hand  after  eighteen  months  of  adequate  treatment,  it  is 
generally  useless  to  expect  recovery  and  the  medical  attendant  must 
be  content  if  he  has  by  this  time  succeeded  in  making  his  patient 
resigned  to  his  loss  and  in  making  the  disabled  limb  as  free  from 
discomfort  and  as  little  in  the  way  as  possible.  Under  these 
circumstances,  if  the  patient  is  in  a  position  to  afford  it,  a  course  of 


1190  Hernia  Cerebri. 

baths  combined  with  massage  at  places  such  as  Gastein,  Ragatz, 
Harrogate  or  Teplitz,  may  be  recommended.  The  change  of  sur- 
roundings, the  mental  recreation  it  promotes,  and  the  outdoor  life 
will  do  as  much  as  anything  can  to  mitigate  the  natural  feeling  of 
misery  induced  by  impaired  activity. 

E.   FARQUHAR   BUZZARD. 


HERNIA   CEREBRI. 

WHEN  this  condition  results  from  a  septic  wound  such  as  a  com- 
pound depressed  fracture,  the  application  of  firm  pressure  by  means 
of  bandages  over  a  dry  dressing  is  sometimes  of  value.  The  local 
application  of  astringents  such  as  alcohol,  alcoholic  solution  of 
tannic  acid  or  zinc  perhydrol,  by  causing  shrinkage  of  the  swelling 
may  also  be  of  assistance.  When  the  condition  is  the  result  of 
trephining  for  the  relief  of  intracranial  pressure  due  to  a  cerebral 
tumour,  no  treatment  is  possible. 

C.  H.  S.  FRANKAU. 


1 191 


HYDROCEPHALUS. 

HYDROCEPHALUS  (that  is,  internal  hydrocephalus,  for  true 
external  hydrocephalus  is  a  rarity)  is  to  be  regarded  as  a  clinical 
symptom  which  may  arise  in  the  course  of  many  differing 
pathological  processes.  It  is  undesirable  to  speak  of  primary  or 
idiopathic  hydrocephalus,  although  the  term  "  congenital  hydro- 
cephalus "  may  be  retained  to  denote  that  variety  which  dates  from 
birth  and  is  associated  with  encephalic  malformations.  So-called 
secondary  hydrocephalus,  produced  mechanically  or  by  irritation 
of  the  pia  or  ependyma,  may  result  from  the  presence  of  tumours 
(abscesses,  caseous  nodules,  parasites)  in  various  situations  (basal, 
mesencephalic,  pituitary,  cerebellar,  pineal,  etc.),  or  may  be 
associated  with  meningeal  or  vascular  conditions  (acute  serous, 
tuberculous,  or  suppurative  meningitis,  epidemic  cerebro-spinal 
meningitis,  venous  sinus  thrombosis,  ependymitis  (serous  or  non- 
suppurative),  etc.,  and  if  the  underlying  condition  is  recognised, 
treatment  must  be  directed  to  it  as  well  as  to  the  relief  of  the 
symptom  that  is  its  expression  (see  under  the  respective  articles). 

Confining  ourselves  in  this  paragraph  to  the  symptomatic 
treatment  of  hydrocephalus,  we  may  begin  with  the  congenital 
variety. 

(1)  Medicinal   Treatment    is,  generally  speaking,  completely 
inefficacious.      Anti-syphilitic    procedures    have   frequently   been 
adopted,  empirically,  but  as  a  rule  without  avail. 

(2)  Lumbar  or  Cranial  Puncture,  the  latter  via  the  anterior 
fontanelle  or  to  one  or  other  side  of  the  sagittal  suture,  has  found 
many  advocates,  and  while  the  general  consensus  of   opinion  in 
this  country  seems  to   be  that  both  methods  are  uncertain  and 
unsatisfactory,  excellent  results  appear  to  have  been  obtained  by 
some  (Grober,  Quincke).     It  is  clear  that  only  certain   types   of 
hydrocephalus  can  possibly  benefit  by  repeated  lumbar  punctures. 

(8)  Various  drainage  devices  have  been  tried  and,  as  a  rule,  have 
been  found  wanting.  Drainage  by  means  of  portions  of  saphenous 
veins  into  the  superior  longitudinal  sinus  (Payr),  direct  intra- 
ventricular  drainage,  subcutaneous  drainage  from  the  ventricles  to 
beneath  sutured  pericranial  integuments  (Miculicz),  peritoneal 
drainage  from  the  spinal  theca  (Gushing)  may  be  mentioned.  As 
Gushing  truly  observes,  "  whatever  method  is  used  it  is  necessary 


1 1 92  Hydrocephalus. 

to  determine  first  of  all  where  the  obstruction  has  taken  place," 
otherwise  failure  is  almost  inevitable.  Yet  the  determination  of 
the  site  of  the  obstruction  may  be  peculiarly  difficult.  Occasionally 
good  results  appear  to  have  ensued.  Bruce  and  Cotterill,  of 
Edinburgh,  have  reported  a  case  where  cure  followed  reopening  of 
the  thickened  roof  of  the  fourth  ventricle  and  drainage. 

Even  though  only  palliative  results  follow  in  carefully  chosen 
cases,  punctures  should  be  tried  and  repeated,  and  where  an  exact 
local  diagnosis  has  been  made  some  form  of  surgical  interference 
may  be  adopted,  although  Auvray  counsels  abstention  as  perhaps 
preferable. 

S.   A.    KINNIER    WILSON. 

REFERENCES. 

Gushing,  H.,  article  "Hydrocephalus"  in  "Osier  and  Macrae's  System  of 
Medicine,"  Oxford,  1910,  VII.,  p.  459. 

Auvray,  Maladies  du  crane  et  de  I'encephale  (Le  Dentu  et  Delbet,  Nouveau 
Trait6  de  Chirurgie,  Tome  XIII.),  Paris,  1909,  p.  482. 

Bruce  and  Cotterill,  Edinburgh  Med.-Chir.  Soc.,  1911,  N.  S.  XXX.  3. 


193 


SURGICAL   TREATMENT   OF   HYDROCEPHALUS. 

MANY  surgical  methods  of  treating  hydrocephalus  have  been 
devised ;  but,  as  the  pathology  of  this  condition  is  somewhat  obscure, 
and  the  cause  when  known  is  irremovable,  their  success  has  not 
been  great.  The  following  operation  has  in  the  writer's  experience 
prevented  increase  in  the  size  of  the  head,  and  is  attended  with 
very  little,  if  any,  risk  to  the  patient  from  the  operative  procedure 
itself. 

Operation. — A  sharp  pedicle  needle,  with  a  good  curve,  is 
threaded  with  No.  12  plaited  silk,  both  having  been  carefully 
sterilised.  The  thread  when  doubled  is  at  least  thirty  inches  long. 
The  head  is  shaved  and  made  thoroughly  aseptic.  A  spot  about 
one  inch  to  one  side  of  the  middle  line  is  chosen  as  near  the 
posterior  part  of  the  anterior  fontanelle  as  possible.  With  a 
tenotome  make  a  tiny  incision  through  the  skin  in  this  position. 
Push  the  threaded  needle  into  the  lateral  ventricle,  curve  it  through 
the  falx  cerebri  into  the  opposite  ventricle,  and  bring  it  through 
the  skin  in  a  corresponding  position  on  the  other  side  of  the  middle 
line.  Withdraw  the  pedicle  needle,  leaving  the  silk  in  situ. 

Thread  the  double  silk  of  one  side  on  to  a  long  probe  and  push 
the  probe  beneath  the  skin  backwards  into  the  nape  of  the  neck. 
Do  the  same  with  the  silk  on  the  other  side.  Cut  off  the  super- 
fluous silk  and  put  a  stitch  into  the  small  wounds  that  have  been 
made  in  order  to  introduce  the  probe  and  the  silk  it  carries  beneath 
the  skin. 

The  procedure  is  the  same  as  in  the  operation  for  lymphangio- 
plastry  as  described  by  Sampson  Handley.  The  doubled  silk  now 
connects  both  ventricles  with  each  other  and  with  the  connective 
tissue  of  the  neck.  As  regards  limiting  the  distension  of  the 
ventricles  the  results  of  this  operation  have  been  most  encouraging. 

H.   S.   PENDLEBURY. 


1 194 


CRANIAL    MENINGOCELE. 

IN  the  majority  of  cases  of  meningocele  in  which  the  child  sur- 
vives birth  no  operative  interference  is  indicated  in  the  first  instance. 
The  swelling  should  be  carefully  protected  from  injury  and  pressure 
which  are  likely  to  produce  ulceration  of  the  skin,  and  operation 
should  be  postponed  with  the  hope  that  with  the  growth  of  the 
cranial  bones  the  opening  into  the  meningocele  may  be  obliterated 
or  greatly  contracted.  When  operation  is  decided  upon  the  sac  is 
exposed  by  a  suitable  incision  and  its  base  is  isolated  as  far  as 
possible  ;  if  there  is  a  definite  pedicle,  this  is  ligatured  with  stout 
catgut ;  if  the  attached  base  is  broad,  the  meningocele  should  be 
cut  away  near  the  base,  but  enough  of  the  membrane  on  either 
side  should  be  left  to  allow  the  edges  to  be  united  by  catgut  sutures. 
Care  should  be  taken  to  avoid  the  sudden  escape  of  a  large  amount 
of  cerebro-spinal  fluid,  as  this  may  produce  profound  shock  or  even 
death.  If  a  considerable  opening  persists  in  the  skull,  it  is  advisable 
to  attempt  to  close  it  either  by  the  means  of  pericranial  flaps  or  by 
some  osteoplastic  operation. 

Operation  is  contra-indicated  when  the  swelling  is  very  large  and 
pulsates  freely,  and  also  when  the  skin  is  greatly  thinned  or 
ulcerated. 

C.  H.  S.  FRANKAU. 


PARAPLEGIA. 

PARAPLEGIA,  by  which  term  is  signified  paresis  or  paralysis  of  the 
lower  extremities,  is  a  symptom  that  may  be  occasioned  by  a 
multitude  of  differing  pathological  conditions.  A  consideration  of 
its  treatment  must  be  prefaced  with  some  remarks  on  its 
pathogeny  and  clinical  varieties,  since  on  a  knowledge  of  these 
depends  a  rational  therapeusis. 

The  customary  division  of  paraplegia  into  "  spastic "  and 
"  flaccid,"  terms  which  explain  themselves  sufficiently,  is  useful 
if  not  always  practical ;  spastic  cases  may  become  flaccid,  a  change 
rightly  regarded  as  serious  from  the  point  of  view  of  prognosis ; 
flaccid  limbs  may  become  spastic,  or  they  may  become  con- 
tractured,  the  latter  a  condition  of  rigidity  not  to  be  confused  with 
true  spasticifcy.  Many  cases  of  paraplegia  are  not  characterised 
by  any  special  degree  of  either  condition.  Nevertheless,  the 
distinction  is  one  that  is  sanctioned  by  clinical  usage  and  by  the 
fact  that  the  general  lines  of  treatment  vary  accordingly. 

Paraplegia  is  said  to  be  either  organic  or  functional  in  origin, 
but  therapeutically  the  distinction  is  of  comparatively  little  value, 
unless  "  funcbional  "  be  held  synonymous  with  "  hysterical,"  which 
it  is  not ;  moreover,  organic  disease  always  reveals  itself  by  a 
disturbance  of  function,  and  the  earliest  symptoms  of  an  organic 
paraplegia  are  not  infrequently  "  functional."  On  every  ground, 
therefore,  it  is  preferable  to  speak  of  "  hysterical  paraplegia  "  (see 
Hysteria),  and  to  discard  the  term  "functional  paraplegia" 
altogether. 

Organic  paraplegia  may  be  cerebral,  spinal  or  cerebro-spinal  in 
origin. 

Paraplegia  of  Cerebral  Causation. — This  is  usually,  though 
not  necessarily,  spastic  in  type.  It  may  be  the  sequel  to  meningitis, 
encephalitis,  tumour  growths  (cerebellar,  pontine,  basal  near  the 
mid  line,  etc.),  vascular  softening  or  haemorrhage,  chronic  hydro- 
cephalus  from  any  cause,  bilateral  cerebellar  lesions  (not  a  true 
paraplegia) ;  it  is  a  symptom  in  Little's  disease,  cerebral  diplegia, 
double  hemiplegia ;  senile  paraplegia,  characterised  by  the  demarche 
a  petits  pas  (short,  shuffling  steps,  one  foot  scarcely  passing  the 
other),  is  commonly  due  to  bilateral  vascular  lesions  in  the  basal 
ganglia. 


1196  Paraplegia. 

Paraplegia  of  Spinal  Origin. — This  may  be  the  result  of 
pathological  changes  inside  or  outside  the  spinal  cord.  Involve- 
ment of  the  pyramidal  paths  usually  produces  a  spastic  paraplegia ; 
invasion  of  the  anterior  horns  a  flaccid  paraplegia,  coupled  with 
muscular  wasting ;  combinations  of  the  two  types  are  of  frequent 
occurrence.  All  spinal  lesions  below  the  lower  part  of  the  lumbar 
enlargement  tend  to  produce  a  flaccid  paraplegia  ;  lesions  higher 
up  may  be  characterised  by  flaccidity  at  the  level  of  the  lesion  and 
spasticity  below  ;  any  spinal  paraplegia  may  be  complicated  by 
sensory,  sphincter,  or  trophic  symptoms. 

(1)  Endogenous. — We  may  expect  paraplegia  from  any  of  the 
numerous  varieties  of   myelitis,  meningo -myelitis  or  meningitis  ; 
in   any   form  of  spinal  vascular  disease,  myelomalacia,  hsemato- 
myelia  ;     in    meiopragia    from    disease    of    spinal    blood-vessels 
(insufficient     vascularisation)  ;     in    any    toxic,    toxi-infective    or 
infective  condition — syphilis,  para-syphilis,  lead,  pellagra,  lathy- 
rism,     poliomyelitis,    Landry's     paralysis,      subacute     combined 
degeneration ;  in  intramedullary  or  intrathecal  tumours  (abscess, 
cyst,  parasites),  syringomyelia,  hydromyelia,  Eriedreich's  disease  ; 
from  traumatisms  of  any  sort,  commotio  spinalis,  caisson  disease ; 
in  certain  familial  diseases,  family  spastic  paralysis,  family  periodic 
paralysis ;   in   progressive   muscular   atrophy,   peroneal   muscular 
atrophy. 

(2)  Exogenous. — The      commonest     causes     of     paraplegia     of 
extrinsic   origin  are  extrathecal  tumours  of  any   sort,  malignant 
disease  of  the  vertebrae,  Pott's  disease  of  the  vertebrae,  caries  sicca 
senilis,  fracture  dislocation  of  the  spinal  column,  laminal  fractures, 
sometimes  associated  with  hasmatorrhachis. 

Paraplegia  of  Cerebro-spinal  Origin. — This  is  seen  in  dis- 
seminated sclerosis,  cerebro-s'pinal  syphilis,  amyotrophic  lateral 
sclerosis,  cerebro- spinal  meningitis. 

No  reference  in  made  here  to  the  numerous  varieties  of 
peripheral  nerve  lesion,  which,  if  its  incidence  is  on  the  lower 
extremities,  will  cause  paraplegia. 

The  multiplicity  of  etiological  factors  in  the  causation  of  para- 
plegia renders  the  bare  diagnosis  of  "  paraplegia  "  as  inadequate 
as  a  diagnosis  of  "  cough,"  although  in  the  early  stages  the 
determination  of  the  nature  of  a  particular  case  may  be  difficult, 
if  not  impossible.  For  a  consideration  of  treatment  directed  to 
the  cause,  the  reader  is  referred  to  the  articles  on  the  various 
conditions  enumerated  above.  In  this  article  attention  is  directed 
solely  to  the  symptomatic  treatment  of  paraplegia  (see  also  Hemi- 
plegia  and  Myelitis). 


Paraplegia.  1197 

Spastic  Paralysis. — Speaking  generally,  no  known  medica- 
ment will  per  se  reduce  spasticity.  A  combination  of  ergot  and 
belladonna  in  pill  may  be  tried.  Involuntary  flexor  (more  rarely 
extensor)  spasms  of  the  legs,  occurring  chiefly  at  night  and  some- 
times with  great  persistence,  may  be  successfully  combated  by 
the  administration  of  veronal  (5  to  10  gr.),  as  an  an ti- spasmodic, 
not  as  a  hypnotic.  The  bromides,  hyoscine  hydrobromide,  and 
other  accepted  nerve  sedatives,  may  on  occasion  prove  useful. 
Sometimes  all  that  is  necessary  is  to  arrange  a  drawsheet  firmly 
and  securely  over  the  legs,  drawing  it  tightly  just  above  the  knees. 
Occasionally  mechanical  extension  with  weights  is  of  service  in 
this  connection  ;  it  has  also  been  used  to  obviate  the  development 
of  contractures.  For  this  purpose,  however,  passive  movements 
are  more  efficacious ;  they  also  prevent  the  formation  of  adhesions. 
Electrical  treatment,  whatever  be  the  form  employed,  is  inadvis- 
able, as  it  only  serves  to  increase  the  tone  of  muscles  already  hyper- 
tonic.  Massage,  likewise,  is  uncalled  for,  except  where  the  trophic 
and  nutritional  condition  of  the  lower  extremities  is  impaired. 
Sometimes  the  reflex  excitability  of  the  legs  is  so  great  that  merely 
handling  the  limbs,  or  touching  or  otherwise  stimulating  the  skin, 
is  sufficient  to  produce  involuntary  movements  :  hence  it  may  be 
useful  to  keep  the  bedclothes  off  the  patient's  limbs  by  a  cradle. 

In  chronic  cases,  where  there  is  reason  to  believe  that  the 
central  lesion  is  stationary,  suitable  tenotomy  or  myotomy 
(division  of  plantar  fascia,  tendo  Achillis,  hamstrings)  may  over- 
come the  vicious  positions  that  result  from  contractures,  and  often 
is  of  the  utmost  value  in  restoring  the  power  of  walking  in  a 
serviceable  manner  to  the  patient.  Recently,  Fb'rster  has  strongly 
advocated  division  of  certain  posterior  spinal  roots  for  a  like 
purpose,  only,  however,  to  counteract  true  paralytic  contractures, 
and  not  where  the  vicious  position  is  due  to  tendinous  or 
ligamentous  retractions.  For  the  plantar  flexors  he  divides  the 
second  sacral  roots ;  for  the  extensors  of  the  leg  the  third  and 
fourth  lumbar ;  for  the  adductors  of  the  thigh  the  second  and  third 
lumbar.  Good  results  have  been  reported  in  a  number  of  instances. 
Flaccid  Paralysis. — Strychnine  is  supposed  to  be  our  thera- 
peutic mainstay  in  flaccid  paraplegia,  but  it  is  not  unreasonable 
to  ask  whether  it  has  not  become  a  therapeutic  fetish.  Where 
there  are  distinct  central  anatomical  lesions  its  value  is  problema- 
tical. As  a  "  general  nerve  tonic  "  in  asthenic  cases,  however — 
and  many  paraplegics  are  debilitated  apart  from  the  local  lesion — 
it  is,  perhaps,  worthy  of  a  place  in  the  physician's  armamentarium. 
Other  general  nerve  tonics,  arsenic,  glycerophosphates,  byno- 


1198  Paraplegia. 

glycerophosphates,  lecithin,  phosphoric  acid,  cannabis  indica,  zinc 
valerianate,  etc.,  may  prove  helpful  for  a  similar  reason. 

Massage  and  electricity  are,  in  many  cases,  invaluable.  Massage 
definitely  aids  paralysed  muscles  to  regain  their  power  as  the  cause 
of  the  paralysis  passes  off.  Either  the  interrupted  or  the  constant 
current  may  be  utilised,  and  it  is  a  good  plan  to  place  the 
indifferent  electrode  over  the  spinal  column  above  the  level  of  the 
lesion,  so  as  to  include  the  latter  in  the  electrolytic  circuit.  The 
constant  current  should  be  employed  if  no  faradic  response  is 
obtainable,  except  with  a  current  so  strong  as  to  be  painful. 
Electrical  treatment  should  be  persevered  with,  although  the 
muscular  contractions  evoked  are  very  small  and  feeble,  but  its  use, 
after  all  local  muscular  response  fails,  is  questionable.  Galvanic 
or  faradic  baths  are  often  the  most  suitable  way  to  administer  treat- 
ment, the  former  especially  with  children. 

The  physician  should  always  guard  against  unnecessary  aggra- 
vation of  the  condition  of  the  legs  through  the  weight  of  the 
bedclothes,  or  otherwise,  by  giving  every  support  he  can  to  the 
limbs.  If  the  feet  drop  they  should  be  kept  at  right  angles  to  the 
leg  by  sand-bags ;  in  recovering  cases,  Gower's  boots  may  be  very 
serviceable.  These  are  leather  cases  enclosing  the  limb  to  below  or 
above  the  knee,  laced  in  front  and  fitted  with  elastic  straps,  tension 
on  which,  continued  for  hours  at  a  time,  if  need  be,  will  bring  the 
foot  or  the  leg  to  the  desired  position. 

Graduated  exercises  should  be  complementary  to  massage.  The 
patient  should  always  be  encouraged  to  make  innervating  efforts, 
though  no  visible  result  ensue.  It  is,  perhaps,  not  sufficiently 
realised  that,  as  was  pointed  out  by  von  Leyden,  a  patient  may  be 
able  to  make  movements  of  the  limbs  under  water,  which  he  is 
unable  to  execute  in  bed.  In  recovering  cases,  therefore,  where 
disuse  of  the  limbs  is  a  barrier  in  the  way  of  improvement,  he 
should  have  the  opportunity  of  making  the  first  attempts  in  this 
way.  The  weight  of  the  limb  may  be  such  as  to  prevent,  say, 
voluntary  flexion  at  the  hip,  but  with  the  support  of  the  water, 
the  movement  may  become  possible. 

In  chronic  cases,  all  lesional  activity  having  ceased,  various 
orthopaedic  devices  may  sometimes  become  desirable — musculo- 
tendinous  transplantations,  nerve-grafting,  subperiosteal  grafts  to 
supplement  paralysed  muscles  by  sound  ones,  arthrodesis  for 
flail-like  joints,  etc.  Each  case,  needless  to  say,  must  be  con- 
sidered on  its  own  merits. 

Eadiotherapy  for  certain  paraplegias  is  still  in  the  experimental 
stage. 


Paraplegia.  1 199 

Genito-urinary  and  Rectal  Symptoms.  —  The  comfort  or 
discomfort  of  a  paraplegic  patient  depends  greatly  on  the  condition 
of  his  organic  reflexes. 

Eetention  cases  must  be  catheterised  two,  three  or  four  times, 
or  oftener,  in  the  twenty-four  hours,  as  the  case  may  be,  and 
irrigation  should  follow  as  a  routine  practice.  No  drug  is  known 
to  exercise  a  specific  action  on  the  condition,  but  helmitol, 
urotropin,  ammonium  benzoate,  etc.,  are  serviceable  in  preventing 
improper  fermentations. 

Incontinence  of  urine  may  sometimes  be  ameliorated  by  the 
administration  of  atropine  or  belladonna  ;  often,  unfortunately, 
these  fail  entirely.  In  male  patients  rubber  urinals  can  be  fixed 
with  comparative  ease ;  similar  arrangements  are  less  satisfactory 
in  the  case  of  the  other  sex.  A  good  and  practical  plan  is  the 
employment  of  an  ordinary  sponge  bag  -with  tapes  and  cotton- 
wool. 

Where  rectal  control  is  defective  simple  enemata  are  preferred  to 
aperients. 

Rarely,  priapism  is  a  distressing  symptom.  Camphor  mono- 
bromate  (5  gr.),  extract  of  salix  nigra  (1  drachm),  water  to  \  oz., 
three  times  a  day,  may  be  recommended. 

Bedsores  are  always  to  be  feared.  Apart  from  unremitting 
attention  to  the  bladder  and  bowels,  to  the  bedclothes,  to  involun- 
tary spasmodic  movements  and  to  approximated  skin  surfaces,  their 
development  may  largely  be  prevented  by  a  daily  or  more  frequent 
toilette  of  methylated  spirit  and  dusting  powder.  Where  the  skin 
is  broken,  however,  peroxide  of  hydrogen  and  chlorinated  soda 
have,  in  the  writer's  experience,  been  exceedingly  useful. 

For  the  further  management  of  paraplegic  cases,  see  seriatim 
under  the  various  spinal  and  cerebral  diseases  concerned. 

S.   A.   KINNIER   WILSON. 

REFERENCES. 

Guinon,  article  in  "  Traite  de  Medecine,"  Charcot-Bouchard,  Paris,  1904, 
IX.,  p.  855. 

Marie,  article  in  "Traite  de  Medecine,"-  Brouardel-Gilbert,  Paris,  1903, 
VIII.,  p.  531. 

Dejerine,  "  S6miologie  du  systeme  nerveux,"  Paris,  1904. 

Forster,  "Zeitschrift  fur  Orthopadische  Chirurgie,"  1908,  XXII.,  p.  203. 

Gottstein,  "  Berliner  Klin.  Wchnschr.,"  1909,  XLVL,  p.  784. 

Rose,  F.,  "  La  Semaine  M6dicale,"  1909,  XXIX.,  p.  313. 


1200 


THE  MEDICAL  TREATMENT  OF  TUMOURS  OF 
THE  BRAIN. 

THE  great  advances  which  have  taken  place  not  only  in  cerebral 
localisation  but  in  the  knowledge  of  the  pathological  factors  which 
underlie  the  symptomatology  of  cerebral  tumours,  together  with  a 
corresponding  improvement  in  the  technique  of  cerebral  surgery, 
have  placed  the  treatment  of  intra-cranial  tumours  within  the  range 
of  practical  surgery.  The  physician  must  make  the  diagnosis  and, 
if  possible,  locate  the  situation  of  the  tumour  ;  but  his  chief  responsi- 
bility is  to  inform  the  patient  or  his  relatives  of  the  nature  of  the 
malady,  and  to  lay  before  them  clearly  (1)  the  ultimate  result  of  the 
disease  if  the  pressure  upon  the  brain  is  not  relieved  ;  (2)  the 
possibilities  of  surgical  treatment  :  (a)  as  a  palliative  measure  for 
the  relief  of  the  general  symptoms,  headache,  vomiting,  optic 
neuritis  and  the  prevention  of  death  from  respiratory  failure,  which 
may  occur  quite  suddenly  in  any  case  of  cerebral  tumour  in  which 
the  intra-cranial  tension  has  not  been  relieved  ;  and  (fe)  as  a  curative 
measure. 

The  number  of  cases  in  which  cerebral  operation  offers  a  prospect 
of  permanent  cure  is  small,  as  it  depends  upon  the  nature, 
the  position,  and  to  a  less  extent  the  size  of  the  tumour.  In  a 
few  cases  it  is  possible  to  make  a  correct  diagnosis  on  all  these 
points  before  an  operation  is  undertaken,  but  in  the  great  majority 
of  cases  the  nature  and  the  extent  of  the  growth  can  only  be 
ascertained  by  operation  and  examination.  For  this  reason, 
although  the  prognosis  must  always  be  grave,  an  operation  as 
an  exploratory  and  palliative  measure  should  always  be  insisted 
upon.  The  employment  of  more  radical  measures,  such  as  the 
removal  of  the  tumour,  depends  upon  the  conditions  found  at  the 
exploratory  operation. 

Although  surgical  treatment  offers  the  only  chance  of  cure  or 
of  an  indefinite  prolongation  of  the  patient's  life,  much  may  be 
done  to  alleviate  the  general  and  local  symptoms  of  the  disease 
both  before  and  after  the  operation  has  been  undertaken. 

For  convenience  in  description,  the  medical  treatment  and 
indications  for  immediate  surgical  interference  may  be  considered 
in  the  following  types  of  cases :  (1)  Cases  presenting  symptoms 
of  intra-cranial  tumour,  but  in  which  no  positive  diagnosis  can  be 


Medical  Treatment  of  Tumours  of  Brain.    1201 

made.  (2)  Cases  of  intra-cranial  tumour  in  which  the  position  of 
the  tumour  has  not  been  localised.  (3)  Cases  of  intra-cranial 
tumour  in  which  the  situation  of  the  tumour  has  been  definitely 
localised. 

Cases  presenting  Symptoms  of  Intra-cranial  Tumour,  but 
in  which  no  positive  Diagnosis  can  be  made. — In  many  cases 
of  cerebral  tumour  the  earliest  symptoms  are  general  in  character — 
headache,  occasional  attacks  of  vomiting  and  optic  neuritis. 
Headache  may  be  present  alone  as  the  earliest  symptom,  or  it  may 
be  combined  with  vomiting.  In  all  cases  repeated  careful  routine 
examinations  should  be  made  with  a  view  to  finding  out  the  cause 
of  the  headache.  In  favour  of  its  being  due  to  intra-cranial  tumour 
are  (1)  the  absence  of  any  previous  history  of  headache  ;  (2)  the 
persistence  and  severity  of  the  headache,  especially  at  night-time 
or  in  the  morning ;  (3)  the  deep-seated  character  of  the  pain  ; 
(4)  the  constant  recurrence  of  the  headache  in  the  same  situation, 
its  aggravation  by  sudden  change  of  posture  and  its  association, 
when  severe,  with  vomiting,  unattended  by  any  nausea  or  digestive 
trouble. 

Vomiting  may  be  an  early  symptom.  It  bears  no  relation  to  the 
taking  of  food,  and  is  associated  with  severe  attacks  of  headache, 
and  often  induced  by  a  sudden  change  of  posture.  It  frequently 
occurs  when  the  patient  first  sits  up  in  bed  in  the  morning. 

Optic  neuritis  may  develop  early  or  late,  its  onset  is  usually 
unattended  by  any  disturbance  of  vision,  and  its  presence  may  be 
unsuspected  until  detected  by  ophthalmoscopic  examination.  It  is 
true  that  a  combination  of  the  above  symptoms  may  be  present  in 
cases  of  renal  disease  ;  but  in  such  cases  local  brain  symptoms  will 
be  absent,  or  if  present  their  onset  will  have  been  sudden,  whereas 
in  intra-cranial  tumours  the  onset  of  paralytic  symptoms  is  usually 
gradual  and  evidence  of  renal  disease  is  wanting. 

As  these  symptoms  are  for  the  most  part  due  to  a  rise  in 
intra-cranial  pressure,  treatment  should  be  directed  to  lowering  it. 
It  is  necessary  to  keep  the  patient's  bowels  freely  opened  and 
promote  diuresis.  For  the  headache  the  best  drugs  are  phenacetin, 
antipyrin,  phenalgin  and  aspirin.  A  useful  combination  for  this 
purpose  is  5  gr.  of  aspirin,  caffein  and  phenacetin,  given  either  in 
tabloid  or  powder  form. 

If  a  patient  suffering  from  cerebral  tumour  should  suddenly 
become  comatose,  croton  oil  should  be  given  at  once,  as  it  will 
often  revive  him,  and  by  preventing  his  sudden  death  enable  an 
operation  to  be  undertaken. 

Some  cases  of  cerebral  tumour,  on  the  other  hand,  commence 

S.T. — VOL.  ii.  76 


I2O2     Medical  Treatment  of  Tumours  of  Brain. 

with  local  or  focal  symptoms,  unattended  by  any  of  the  general 
symptoms.  Thus  a  patient  may  suffer  from  fits,  either  localised  or 
general  in  character,  or  he  may  slowly  develop  paralysis.  In  such 
cases  it  may  not  be  possible  to  diagnose  the  cause  of  these 
symptoms,  as  they  may  be  due  to  epilepsy,  vascular  disease,  or 
syphilitic  cerebral  disease.  The  points  in  favour  of  their  being  due 
to  intra-cranial  tumour  are  (1)  the  constant  situation  of  the  onset 
of  the  fits ;  (2)  the  development  of  permanent  and  paralytic 
symptoms  in  the  parts  affected  by  the  fit ;  (3)  the  gradual  onset 
of  paralytic  symptoms ;  and  (4)  the  development  of  the  general 
symptoms  of  intra-cranial  tumour  in  association  with  them. 

Medical  Treatment  of  the  Local  Symptoms  in  a  Case 
where  the  Patient  is  suffering  from  Fits. — It  is  often  advisable 
to  postpone  giving  sedative  treatment  such  as  bromide  in  order 
that  the  character  of  the  fit  may  be  observed  and  the  patient 
examined  immediately  after,  as  in  some  cases  the  observation  of  a 
fit  may  enable  one  to  distinguish  between  idiopathic  epilepsy  and 
fits  due  to  some  local  irritative  lesion.  Once  the  fits  have  been 
observed,  or  where  the  patient  is  having  frequent  fits,  bromide 
should  be  given,  the  dose  being  adjusted  to  the  requirements  of 
each  case.  It  must  not  be  forgotten  that  bromide  treatment  may 
stop  the  occurrence  of  fits  and  to  a  certain  extent  mask  the 
development  of  the  symptoms,  and  therefore  it  is  essential  that 
such  cases  should  be  examined  carefully  at  frequent  intervals.  To 
withhold  bromide  in  a  case  of  cerebral  tumour  in  which  the  patient 
is  suffering  from  fits  is  bad  practice,  as  haemorrhage  may  occur 
into  the  tumour  during  a  fit,  or  the  patient  may  become  comatose 
or  die  from  cardiac  failure  as  a  result  of  repeated  fits,  which  if 
treated  in  time  would  never  have  reached  such  severity  as  to 
endanger  life.  Paralysis,  when  it  occurs,  should  be  treated  on 
general  principles,  but  the  importance  of  a  slow  increase  in  the 
paralysis  as  an  indication  of  a  progressive  lesion  must  ever  be 
borne  in  mind. 

Cases  of  Intra-cranial  Tumour  in  which  the  Position  of  the 
Tumour  has  not  been  Localised. — As  a  general  rule,  when  a 
tumour  has  developed  all  the  cardinal  symptoms  and  been  diagnosed 
though  not  localised,  it  is  not  wise  to  delay  operation.  It  may  in 
some  cases  be  possible  to  localise  the  tumour  as  being  either  above 
or  below  the  tentorium. 

If  the  tumour  is  above  the  tentorium  there  is  not  so  much  risk 
of -sudden  death  from  respiratory  paralysis,  and  therefore  in  some 
instances  it  is  justifiable  to  wait  and  see  whether  a  correct 
localisation  can  be  made,  but  this  period  should  not  exceed  six 


Medical  Treatment  of  Tumours  of  Brain.    1203 

weeks.  Operation  must  be  undertaken  immediately  if  the  patient 
tends  to  become  comatose  or  to  suffer  from  any  respiratory 
disability,  or  if  the  patient's  vision  begins  to  deteriorate  :  thus  it  is 
absolutely  essential  that  the  vision  should  be  repeatedly  and 
carefully  tested  as  to  its  acuity  and  the  condition  of  the  visual 
fields.  Any  deterioration  in  vision  must  be  taken  as  a  sign  that 
operation  should  not  be  delayed,  as  to  do  so  is  to  risk  permanent 
blindness.  In  cases  where  the  tumour  is  presumably  subtentorial 
in  position,  there  is  a  constant  danger  of  sudden  death  from 
anaemia  of  the  respiratory  centres,  and  although  careful  attention 
to  the  condition  of  the  bowels  and  guarding  against  sudden  changes 
of  posture  may  minimise  this,  it  can  only  be  removed  by 
deconipressive  operation  performed  beneath  the  tentorial  level. 

Cases  of  Intra-cranial  Tumour  in  which  the  Situation 
of  the  Tumour  has  been  definitely  Localised.— Operation 
should  not  be  delayed,  and  the  skull  should  be  opened  over 
the  site  of  the  tumour.  If  the  tumour  is  not  intra-cerebral, 
that  is,  if  it  is  an  endothelioma,  fibroma,  fibro-sarcoma  or  gumma, 
it  should  be  removed.  If,  on  the  other  hand,  it  is  intra-cerebral, 
its  removal  should  not  be  attempted  if  the  tumour  is  malignant  and 
of  large  size,  or  so  situated  that  its  removal  would  result  in  paralysis 
or  aphasia. 

In  many  cases  where  the  nature  of  the  tumour  is  doubtful 
the  prescribing  of  a  course  of  anti-syphilitic  treatment  has  been 
recommended.  In  all  cases  a  Wassermann  reaction  should  be 
taken ;  if  negative,  no  time  should  be  wasted  in  anti-syphilitic 
treatment ;  on  the  other  hand,  should  it  be  positive,  active  anti- 
syphilitic  treatment  should  be  carried  out.  If,  despite  this,  the 
symptoms  increase  or  the  patient's  vision  deteriorates,  operation 
must  not  be  delayed.  It  must  always  be  remembered  that  in  the 
case  of  cerebral  gummata  operation  is  often  necessary  for  the  relief 
of  pressure,  and  that  timely  intervention  may  save  the  patient's 
life  by  removing  the  immediate  cause  of  death,  but  the  cure  of  the 
condition  and  the  prevention  of  its  recurrence  depends  entirely  on 
medical  treatment. 

A  medical  man  is  often  asked  as  to  the  risk  of  operation.  In 
every  case  there  is  less  risk  in  performing  palliative  operation 
than  in  leaving  a  patient  suffering  from  intra-cranial  tumour 
unoperated  upon,  provided  that  the  surgeon  is  especially  skilled 
in  this  branch  of  surgery. 

T.  GRAINGER  STEWART. 


76—2 


1204 


SURGICAL  TREATMENT   OF  TUMOURS   OF  THE 

BRAIN. 

SURGICAL  intervention  in  tumours  of  the  brain  may  be  described 
as  radical  and  palliative.  The  former  consists  of  an  operation  which 
aims  at  complete  removal  of  the  tumour.  The  latter  is  undertaken 
solely  for  the  relief  of  intra-cranial  tension  and  the  distressing 
symptoms  due  to  this  tension,  and  makes  no  attempt  at  the  removal 
of  the  tumour  itself.  Obviously,  in  order  that  an  operation  may  be 
radical,  not  only  must  a  diagnosis  of  intra-cranial  tumour  be  made, 
but  its  localisation  be  accurately  determined.  An  operation  begun 
as  a  radical  one  may  end  as  a  palliative  one,  owing  to  the  tumour 
being  irremovable  or  the  localisation  incorrect.  Even  in  cases  in 
which  the  tumour  has  been  definitely  localised  it  is  impossible  to 
say  before  operation  whether  the  case  will  be  suitable  for  palliative 
rather  than  radical  treatment. 

The  duration  of  the  disease  is  no  guide  to  the  nature  and  size  of 
the  tumour.  Nevertheless,  operation  should  always  be  undertaken 
with  the  object  of  exposing  the  tumour.  Should  the  growth  not  be 
found  or  prove  to  be  an  inoperable  one,  the  question  of  a  palliative 
treatment  at  once  arises.  The  palliative  operation,  however,  must 
not  be  regarded  as  a  substitute  for  a  radical  one.  Whenever 
possible,  the  tumour  should  be  removed. 

Palliative  Operations.— It  is  now  well  recognised  that  palliative 
operations  are  not  only  free  from  danger  to  life,  but  are  of  the 
greatest  use  in  relieving  distressing  symptoms,  pain,  and  especially 
progressive  optic  neuritis.  The  relief  of  these  symptoms  is  often 
permanent  through  the  remainder  of  the  life  of  the  patient.  There 
are  two  groups  of  cases  in  which  a  palliative  or  decompressive 
operation  should  be  undertaken :  (1)  Those  in  which  the  tumour 
cannot  be  removed,  though  localised  ;  (2)  those  in  which  the  tumour 
cannot  be  localised,  but  where  the  operation  is  demanded  for  extreme 
headache,  and  progressive  loss  of  vision.  Sanger  suggests  that  the 
best  time  for  a  palliative  operation  in  these  cases  is  when  vision 
commences  to  fail.  If  the  operation  is  delayed  till  later,  some  optic 
atrophy  always  remains.  No  other  palliative  operation,  such  as 
puncture  of  the  lateral  ventricle  or  lumbar  puncture,  can  be  com- 
pared in  efficiency  with  trephining.  Indeed,  lumbar  puncture  in 
cases  of  brain  tumour  is  not  to  be  recommended  as  a  therapeutic 


Surgical  Treatment  of  Tumours  of  Brain.    1205 

measure,  owing  to  its  unreliability  and  transitory  effects.  Moreover, 
it  is  by  no  means  a  harmless  procedure.  Fatal  results  have  been 
recorded  in  intra-cranial  tumours-  with  increased  intra-cranial 
tension.  Grtmprecht  reports  17,  and  Kous  14,  such  cases.  In 
many  of  the  fatal  cases  death  was  due  to  cessation  of  respiration, 
owing  probably  to  disturbance  of  hydrostatic  equilibrium,  causing  a 
lesion  in  the  respiratory  centre  of  the  medulla.  In  many  cases 
death  occurred  within  a  few  minutes.  In  no  case  was  artificial 
respiration  of  any  avail. 

In  performing  the  decompression  operation  there  are  two 
important  points  to  be  kept  in  view :  (1)  The  opening  should  be  over 
as  silent  and  unimportant  an  area  of  the  cortex  as  possible ; 
(2)  means  should  be  taken  to  prevent  an  unnecessarily  large  hernia 
cerebri.  The  occurrence  of  the  latter  can  be  obviated  by  the  intra- 
muscular method,  by  which  means  the  muscles  and  fascia  act  as  a 
check  to  the  brain. 

An  important  point,  and  one  which  must  be  decided  during  an 
operation  for  cranial  tumour,  is  that  of  exploration  of  subcortical 
growth.  Should  these  cases  be  regarded  as  inoperable  and  an 
attempt  to  find  the  growth  be  abandoned  ?  The  answer  to  this 
question  depends  upon  how  far  by  subcortical  exploration  we  may  be 
interfering  with  the  functions  of  the  brain.  Remembering  always 
that  if  the  growth  is  not  removed  death  will  certainly  follow,  the 
amount  of  permanent  defect  resulting  from  the  operation  is  an 
important  consideration,  and  the  responsibility  of  accepting  it  one 
which  must  be  left  to  the  patients  and  their  friends.  The  extent  of 
paralysis  will  depend  on  the  situation  of  the  tumour  and  the  amount 
of  brain  tissue  it  is  necessary  to  remove  in  enucleating  the  tumour. 
A.  certain  amount  of  recovery  from  post-operative  paralysis  may  be 
predicted  with  confidence,  and  it  is  astonishing  in  many  cases  how 
complete  this  return  of  function  may  be.  The  want  of  success  in 
obtaining  a  radical  cure  is  usually  due  to  the  infiltrating  nature  of 
the  tumour  precluding  the  possibility  of  its  entire  removal. 

Radical  Operations. — The  surgery  of  the  brain  differs  in  no 
wise  from  that  in  other  parts  of  the  body,  in  that  the  earlier  the 
disease  is  recognised  and  localised  the  more  favourable  is  the  chance 
of  performing  a  radical  operation.  Seeing  that  the  disease  is 
always  incurable  and  fatal  without  operation,  any  case  of  brain 
tumour  may  be  described  as  operable  in  which  the  tumour  can  be 
wholly  or  partially  removed.  Those  cases  in  which  the  tumour  is 
not  localised,  or  being  localised,  is  inaccessible,  and  show  pro- 
gressive optic  neuritis,  do  not  admit  of  any  discussion  ;  they  should 
be  decompressed  at  an  early  stage  before  vision  begins  to  fail. 


1206    Surgical  Treatment  of  Tumours  of  Brain. 

Grave  responsibility  rests  upon  the  medical  attendant  who  allows 
a  patient  to  become  blind  through  optic  atrophy  due  to  tumour. 
While  the  accessibility  or  inaccessibility  of  a  brain  tumour  is  the 
main  factor  in  the  success  of  the  operation,  the  nature  of  the 
growth  must  also  be  considered,  inasmuch  as  localised  tumours 
are  easier  of  removal  than  vascular  and  infiltrating  growths. 

The  fact  should  be  strongly  emphasised  that  syphilitic  tumours 
require  to  be  dealt  with  surgically  on  precisely  similar  lines  to 
those  which  obtain  in  other  forms  of  tumour.  Valuable  time  is 
lost  in  pushing  anti-syphilitic  remedies  after  the  symptoms  show  no 
sign  of  yielding  at  all.  There  are  chronic  syphilitic  tumours  that  no 
amount  of  mercury  or  iodide  of  potassium  will  cure.  It  is  no  un- 
common event  to  see  symptoms  due  to  gumma  continue  to  increase 
while  the  patient  is  under  syphilitic  treatment.  Surgical  interfer- 
ence is  indicated  where  symptoms  are  increasing  in  spite  of  local 
medicinal  treatment,  and  where  the  localisation  is  exact.  It  is 
impossible  to  lay  down  any  hard  and  fast  rule  as  to  how  long  anti- 
syphilitic  treatment  should  be  continued  before  having  recourse  to 
surgical  intervention ;  but  it  may  be  said  generally  that  when  the 
diagnosis  and  localisation  have  been  arrived  at,  unless  there  is 
very  decided  improvement  in  six  weeks'  time,  operation  should  be 
performed.  Indeed,  immediate  operation  is  called  for  in  those 
cases  where  the  symptoms  are  urgent,  the  risk  to  life  being  too 
great  to  try  medicinal  measures.  By  the  operative  relief  of  urgent 
symptoms  time  is  gained  for  the  subsequent  use  of  anti-syphilitic 
remedies. 

The  radical  operation  may  be  performed  at  one  sitting  or  in  two 
steps,  as  a  means  of  reducing  the  risk  of  death  from  shock  to  a 
minimum.  In  the  latter  case  the  bone  is  removed  or  an  osteo- 
plastic  flap  turned  down,  and  a  week  later  the  wound  opened  and 
the  dura  attacked.  This  method,  however,  need  not  be  followed 
where  the  condition  of  the  patient  does  not  centra-indicate  a  one- 
stage  operation.  The  question  of  proceeding  with  the  operation 
may  well  be  left  to- the  end  of  the  first  stage,  the  decision  depending 
upon  the  condition  of  the  patient  with  reference  to  shock  at  the 
time.  The  chief  danger  arises  from  interference  with  the  respi- 
ratory and  cardiac  centres,  due  .to  pre-operative  pressure  on  the 
medulla  or  to  post-operative  oedema,  resulting  from  the  relief  of  that 
pressure.  Operation  is  useless  when  the  heart  has  failed,  but  should 
be  attempted  when  respiration  only  is  failing  and  the  heart  is 
continuing  to  beat. 

From  the  point  of  view  of  operation  cases  of  brain  tumour  may 
be  divided  into  three  classes  :  (1)  Those  in  which  the  tumour  is 


Surgical  Treatment  of  Tumours  of  Brain.    1207 

completely  removed  and  the  patient  cured ;  (2)  those  in  which  it 
is  removed  in  part,  with  temporary  benefit  to  the  patient ;  (3)  those 
in  which  the  tumour  cannot  be  removed  at  all,  but  symptoms  are 
relieved  by  a  decompression  operation. 

The  term  "  decompression  "  implies  not  simple  trephining  alone, 
but  the  removal  of  a  considerable  portion  of  bone  on  one  or  both 
sides  of  the  cranium,  together  with  the  removal  of  the  dura  or  the 
free  opening  of  it. 

DONALD  ARMOUR. 


I2O8 


DISEASES  AND  AFFECTIONS  OF  THE  SPINAL 

CORD. 

CAISSON    DISEASE, 

THE  treatment  of  caisson  disease  divides  itself  naturally  into  the 
preventive  and  remedial  measures. 

Preventive  Measures. — The  pathology  of  this  disease  is  based 
on  the  fact  that,  under  increased  atmospheric  pressure,  the  fluid 
tissues  of  the  body  absorb,  through  the  lungs  and  the  circulation, 
increased  quantities  of  air,  the  nitrogen  of  which  is  liberated  in  the 
form  of  bubbles  if  the  body  is  transferred  too  rapidly  from  the 
increased  pressure  to  normal  conditions.  If  the  transference,  or 
decompression,  as  it  is  technically  described,  is  allowed  to  take 
place  slowly,  the  surplus  gas  is  eliminated  through  the  lungs  with- 
out the  formation  of  bubbles.  The  formation  of  bubbles  in  the 
tissues,  particularly  in  those  of  the  nervous  system,  is  responsible 
for  the  serious  and  not  infrequently,  fatal  consequences  of  the 
disease. 

In  order  to  prevent  the  evil  effects  of  rapid  decompression, 
certain  precautions  must  be  taken.  The  higher  the  atmospheric 
pressure  under  which  a  man  works  the  shorter  must  be  the  length 
of  the  shift.  The  process  of  decompression  must  be  slow  ;  for 
instance,  twenty  minutes  must  be  allowed  for  every  atmosphere  of 
pressure.  According  to  Leonard  Hill,  the  early  stages  of  decom- 
pression may  be  carried  out  rapidly,  but  an  adequate  time  must  be 
spent  in  a  "  lock  "at  18  to  20  Ib.  pressure  before  returning  to 
normal  atmospheric  conditions.  Finally,  it  has  been  shown  that 
men  who  are  young,  thin,  wiry  and  in  good  health  are  less  liable 
to  develop  symptoms  than  those  who  are  older,  fatter  or  in  any 
way  debilitated. 

Remedial  Measures. — The  only  satisfactory  method  of  dealing 
with  a  case  of  the  disease,  when  the  symptoms  are  developing  or 
have  only  very  recently  developed,  is  rapid  recompression.  For 
this  purpose  it  is  customary  to  provide  "  locks  "  on  the  surface, 
where  caisson  work  is  being  carried  on,  in  order  that  the  earliest 
symptoms  of  the  disease  may  be  met  by  exposing  the  patient  to 
increased  pressure.  It  is  very  necessary  to  remember  that  the 
final  decompression  must  be  performed  with  great  care  so  as  to 
avoid  a  recurrence  of  the  symptoms.  The  fact  that  the  onset  of 


Caisson  Disease.  1209 

the  disease  is  sometimes  delayed  makes  it  desirable  that  men 
who  have  worked  under  pressure  should  not  be  allowed  to  depart 
out  of  reach  of  the  recompression  lock  within  an  hour  of  their 
ascent  to  the  surface. 

The  treatment  of  cases  in  which  recompression  has  not  been 
practised  or  only  adopted  too  late,  resolves  itself  into  the  relief  of 
pain  and  paralysis.  The  pain  may  be  met  by  morphia  if  the  state 
of  the  patient's  circulation  and  respiration  permits,  and  the  paralysis, 
after  a  period  of  rest,  may  be  influenced  beneficially  by  a  course 
of  regulated  exercises  and  massage.  In  cases  of  severe  paraplegia 
the  clinical  aspect  resembles  that  of  myelitis,  and  general  directions 
with  regard  to  the  management  of  the  bladder,  bowels  and  skin 
may  be  found  in  the  article  devoted  to  this  condition. 

E.  FARQUHAR  BUZZARD 


I2IO 


H^EMATOMYELIA. 

THE  treatment  of  haematomyelia  naturally  divides  itself  into  that 
of  the  acute  stage  and  that  of  the  stage  of  repair. 

Acute  Stage. — Immediate  and  appropriate  measures  are  of 
supreme  importance  from  the  moment  of  the  onset  of  symptoms, 
•which  are  usually  rapid  if  not  sudden  in  their  development.  For 
this  reason  any  case  of  sudden  paraplegia  following  a  slight  or 
severe  strain  or  injury,  or  even  occurring  without  apparent  cause 
in  a  healthy  individual,  should  be  regarded  as  possibly  due  to 
spinal  haemorrhage,  especially  if  the  signs  point  to  the  cervical 
enlargement  as  the  site  of  lesion.  The  patient  must  be  removed  to 
bed  with  the  greatest  care,  and,  if  possible,  be  given  a  hypodermic 
injection  of  morphia  before  any  necessary  manipulations  are  carried 
out.  A  water  mattress,  if  possible,  should  be  prepared  at  once. 
The  question  of  the  patient's  posture  is  probably  of  little  import- 
ance, although  some  authorities  advocate  a  prone  and  some 
a  lateral  position.  Slight  changes  must  be  made  with  great  care 
from  time  to  time  in  order  to  avoid  pressure  sores,  and  it  is 
probable  that  the  patient  will  rest  most  comfortably  aud  effectually 
if  placed  on  his  back  to  begin  with,  and  afterwards  tilted  a  little  to 
one  side  or  the  other.  At  this  stage  an  injection  of  the  liquor 
ergotae  hypodermica  (10  min.)  [U.S.P.  ext.  ergot.,  gr.  J]  may  be 
given,  although  its  haemostatic"  value  in  these  cases  can  hardly  be 
taken  as  proved.  Retention  of  urine  must  be  anticipated  and 
catheterisation  instituted  before  overflow  incontinence  leads  to 
soaking  of  the  sheets  and,  what  is  more  important,  soaking  of  the 
patient's  skin. 

The  usual  methods  for  preventing  bedsores,  rubbing  the  skin  with 
spirit  and  the  free  use  of  a  non-irritating  antiseptic  powder  (zinc 
oxide  1,  starch  2),  with  daily  ablutions,  should  be  employed  from  this 
time  onwards,  instructions  being  given  to  the  nurse  that  a  minimum 
of  movement  is  essential.  If  acute  pain  is  present  the  morphia  may 
be  repeated  and  the  patient  should  be  warned  that  all  voluntary 
movements,  sneezing,  coughing,  etc.,  are  likely  to  be  injurious. 
Forty-eight  hours  may  be  allowed  to  elapse  before  the  bowels  are 
opened  by  means  of  a  gentle  laxative  followed  by  an  enema.  The 
administration  of  sedatives  and  narcotics  must  be  regulated  by  the 
condition  of  the  heart  and  respiration,  especially  in  elderly  persons, 


Haematomyelia.  1211 

in  whom  cardiac  failure  or  hypostatic  pulmonary  congestion  may 
be  feared. 

The  period  of  complete  rest  should  not  be  less  than  six  or  eight 
weeks,  but  after  the  first  week  the  nurse  may  take  each  limb  in 
turn  and  perform  gentle  passive  movements  at  the  various  joints 
in  order  to  prevent  the  formation  of  arthritic  adhesions  and  to 
guard  against  the  rigidity  which  is  likely  to  supervene.  At  the 
same  time  she  should  take  care  that  the  position  in  which  limbs 
are  placed  is  frequently  varied,  making  use  of  sand-bags  and  pillows 
for  that  purpose. 

Stage  of  Repair. — Two  months  having  elapsed  since  the  onset 
of  symptoms,  it  will  probably  be  found  that  the  extent  of  paralysis 
has  already  diminished  and  measures  directed  to  the  promotion  of 
recovery  may  be  undertaken  with  more  freedom.  The  common 
site  of  haemorrhage  is  in  the  cervical  enlargement,  and  therefore 
the  majority  of  cases  present  atrophic  palsy  of  the  hands  and  arms, 
together  with  spastic  palsy  of  the  trunk  and  legs.  Massage  and 
galvanism  should  be  used  for  the  atrophied  muscles  and  passive 
movements  of  all  four  extremities  continued  daily.  At  the  same 
time  the  patient  should  be  encouraged  cautiously  to  attempt 
voluntary  movements  on  his  own  account  and  may  undertake 
regular  exercises  against  graduated  resistance  offered  by  his 
attendant.  If  the  legs  are  spastic,  only  gentle  rubbing  should  be 
used  for  them,  and  electrical  currents  in  these  r/arts  are  better 
avoided.  Painful  flexor  spasms  may  be  mitigated  by  the  adminis- 
tration of  tincture  of  belladonna  or  tincture  of  cannabis  indica  in 
10-min.  doses,  with  an  occasional  dose  of  veronal  at  night.  The 
use  of  belladonna  may  also  be  beneficial  if  micturition  is  frequent 
and  precipitate. 

E.  FARQUHAR  BUZZARD. 


1212 


MYELITIS. 

IT  is  usual  in  writing  an  article  on  the  pathology,  sj'mptoma- 
tology,  etc.,  of  myelitis  to  indicate  different  forms  of  the  disease 
according  to  their  clinical  or  etiological  features.  In  dealing  with 
the  treatment  of  the  disease,  on  the  other  hand,  it  is  only  necessary 
to  specify  two  varieties,  the  syphilitic  and  the  non-syphilitic. 

The  treatment  of  the  syphilitic  cases  includes  the  administration 
of  anti-syphilitic  remedies  as  well  as  the  general  measures  which 
are  applicable  to  all  forms  of  myelitis  and  which  form  the  subject 
of  this  article.  For  the  methods  of  administering  anti-syphilitic 
drugs,  such  as  mercury,  arsenic  and  the  iodides  of  potassium  or 
sodium,  the  reader  is  referred  to  the  article  on  Cerebro-spinal 
Syphilis. 

In  considering  the  method  of  administering  mercury  it  should  be 
remembered  that  parts  which  are  quite  anaesthetic  are  unsuitable 
for  inunctions  or  for  deep  injections,  owing  to  the  vulnerability  of 
the  tissues. 

Cases  of  myelitis  which  are  non-syphilitic  are  uncommon  and 
are  the  result  of  infection  of  the  spinal  cord  by  various  bacterial 
organisms  or  their  toxins.  In  some  cases  the  particular  organism 
may  be  known  or  suspected  because  the  disease  in  the  spinal  cord 
has  followed  an  infective  process  elsewhere.  Thus,  a  typhoid 
myelitis  is  recognised  as  a  complication  or  sequela  of  typhoid  fever. 
In  other  instances  the  spinal  lesion  appears  to  be  primary  and 
spontaneous,  and,  unless  the  causative  organism  is  discovered  in 
the  cerebro-spinal  fluid  by  means  of  lumbar  puncture,  their 
bacteriology  remains  obscure.  Our  knowledge  of  these  cases  is  not 
yet  sufficiently  far  advanced  for  advantage  to  be  taken  of  serum  or 
vaccine  therapy  in  dealing  with  them.  Generally  the  damage  to 
the  spinal  marrow  is  fully  established  and  the  acute  stage  almost 
over  before  we  are  in  possession  of  certain  information  as  to  its 
bacterial  origin. 

On  the  other  hand,  it  is  important  for  the  benefit  of  future 
victims  that  in  every  case  of  myelitis  lumbar  puncture  should  be 
performed  and  the  cerebro-spinal  fluid  subjected  to  a  most  careful 
examination. 

Prophylaxis. — So  sporadic  and  uncommon  is  myelitis  of  the 
non-syphilitic  type  that  prophylactic  measures  can  hardly  be 


Myelitis.  1213 

specifically  indicated  in  any  particular  individual.  The  mere  fact 
that  so  serious  a  disease  may  possibly  follow  or  complicate  any  of 
the  acute  infective  fevers  or  any  septic,  focus  in  other  parts  of  the 
body  should  warn  medical  men  against  making  light  of  these  con- 
ditions and  should  stimulate  them  to  do  all  in  their  power,  both  to 
increase  the  patient's  resistance  by  careful  attention  to  matters  of 
hygiene  and  diet  and,  secondly,  to  exercise  a  wise  supervision 
during  the  period  of  convalescence,  guarding  particularly  against 
injury  or  over-fatigue  of  the  nervous  system.  A  particular  form  of 
myelitis  has  been  described  as  occasionally  associated  with 
pregnancy  or  the  puerperium,  but  little  is  known  about  the 
essential  factors  in  its  causation.  It  would  be  going  too  far  to  say 
that  the  possibility  of  such  a  complication  should  present  itself  to 
any  one  who  has  to  deal  with  a  pregnant  woman  or  a  confinement. 
Prophylactic  measures  in  syphilitic  cases  really  resolve  them- 
selves into  the  efficient  treatment  of  the  primary  chancre  and  is 
discussed  in  the  articles  on  Syphilis  and  Cerebro-spinal  Syphilis. 

TREATMENT  OF  THE  ACUTE  STAGE. 

The  premonitory  symptoms  of  myelitis  are  usually  too  slight  and 
of  too  short  duration  to  allow  of  any  effective  measures  being  taken 
before  the  disease  is  fully  developed,  except  in  the  case  of  the 
syphilitic  cases  in  which  an  alert  physician  may  sometimes  institute 
mercurial  treatment  sufficiently  early  to  render  the  attack  abortive. 

As  soon  as  the  diagnosis  of  acute  myelitis  is  made,  the  patient 
should  be  placed  at  rest  on  a  water-bed  and  in  charge  of  trained 
nurses,  either  at  home  or  in  a  nursing  home  or  hospital.  The 
nursing  of  a  case  of  myelitis  cannot  be  entrusted  to  any  but 
experienced  hands.  Although  rest  is  of  great  importance  and 
must  be  secured  by  forbid'ding  any  voluntary  movements  on  the 
part  of  the  patient,  a  change  of  position  should  be  made  every 
three  or  four  hours  by  the  nurses  in  charge.  Although  some 
authorities,  on  theoretical  grounds,  advocate  the  placing  of  the 
patient  on  his  stomach,  the  writer  does  not  believe  that  the  supine 
position  has  a  harmful  influence  on  the  disease  and  is  quite  con- 
vinced that  prolonged  lying  in  the  prone  position  is  unnecessary 
and  irksome.  It  is  better  to  shift  the  patient  at  intervals,  alter- 
nating between  the  prone,  supine  and  lateral  positions.  In  this 
way  the  nurse  will  find  assistance  in  the  prevention  of  bedsores, 
and  the  patient  will  be  less  likely  to  suffer  from  the  stiffness  and 
cramp  produced  by  too  long  fixation  in  one  attitude.  Care  must  be 
taken  to  see  that  the  clothes  and  sheets  in  contact  with  the  skin 
are  smoothed  out,  and  it  is  generally  advisable  to  provide  a  cradle 


1 2 14  Myelitis. 

at  once  in  order  to  prevent  the  weight  of  bedclothes  pressing  upon 
the  paralysed  legs,  and  so  tending  to  excessive  extension  of  the 
ankles.  The  legs  should  be  kept  separate,  but  not  allowed  to  lie 
for  long  in  a  position  of  external  rotation  which  they  will  tend  to 
assume  if  left  uncared  for.  Well-padded  sand-bags  may  be  used 
for  maintaining  desirable  positions  of  the  lower  extremities. 
Points  of  pressure,  such  as  the  sacrum,  the  trochanters,  the  ischial 
tuberosities  and  the  heels  must  be  carefully  watched  and,  if  any 
redness  is  detected,  guarded  by  means  of  ring  cushions,  either 
pneumatic  or  made  of  soft  wool  and  smooth  bandages. 

The  whole  cutaneous  surface  must  be  washed  two  or  three  times  in 
the  twenty-four  hours  and  dried  thoroughly  with  a  soft  towel.  Parts 
which  are  exposed  to  pressure  should  be  rubbed  for  several  minutes 
with  the  palm  of  the  hand  moistened  with  spirit.  The  rubbing  is 
more  important  than  the  spirit  and  helps  to  prevent  the  formation 
of  bedsores  by  promoting  the  circulation  in  parts  where  there  is 
anaesthesia  and  vasomotor  paralysis.  After  rubbing,  the  parts 
should  be  dusted  with  a  powder  composed  of  equal  parts  of  starch 
and  zinc  oxide.  In  addition  to  the  routine  ablutions  those 
parts  of  the  body  which  are  exposed  to  soiling  by  evacuations  from 
the  bladder  or  bowel  must  be  carefully  washed,  dried  and  rubbed 
whenever  soiling  occurs.  In  many  cases  evacuations  are  passed 
without  the  knowledge  of  the  patient  and  must  be  constantly  looked 
for  by  the  nurse  so  that  the  skin  does  not  become  sodden. 

The  excretory  functions  of  the  patient  claim  immediate  attention, 
and  if  urine  is  not  passed  naturally  the  bladder  must  be  emptied  by 
means  of  a  catheter  at  regular  intervals  of  six  or  eight  hours.  The 
catheterisation  must  be  done  by  someone  who  understands  perfectly 
antiseptic  principles. 

In  the  case  of  both  male  and  female,  patients  a  rubber  catheter 
should  be  used  for  choice  and  boiled  before  being  passed.  After 
use  it  should  be  thoroughly  washed  in  water  and  syringed  through 
with  1  in  40  carbolic  lotion.  It  may  then  be  dried  or  placed  in  a 
bottle  containing  a  solution  of  perchloride  of  mercury  in  glycerine 
(1  in  1,000),  or  in  3  per  cent,  carbolic  acid  until  it  is  required,  when 
it  should  again  be  boiled.  The  surface  surrounding  the  urethral 
opening  should  be  swabbed  with  a  mild  disinfectant  and  the  cathe- 
ter smeared  with  carbolised  vaseline  before  it  is  passed  into  the 
bladder.  The  objection  to  the  use  of  a  glass  catheter  for  female 
patients  suffering  from  myelitis  only  holds  good  when  they  are 
subject  to  flexor  spasms  which  may  be  excited  by  the  passage  of  the 
catheter  and  cause  breakage  of  the  latter  in  situ. 

When  a  bed-pan  or  slipper  is  used  it  is  always  advisable  for  the 


Myelitis.  1215 

nurse  to  have  one  assistant,  as  it  is  difficult  to  place  either  article 
in  position  without  injuring  the  skin  over  the  buttocks  unless  the 
patient  can  be  lifted. 

When  the  vesical  sphincter  is  paralysed  and  urine  dribbles  away, 
a  glass  or  porcelain  urinal  may  be  used  by  male  patients,  but  the 
anaesthetic  glans  penis  must  be  carefully  protected  by  soft  pads  of 
wool  from  the  liability  to  sores  caused  by  pressure  and  friction 
against  the  hard  substance,  and  similar  precautions  must  be  taken 
to  prevent  pressure  upon  the  skin  on  the  internal  surface  of  the 
thighs.  With  female  patients  it  is  best  to  place  a  large  pad  of  some 
absorbent  wool,  frequently  renewed,  in  the  perinaeum.  A  satis- 
factory female  urinal  is  not  to  be  obtained,  but  a  substitute  can  be 
improvised  by  making  a  mackintosh  envelope,  which  is  filled  with 
wool  and  so  placed  that  the  triangular  end  is  slipped  under  the 
buttocks  and  the  open  mouth  of  the  envelope  kept  in  apposition  to 
the  vulva.  By  renewing  this  whenever  urine  has  been  passed  the 
bed  will  not  be  soiled. 

With  regard  to  the  bowels,  an  initial  purge,  such  as  calomel  or 
jalap,  should  be  given  early  and  subsequently  an  evacuation 
secured  every  day,  or  every  other  day,  by  means  of  a  dose  of 
cascara  at  night  and  an  enema  in  the  morning.  If  the  anal 
sphincter  is  relaxed  a  daily  enema  will  probably  prevent  too 
frequent  soiling  by  thoroughly  emptying  the  lower  part  of  the 
large  intestine.  In  these  patients  there  is  often  a  tendency  to  con- 
stipation and  the  formation  of  hard  dry  faecal  masses  in  the  colon 
and  rectum.  Attention  to  the  evacuations  is  indicated  in  order  to 
guard  against  this  accident,  and,  if  necessary,  the  rectum  must  be 
cleared  out  by  means  of  the  inserted  finger.  In  myelitis  of  the  upper 
dorsal  region  splanchnic  palsy  is  sometimes  a  troublesome  symptom 
in  the  acute  stages  and  may  occasion  discomfort  and  respiratory 
embarrassment  owing  to  the  distension  of  the  intestine  by  gas.  This 
may  be  relieved  by  means  of  turpentine  stupes  or  may  necessitate 
the  passage  of  a  long  rectal  tube  in  order  to  allow  gas  to  escape. 

The  question  of  drugs  in  cases  of  myelitis  which  are  not 
syphilitic  in  origin  is  of  comparatively  minor  importance.  Fever 
is  usually  present  at  the  outset,  and  the  following  mixture  may  be 
given  every  six  hours  :  Salicin.,  gr.  15  ;  Spirit.  ^Etheris  Nitrosi,  5ss ; 
Liq.  Ammon.  Acetat.,  5J ;  Aq.  Camphorae,  ad  jj  [U.S.P.  *fy. 
Salicin.,  gr.  15  ;  Spirit.  ^Etheris  Nitrosi,  533  ;  Liq.  Ammon.  Acetat. 
oj ;  Aq.  Camphors,  51]  ;  Aquam,  ad.  jj] .  It  may  be  preferred  to  give 
urotropin  in  10-gr.  doses  at  similar  intervals  on  the  ground  that  this 
substance  has  a  bactericidal  influence  on  the  cerebro-spinal  fluid. 

Pain  in  the  acute  stage  is  rarely  severe  enough  to  require  more 


I2i6  Myelitis 

than  a  dose  of  phenacetin  or  phenazone,  but  morphia  may  be  given 
if  the  circulation  and  respiration  are  not  interfered  with  by  the 
disease,  as  is  sometimes  the  case  in  myelitis  of  the  upper  dorsal 
and  cervical  regions. 

Any  tendency  to  bronchitis  must  be  guarded  against  by  avoid- 
ance of  exposure  to  chills,  especially  during  the  necessary  ablutions, 
and  if  catarrh  develops,  expectorants  and  stimulants  may  be  ad- 
ministered. A  hypodermic  injection  of  strychnine  and  atropine  is 
sometimes  useful  in  these  circumstances. 

The  writer  does  not  advocate  local  treatment  in  the  way  of 
cupping,  the  application  of  heat  or  cold  to  the  spine,  the  use  of  the 
actual  cautery,  etc.,  in  the  acute  stage  of  myelitis.  It  is,  to  say  the 
least,  problematical  whether  the  disease  is  influenced  in  any  way  by 
such  measures,  and  it  is  certain  that  they  entail  considerable,  and 
probably  unnecessary,  disturbance  of  the  patient.  Unless  great  care 
is  exercised,  moreover,  there  is  always  the  risk  of  injuring  the  skin 
and  deeper  tissues  in  regions  which  are  trophically  abnormal  and 
therefore  prone  to  the  formation  of  sores. 

The  diet  should  be  that  usually  prescribed  in  acute  fevers,  milk 
forming  its  chief  constituent.  Alcohol  is  better  avoided,  unless  it 
is  indicated  as  a  stimulant  in  the  face  of  cardiac  feebleness,  when 
strychnine  or  digitalin  hypodermically  are  probably  more  suitable. 

TREATMENT   OF   THE   CHRONIC   STAGE. 

As  soon  as  the  patient's  temperature  has  returned  to  normal  and 
there  is  no  evidence  of  the  disease  making  further  progress,  the  first 
duty  of  the  medical  attendant  is  to  promote  the  recovery  of  those 
parts  which  are  paralysed.  The  measures  which  are  necessary  for 
this  end  are  not  uncommonly  neglected,  with  the  result  that  the 
patient  develops  osteoarthritic  changes,  muscular  contractures,  etc., 
which  prove  very  obstinate  to  later  treatment  and  materially  hamper 
his  regaining  the  use  of  his  paralytic  limbs.  Within  a  week  of  the 
onset  of  symptoms  the  nurse  should  be  directed  to  take  each  limb  in 
turn  and  perform  gentle  passive  movements  at  all  joints,  as  well  as 
gentle  massage  to  all  muscles.  This  should  be  done  every  day  and 
at  the  same  time  care  should  be  taken  that  the  limbs  are  not  allowed 
to  remain  fixed  in  any  position  for  more  than  a  few  hours  at  a  time. 

As  power  begins  to  return  more  massage  may  be  given  and  passive 
movements  carried  out  with  greater  frequency.  At  this  period  the 
co-operation  of  the  patient  must  be  requisitioned  and  he  must  be 
induced  to  force  impulses,  as  it  were,  through  the  blocked  lines.  This 
important  part  of  the  treatment  may  be  encouraged  by  persuading 
the  patient  to  help  in  the  performance  of  passive  movements,  and, 


Myelitis.  1217 

as  the  ability  to  do  so  increases,  by  offering  regulated  resistance  to 
his  voluntary  efforts.  These  measures  are  apt  to  be  forgotten,  the 
patient  relying  too  much  on  what  may  result  from  massage  and  elec- 
trical treatment  and  too  little  on  what  he  can  bring  about  himself. 

Spasticity  of  the  lower  limbs  is  one  of  the  formidable  troubles 
resulting  from  myelitis  above  the  lumbar  region  and  for  this  reason  it 
is  well  to  avoid  applying  energetic  massage,  electrical  or  stimulating 
treatment  of  any  kind  to  spastic  parts.  When  spasticity  is  present 
strychnine  should  not  be  administered,  ergot  and  belladonna  being 
more  suitable  drugs  in  these  circumstances.  Painful  flexor  spasms, 
which  are  common  when  spasticity  is  marked,  are  very  difficult  to 
influence  and  particularly  liable  to  interfere  with  the  patient's  sleep. 
The  spasms  may  be  excited  by  contact  with  the  overlying  bedclothes, 
so  that  the  latter  should  be  separated  from  the  lower  limbs  by 
means  of  a  cradle.  Light  weights  applied  so  as  to  keep  the  legs 
extended  are  sometimes  useful  and  it  may  also  become  necessary  to 
give  such  drugs  as  veronal,  sulphonal  or  hydrobromide  of  hyoscine 
to  combat  the  reflex  excitability  of  the  spinal  centres.  In  protracted 
cases  of  the  kind,  in  which  no  relief  is  obtained  by  these  measures, 
it  is  justifiable  to  consider  the  advisability  of  dividing  a  few  of  the 
lumbo-sacral  posterior  nerve  roots,  but  this  procedure  must  not  be 
contemplated  so  long  as  there  is  reasonable  hope  of  natural  improve- 
ment taking  place. 

Those  parts  which  are  the  seat  of  atrophic  flaccid  palsy  require 
massage  and  electricity.  That  form  of  current  should  be  chosen 
which  excites  contraction  of  the  paralysed  muscles,  and  the  treat- 
ment should  be  carried  out  daily  by  someone  who  has  the  necessary 
training,  and  continued  so  long  as  the  response  to  electricity  shows 
that  the  damage  to  spinal  centres  is  not  irreparable. 

During  this  stage  cystitis  may  prove  a  troublesome  and  dangerous 
complication  even  when  every  care  has  been  taken  in  the  way  of 
aseptic  catheterisation.  The  inflammation  of  the  bladder<must 
be  treated  by  means  of  irrigation  once  or  twice  daily,  and  the  oral 
administration  of  urotropin,  boric  acid,  salol,  etc.  Good  results  will 
usually  follow  washing  out  the  bladder  with  a  4  per  cent,  solution  of 
boric  acid,  or  sulphate  of  quinine  in  the  proportion  of  3  gr.  to  the 
pint,  and  giving  5  gr.  of  urotropin  with  10  gr.  of  boric  acid  three 
times  a  day  by  the  mouth.  If  symptoms  of  indigestion  or  diarrhoea 
supervene,  the  boric  acid  should  be  discontinued,  and  it  is  often 
advisable  to  change  from  one  mild  antiseptic  lotion  to  another  for 
the  purpose  of  irrigation,  when  the  case  proves  intractable.  In 
performing  irrigation  the  bladder  should  first  of  all  be  emptied  and 
then  washed  out  until  the  returned  fluid  is  free  from  turbidity. 

S.T. — VOL.  ii.  77 


I2i8  Myelitis. 

Precipitate  Micturition  is  a  common  residual  symptom  in 
cases  which  have  so  far  recovered  as  to  be  able  to  get  about  with 
or  without  assistance,  and  it  may  be  necessary  to  provide  such 
patients  with  some  form  of  portable  urinal.  These  are  made  of 
indiarubber  and  can  be  obtained  for  either  sex  ;  but  in  the  case  of 
female  patients  who  are  unable  to  afford  the  expensive  article,  a 
more  or  less  satisfactory  substitute  may  be  found  in  a  mackintosh 
sponge  bag,  which  can  be  filled  with  wool  and  slung  in  position. 

Reference  has  already  been  made  to  the  prevention  of  bedsores. 
Unfortunately  the  latter  may  develop  in  spite  of  all  precautions, 
and  every  effort  must  be  invoked  not  only  to  promote  their 
healing,  but  to  discourage  their  tendency  to  spread  and  involve 
the  deeper  tissues.  As  long  as  the  skin  is  unbroken  and  only 
reddening  is  present,  further  developments  may  often  be  prevented 
by  frequent  rubbing,  to  which  reference  has  already  been  made, 
and  by  protecting  the  part  from  further  pressure.  A  slight 
abrasion  may  be  treated  either  with  boracic  powder  or  boracic 
ointment,  but  deeper  sores  require  more  serious  attention.  All 
unhealthy  matter  and  exudation  should  be  swabbed  or  syringed 
away  with  a  peroxide  of  hydrogen  lotion  consisting  of  the  official 
solution  mixed  with  equal  parts  of  water.  Having  done  this,  the 
sore  should  be  plugged  with  lint  soaked  in  a  zinc  sulphate  lotion 
(2  gr.  to  the  ounce)  and  the  edges  of  the  wound  rubbed  dry  with 
spirit.  A  large  sheet  of  dry  lint  may  be  placed  over  the  whole 
of  the  part,  but  it  should  be  so  adjusted  that  movements  of  the 
patient  will  not  lead  to  wrinkling  or  folds.  Instead  of  plugging 
with  soaked  lint,  the  sore  may  be  tilled,  after  syringing,  with 
sorbefacin  (a  handy  surgical  dressing  containing  menthol,  thymol 
and  boracic  acid  in  a  fatty  basis)  which  gives  very  good  results. 
Such  dressings  must  be  renewed  at  frequent  intervals. 

When  progress  towards  recovery  appears  to  have  reached  a 
standstill  it  is  time  to  remove  the  patient  to  other  surroundings 
and  the  choice  of  the  latter  will  naturally  depend  upon  the 
amount  of  locomotive  power  which  he  has  regained.  In  the  case 
of  well-to-do  patients  resort  may  be  had  to  English  or  continental 
spas,  where  a  course  of  thermal  baths  and  the  change  of  air  and 
scene  may  have  further  beneficial  results.  Unfortunately,  the 
recovery  from  myelitis  is  often  incomplete,  and  both  patient  and 
doctor  may  have  to  be  content  with  a  condition  in  which  the 
ability  to  resume  ordinary  occupations  is  more  or  less  impaired. 

E.    FARQUHAR    BUZZARD. 


1219 


SYRINGOMYELIA. 

THOUGH  the  cases  included  under  syringomyelia  form  a  definite 
entity,  their  symptoms  may  be  due  to  different  pathological  pro- 
cesses. In  one  class  the  central  cavity  in  the  cord  results  from  the 
breaking  down  of  a  gliomatous  tumour ;  in  another  it  is  due  to  a 
primary  gliosis  with  secondary  rarefaction. 

As  might  be  expected,  therapeutic  measures  can  have  little 
influence  on  the  course  of  these  lesions,  so  treatment  must  be 
mainly  symptomatic.  There  is  considerable  evidence  that  the 
disease  may  set  in  after,  or  become  aggravated  by,  traumatic 
injuries  to  any  part  of  the  body,  but  especially  to  the  vertebral 
column,  and  the  patient  should  consequently  be  warned  of  their 
possible  ill-effects.  As  the  local  trophic  disturbances,  such  as 
arthropathies,  perforating  ulcers  and  whitlows,  may  be  excited  by 
local  injuries,  care  should  be  taken  to  avoid  them.  The  insensitive- 
ness  to  painful  and  thermal  stimuli  increases  the  danger,  since 
trivial  injuries  that  may  lead  to  serious  septic  processes  may  be 
unobserved  and  left  untreated.  When  developed,  these  trophic 
disturbances  should  be  dealt  with  on  ordinary  surgical  and 
antiseptic  principles.  Even  amputation  may  be  advisable  when 
there  is  extensive  destruction  or  suppuration  of  bone  or  other 
tissues.  Surgical  intervention  ia  joint  lesions  is  useless  and 
inadvisable. 

The  disturbances  due  to  the  atrophic  palsies  may  often  be 
relieved  by  massage  and  faradisni  of  the  muscles,  while  the 
spastic  symptoms  should  be  treated  by  the  ordinary  means. 
Belladonna  and  ergot  are  useful  in  relieving  the  flexor  spasms 
that  occur  in  the  more  spastic  cases ;  veronal  in  moderate 
doses  is  more  efficient  but  less  suitable  for  continuous  adminis- 
tration. 

Gramenga,  Raymond  and  others  have  recorded  favourable 
influence  on  the  symptoms,  as  well  as  on  the  course  of  the 
disease,  from  the  application  of  Rontgen  rays  to  the  spinal 
column.  Beaujard  and  Lhermitte,  who  obtained  excellent  results 
from  this  treatment,  recommend  the  application  of  rays  of 

77—2 


I22O  Syringomyelia. 

moderate  strength  once  or  twice  a  week  to  the  spine.  Touchard 
and  Fabre  observed  definite  improvement  following  repeated 
application  of  radium  to  the  spine  at  the  level  of  the  chief  medul- 
lary disease. 


GORDON  HOLMES. 


EEFEEENCES. 


Eiv.  Critica  di  Clin.  Med.,  1906. 

Semaine  Med.,  Paris,  1907,  XXVII.,  p.  193. 

Eev.  Neurologique,  Paris,  1909,  XVII.,  p.  647. 


1221 


TUMOURS  OF  THE  SPINAL  CORD. 

SPINAL  TUMOUKS  may  originate  in  four  situations : 

(1)  In  the  vertebrae,  the  cord  symptoms  being   due   to   indirect 
pressure. 

(2)  Outside  the  dura,  between  the  outer  surface  of  the  dura  and 
the  bone  of  the  vertebral  canal  (extra-dural  meningeal  tumour). 

(3)  Within  the  dura  mater,  between  the  cord  and  the  inner  sur- 
face of  the  dura  (intra-dural  meningeal  tumours). 

(4)  Within  the  cord  substance  (intra-medullary  tumours). 
What  is,  however,  understood  by  the  term  tumour  of  the  spinal 

cord  is  an  extra-medullary  but  intra-spinal  growth  giving  no  evidence 
of  its  existence,  except  by  the  symptoms  of  medullary  pressure 
which  it  produces. 

Tumours  of  the  fourth  group,  and  most  of  those  of  the  first  group, 
are  unsuitable  for  surgical  treatment,  save  for  such  treatment  as  is 
directed  towards  relief  of  pain.  In  cases  of  tumour  of  the  vertebrae 
compressing  the  cord,  operative  treatment  will  not  give  permanent 
relief,  except  in  very  rare  non-malignant  forms  of  growth. 

The  most  practical  classification  of  cases  of  spinal  cord  tumours 
for  clinical  purposes  is  :  (1)  Medullary,  or  tumours  of  the  cord  ; 
(2)  extra-medullary,  or  tumours  of  any  of  the  envelopes.  This 
classification  is  based  on  the  seat  of  the  tumour,  irrespective  of  the 
nature  of  the  tissue  from  which  it  grows. 

As  regards  treatment,  too  great  stress  cannot  be  laid  on  the  im- 
portance of  early  operation.  It  should  be  performed  without  delay, 
as  soon  as  the  diagnosis  is  made. 

Owing  to  the  infrequency  of  gumma,  it  is  even  unwise  to  postpone 
operation  for  the  sake  of  trying  anti-syphilitic  treatment,  if  there 
is  no  evidence  whatever  of  the  syphilitic  nature  of  the  tumour. 
Delay  in  operating,  in  order  to  give  a  trial  to  an ti- syphilitic  treat- 
ment, may  be  the  cause  of  an  unsuccessful  result  when  the 
operation  is  finally  performed. 

For  the  successful  operative  treatment  of  spinal  tumour,  not  only 
is  a  correct  differential  diagnosis  necessary,  but  the  growth  must 
be  exactly  localised  by  a  consideration  of  the  upper  limit  of  the 
motor  and  sensory  symptoms. 

It  is  necessary  to  seek  for  the  highest  seat  of  the  sensory  and 
paralytic  symptoms  and  to  refer  them  to  the  highest  segment  of  the 


1222  Tumours  of  the  Spinal  Cord. 

cord  which  could  be  in  question,  and  finally  to  ascertain  the  dorsal 
spine  which  corresponds  to  the  upper  segment.  Owing  to  the  fact 
that  the  tumour  is  found  higher  than  is  anticipated  from  the 
symptoms,  Bruns  states  that  "  if  symptoms  of  a  sensory  nature 
point  to  any  one  dorsal  segment  of  the  cord  being  pressed  upon  by 
the  tumour,  the  operation  should  expose  the  dorsal  segment  one  or 
even  two  levels  higher." 

With  very  few  exceptions,  it  is  impossible  to  determine  the 
nature  of  the  tumour  before  operation.  Gummata  are  very  rare  in 
the  spinal  canal,  and  as  before  stated,  it  is  never  worth  while  to 
delay  operation  for  the  sake  of  trying  anti-syphilitic  treatment.  It 
is  only  in  syphilitic  growths  that  medicinal  treatment  can  be  of 
use,  and  here  it  is  only  in  the  early  stages  that  such  treatment  can 
be  of  value  if  employed  at  all.  If  used  at  all,  syphilitic  remedies 
should  be  commenced  at  the  earliest  possible  moment  and  pushed 
with  vigour.  Operative  treatment  affords  the  only  chance  of  relief 
in  other  kinds  of  growth. 

Tumours  within  the  substance  of  the  cord,  excepting  in  rare 
instances,  cannot  be  removed  without  producing  additional  injury 
to  the  cord.  Fortunately,  however,  the  greater  number  of  spinal 
tumours  are  extra-medullary. 

All  the  evidence  which  we  now  have  points  to  extreme  repara- 
tive  power  on  the  part  of  the  cord,  which  has  been  simply  suffering 
from  pressure,  and  to  an  almost  equally  remarkable  tolerance  of 
operative  interference. 

It  would  seem  proper,  therefore,  to  conclude  that  every  case  of 
focal  spinal  lesion,  thought  to  depend  upon  a  tumour,  and  not  a 
distinctly  malignant  and  generalised  disease,  should  be  regarded 
as  amenable  to  operative  interference,  no  matter  how  marked  and 
long  continued  the  symptoms  of  pressure  may  be. 

In  cases  which  are  hopeless  as  regards  the  restoration  of  func- 
tion, it  should  be  considered  whether  it  may  not  be  advisable  to 
operate  merely  for  the  relief  of  pain,  even  when  there  is  no  hope  of 
restoring  the  function  of  the  damaged  cord.  The  pain  in  some 
cases  is  excruciating,  and  the  sufferings  of  the  patient  are  intense. 
In  such  cases  an  operation  with  a  view  to  the  removal  of  the 
source  of  irritation,  or  to  the  section  of  the  posterior  spinal  roots 
affected,  should  be  considered. 

Medicinal  treatment  can  only  be  directed  towards  making  the 
patient  comfortable  and  preventing  many  secondary  consequences, 
such  as  cystitis  and  bed-sores.  To  relieve  the  pain,  resort  must  be 
had  to  anodynes.  The  greatest  attention  should  be  paid  to  the 
bladder  in  order  to  prevent  the  development  of  cystitis  and  its 


Tumours  of  the  Spinal  Cord.  1223 

consequences,  and  an  equal  amount  of  attention  should  be  given  to 
the  prevention  of  the  formation  of  bed-sores.  Should  the  forma- 
tion of  bed-sores  take  place,  ordinary  surgical  measures  should  be 
employed  to  keep  them  clean  and  prevent  septic  absorption. 

Operation. — The  operation  for  the  removal  of  spinal  tumours  is 
that  known  as  laminectomy  or  rhachiotorny. 

The  description  given  here  is  based  upon  the  operation  as 
performed  by  the  writer,  though  doubtless  it  differs  in  no  essential 
detail  from  other  surgeons'  methods. 

The  patient  is  prepared  in  the  usual  way  for  major  operations. 
Should  a  bed-sore  be  present,  it  is  sealed  up  under  antiseptic 
gauze,  and  covered  with  a  large  piece  of  adhesive  plaster.  If  the 
incision  is  to  be  placed  in  the  cervical  region,  the  scalp  is  shaved 
and  carefully  cleansed  behind  a  line  joining  the  two  pinnae  across 
the  vertex. 

Chloroform  anaesthesia  is  induced  by  means  of  a  Vernon  Harcourt 
inhaler,  and  oxygen  is  administered  during  the  operation  as 
indicated  by  the  condition  of  the  pulse,  respiration,  and  the  blood. 

The  patient  lies  upon  his  right  side,  with  his  back  arched  close 
to  the  edge  of  the  table  and  his  knees  flexed,  the  upper  one  lying 
in  front  of  the  lower.  This  position  is  maintained  by  flexing  the 
upper  arm  at  the  elbow  and  placing  the  hand  palm  downwards 
upon  the  table  just  in  front  of  the  body  ;  the  arm  is  steadied  in 
this  position  by  a  nurse,  who  stands  in  front  of  the  patient.  A 
specially  devised  arm-rest,  fixed  to  the  table,  may  be  employed. 
By  either  of  these  devices  not  only  is  the  patient  prevented  from 
rolling  over  on  to  his  face,  but  interference  with  respiration  is 
reduced  to  a  minimum. 

The  first  assistant  stands  on  the  same  side  of  the  patient  as  the 
operator,  facing  the  patient's  feet.  A  second  assistant  stands  on 
the  opposite  side  of  the  patient.  His  duty  is  to  hold  the  upper 
retractor  in  the  wound  when  required. 

An  incision  4  to  6  inches  in  length  is  then  made  in  the 
middle  line  of  the  back,  with  its  centre  over  the  segment  of  the 
spinal  cord  it  is  desired  to  expose. 

The  incision  is  carried  at  once  down  to  the  tips  of  the  spinous 
processes.  The  knife  is  then  carried  along  the  lower  sides  of  the 
spinous  processes,  cutting  through  close  to  the  bone  all  muscular 
and  tendinous  attachments,  until  the  laminae  are  reached. 

A  broad  raspatory  is  then  used  to  clear  the  muscular  mass  off 
the  posterior  surface  of  the  laminae.  No  attempt  is  made  to  catch 
any  vessels  with  artery  forceps.  The  bleeding  is  almost  entirely 
venous.  An}7  endeavour  to  seize  the  vessels  with  artery  forceps 


1224  Tumours  of  the  Spinal  Cord. 

only  tears  or  bruises  the  muscular  tissue  amongst  which  they  lie, 
and  gives  rise  to  necrosis  afterwards.  Moreover,  much  valuable 
time  will  be  wasted. 

The  bleeding  is  readily  and  certainly  stopped  by  packing  the 
wound  with  gauze  taken  from  boiled  water  at  115°  F.  Exactly 
the  same  procedure  is  carried  out  upon  the  upper  side  of  the 
spinous  processes.  By  the  time  that  the  upper  laminae  are  cleared 
and  this  part  of  the  wound  packed,  the  bleeding  will  have  been 
entirely  checked  below.  As  soon  as  the  wound  is  dry,  the  skin 
and  muscle  mass  are  retracted,  and  three  or  four  spinous  processes 
are  cut  through  at  their  bases  by  means  of  bone  forceps,  and  removed. 

The  processes  selected  are  those  of  the  vertebrae,  the  laminae  of 
which  it  is  intended  to  remove.  Then  the  laminae  are  cut  through 
as  far  out  as  possible  on  either  side  by  bone  forceps  and  removed. 
The  outer  surface  of  the  dura  mater  is  then  exposed  by  gently 
scraping  or  pushing  aside  the  loose  fatty  areolar  tissue  covering  it. 

The  presence  or  absence  of  pulsation  is  ascertained.  A  careful 
examination  is  then  made  to  ascertain  if  the  tumour  is  extra-dural. 
The  dura  is  gently  displaced  first  to  one  side  and  then  to  the 
other,  and  its  lateral  aspects,  together  with  the  issuing  nerve  roots, 
examined. 

By  means  of  a  long  blunt  probe  or  seeker,  the  anterior  surface 
is  also  explored  upwards  and  downwards.  Having  convinced  one- 
self that  the  tumour  is  not  extra-dural,  the  dura  mater  is  opened 
along  its  posterior  middle  line  and  the  cut  edges  retracted  to  either 
side. 

For  this  purpose  the  cut  edge  may  be  seized  on  either  side  by 
means  of  angular  forceps.  The  cord  is  then  carefully  examined 
much  in  the  same  way  as  the  spinal  canal  was.  When  found,  the 
tumour  is  removed  as  its  situation  and  connections  demand.  In 
one  case  it  will  shell  out,  in  another  it  will  be  firmly  adherent 
to  the  dura,  or  to  one  or  more  nerve  roots  which  may  have  to  be 
sacrificed. 

Should  it  be  intra-medullary,  the  question  will  arise  as  to 
whether  an  attempt  should  be  made  to  remove  it  or  not.  Each 
case  must  be  judged  on  its  merits.  The  general  aspect  of  the 
subject  has  been  already  discussed. 

On  removal  of  the  tumour,  the  dura,  if  opened,  is  stitched  up  by 
a  few  fine  catgut  or  horsehair  sutures.  The  muscles  are  then 
brought  together  by  catgut  sutures,  and  finally  the  skin  is  closed  by 
interrupted  silkworm-gut  sutures.  A  drain  is  rarely  necessary,  but, 
if  required,  a  small  gauze  wick  covered  with  protective  tissue  may 
be  left  in  for  twenty-four  hours. 


Tumours  of  the  Spinal  Cord.  1225 

Should  the  tumour  not  be  discovered  in  the""area  of  the  cord  and 
meninges  exposed,  it  may  be  considered  advisable  to  remove  one 
or  more  laminae,  usually  in  an  upward  direction,  to  give  further 
exposure.  This  will  depend  upon  the  condition  of  the  cord  with 
reference  to  pulsation  at  the  seat  of  exposure,  and  also  upon  the 
symptoms  upon  which  the  diagnosis  has  been  based. 

An  abundance  of  gauze  dressings  are  applied,  covered  with  wool, 
and  the  whole  retained  in  place  by  a  many-tailed  bandage.  No 
splint  of  any  kind  is  required. 

The  patient  is  placed  flat  on  his  back  in  bed,  with  his  head 
slightly  raised,  or  if  the  operation  has  been  in  the  cervical  region, 
supported  between  sandbags.  It  is  advisable  to  have  recourse  to 
a  water-bed  in  most  cases. 

The  dressings  are  changed  at  the  end  of  twenty-four  to  forty- 
eight  hours,  and  as  often  afterwards  as  the  comfort  of  the  patient 
demands.  The  stitches  should  not  be  removed  for  at  least  ten 
days  or  a  fortnight. 

In  cases  in  which  there  occurs  a  leakage  of  cerebrospinal  fluid 
through  the  wound,  urotropine  (in  10-gr.  doses)  should  be  adminis- 
tered three  times  daily,  and  every  precaution  taken  to  prevent 
infection  of  the  wound,  by  frequent  dressings  under  strict  aseptic 
precautions.  The  recumbent  posture  should  be  maintained  for  at 
least  six  weeks,  with  such  slight  alterations  in  position  as  may  add 
to  the  comfort  of  the  patient. 

During  this  period  massage,  passive  movements  and  electrical 
treatment  should  be  employed  to  maintain  muscular  nutrition  and 
prevent  the  formation  of  contractures. 

DONALD  ARMOUR. 


1226 


VASOMOTOR  AND  TROPHIC  DISEASES. 

ACROMEGALY. 

IN  this  affection,  as  its  name  implies,  there  is  considerable 
enlargement  of  the  extremities  and  also  of  many  parts  of  the  face, 
such  as  the  lower  jaw,  the  brows,  the  malar  eminences  and  the 
nose.  It  is  especially  prone  to  develop  in  individuals  who  are  above 
the  normal  height,  and  quite  a  large  proportion  of  giants  are 
acromegalic.  The  symptoms  probably  depend  on  some  functional 
alteration  of  the  pituitary  gland,  where  in  many  of  the  cases  gross 
anatomical  changes  have  been  found.  The  changes  consist  in  the 
gland  being  greatly  increased  in  size,  mostly  due  to  sarcomatous  new 
growth,  so  that  an  intra-cranial  tumour  is  formed,  which  raises  the 
intra-cranial  pressure  and  leads  to  intense  pain  and  vomiting.  From 
its  situation  the  tumour  presses  on  the  optic  chiasma  and  causes 
blindness  on  the  nasal  side  of  each  retina,  bi-temporal  hemianopsia. 

The  treatment  depends  on  whether  the  proper  symptoms  of 
acromegaly  exist  alone,  or  whether  they  are  accompanied  by  signs 
of  a  tumour  in  the  sella  turcica.  In  the  absence  of  symptoms 
suggesting  the  existence  of  a  tumour,  there  is  little  to  be  done  in 
the  way  of  treatment.  Some  patients  are  able  to  pursue  their 
ordinary  avocations  without  any  special  discomfort  beyond  the 
purchase  of  larger  hats,  gloves  and  boots.  Others  suffer  from 
muscular  weakness,  and,  if  poor,  tend  to  drift  into  the  workhouses. 
Experiments  have  been  made  with  the  administration  of  pituitary 
and  thyroid  extracts,  but  neither  seem  to  have  any  real  influence 
over  the  complaint,  though  some  cases  have  been  said  to  improve 
while  taking  extracts  of  the  thyroid  gland.  The  other  class  of 
patients  where  there  is  evidence  of  a  tumour  calls  for  instant 
treatment,  since  they  suffer  from  visual  defects  and  intense  pain  in 
the  head,  and  there  is  a  probability  of  their  early  death.  As  pointed 
out  by  Sir  Victor  Horsley,  the  only  satisfactory  treatment  consists 
in  the  removal  of  the  tumour  by  the  knife,  and  there  should 
be  no  delay  in  calling  for  the  surgeon's  aid.  Unfortunately  com- 
plete ablation  of  the  pituitary  gland  in  arn'mals  always  leads  to 
death  ;  there  is  not  sufficient  evidence  as  to  its  effect  in  human 
beings,  but  it  is  unlikely  that  they  would  differ  from  animals. 


Achrondroplasia.  1227 

Short  of  removal  of  the  tumour  the  treatment  can  he  merely  pallia- 
tive, the  pain  being  deadened  as  far  as  possible  by  such  drugs  as 
phenacetin,  phenazone  and  morphia. 


ALFRED  M.  GOSSAGE. 


REFERENCE. 
Hoisley,  Sir  Victor,  Brit.  Med.  Journ.,  1906,  I.,  p.  323. 


ACHRONDROPLASIA  (CHRONDRODYSTROPHIA 

FCETALIS). 

OWING  to  a  defective  development  of  cartilage  there  is  in  this 
disease  a  deficiency  in  the  length  of  the  long  bones  of  the  limbs 
compared  with  the  trunk.  The  humeri  and  femora  are  specially 
affected.  The  hands  take  on  a  characteristic  shape,  which  has  been 
called  the  "  trident  hand,"  and  there  is  also  a  shortening  of  the 
base  of  the  skull,  which  causes  a  marked  depression  at  the  root  of 
the  nose.  The  condition  has  been  called  foetal  rickets,  since  it  is 
already  manifest  at  birth  ;  but,  although  several  of  the  affected 
infants  become  rickety  later  on,  there  is  no  real  connection  with 
rickets.  In  the  majority  of  cases  the  children  are  born  dead  or  die 
shortly  after  birth.  A  certain  proportion,  however,  survives,  and 
except  for  the  deformities  the  survivors  are  not  inferior,  mentally 
or  physically,  to  normal  children.  The  complaint  cannot  be 
influenced  by  treatment. 

ALFRED  M.  GOSSAGE. 


1228 


ANGIONEUROTIC    CEDEMA. 

IN  this  condition  there  is  a  tendency  to  the  development  of 
cedematous  patches  on  the  skin  and  mucous  membranes,  the  patches 
varying  in  size  from  that  of  a  hean  up  to  an  area  as  large  as  the 
palm  of  the  hand.  The  oedema  appears  in  attacks  lasting  several 
days  or  weeks,  and  the  intervals  between  the  attacks  vary  from 
a  few  days  to  some  months  or  even  years.  Each  patch  of  oedema 
lasts  only  a  few  hours,  but  the  attack  is  continued  by  the  successive 
appearance  of  fresh  patches  in  different  parts  of  the  bod}r.  The 
oedema  shows  itself  especially  on  exposed  surfaces,  such  as  the  face  or 
hands,  but  may  also  affect  the  covered  parts  of  the  trunk.  Impli- 
cation of  the  mucous  membranes  may  lead  to  difficulty  in  speaking 
or  eating  from  the  enormous  swelling  of  the  lips  or  tongue  ;  diffi- 
culty of  swallowing  from  swelling  of  the  pharynx ;  urgent  and  even 
fatal  dyspnoea,  from  involvement  of  the  larynx.  The  mucous  mem- 
branes of  the  abdominal  viscera  are  not  always  spared,  colic  and 
vomiting  resulting  when  the  stomach  is  attacked,  and  intense 
abdominal  pain  and  diarrhoea  when  the  small  intestine  is  implicated, 
so  that  in  several  cases  abdominal  section  has  been  performed  from 
the  mistaken  diagnosis  of  intussusception.  The  disorder  is  often 
hereditary,  and  has  sometimes  been  traced  back  through  many 
generations  ;  but  as  far  as  can  be  judged  from  the  recorded  families, 
it  seems  only  to  pass  through  individuals  who  themselves  exhibit 
the  liability,  so  that  normal  members  of  an  affected  family  may  be 
assured  that  they  are  not  likely  to  transmit  it  to  their  descendants. 

The  fluctuating  and  temporary  character  of  the  oedema,  as  well 
as  the  irregular  and  often  protracted  intervals  between  the  attacks, 
render  the  proper  estimation  of  the  effect  of  treatment  very  difficult. 
Of  first  importance  is  attention  to  the  general  condition  of  the 
patient.  The  sufferers  are  frequently  highly  neurotic  individuals, 
showing  symptoms  of  hysteria,  and  to  a  still  greater  extent  of 
neurasthenia.  With  improvement  of  the  general  health  the  ten- 
dency to  oedema  often  disappears,  hence  freedom  from  worry,  open- 
air  life,  hydrotherapy,  general  massage  and  electricity  may  all  be 
of  the  greatest  benefit.  It  seems  possible  that  some  of  the  cases 
are  due  to  intestinal  intoxication ;  at  any  rate,  several  cures  have 
been  reported  after  the  use  of  intestinal  disinfectants,  such  as 
aspirin,  menthol  and  camphor.  Unlike  the  closely  allied  condition 


Angioneurotic  (Edema.  1229 

of  urticaria,  particular  articles  of  diet  do  not  seem  to  have  any 
influence  in  causing  the  development  of  the  oedema,  but  fish  and 
strawberries  have  been  reputed  to  have  a  causal  relation  in  one  or  two 
patients.  If  any  aliment  be  discovered  to  have  a  malign  influence, 
it  should,  of  course,  be  avoided.  The  number  of  drugs  that  have 
been  recommended  for  use  is  enormous,  chiefly  on  account  of  ex- 
perience in  individual  cases,  but  on  wider  trial  most  of  them  have 
been  found  useless.  Sir  \V.  Osier  says  that  the  only  drugs  which  he 
has  found  of  benefit  have  been  nitroglycerine  (or  the  nitrites)  and 
calcium.  The  former  he  prescribes  in  ascending  doses  until  the 
effects  are  felt,  viz.,  flushing  of  the  face  and  throbbing  of  the  vessels. 
The  treatment  should  be  continued  for  ten  days,  and  then  an  interval 
of  five  days  allowed,  after  which  it  should  be  re-commenced. 
Calcium  may  be  prescribed  as  15  to  20  gr.  of  the  lactate  three 
times  a  day.  It  has  been  reported  to  have  benefited  several  cases ; 
but  the  writer  obtained  no  result  from  it  in  two  patients,  and  others 
have  had  a  similar  experience.  Purin-free  diet  and  a  diet  with  a 
very  limited  amount  of  carbohydrates  have  both  been  recommended, 
and  both  seem  to  have  been  of  value  in  some  cases  and  quite  useless 
in  others. 

The  severer  conditions  associated  with  oedema  of  the  mucous 
membranes  often  require  active  treatment.  Fortunately,  however, 
the  local  oedema  only  lasts  a  few  hours.  Gastric  or  intestinal 
oedema  may  simulate  intestinal  obstruction,  but  will  never  require 
operation,  and  the  pain  may  usually  be  relieved  by  hot  stupes. 
If  this  is  not  successful,  a  hypodermic  injection  of  morphia  will 
become  necessary.  (Edema  of  the  larynx  may  necessitate  local 
scarification  or  tracheotomy  to  save  life.  The  tendency  for  the 
development  of  this  dangerous  complication  is  much  greater  where 
the  condition  is  hereditary,  and  must  always  cause  grave  anxiety  in 
this  class  of  patients. 

ALFRED  M.  GOSSAGE. 

EEFERENCES. 

Osier,  Sir  W.,  Osier  and  McCrae,  "System  of  Medicine,"  1909,  VI.,  p.  648. 
Cassirer,  "Die  Yasomotorish-Trophischen  Neurosen,"  Berlin,  1901. 


1230 


ERYTHROMELALGIA. 

THIS  is  a  rare  but  excessively  painful  affection,  characterised 
by  hypersemia  of  one  or  more  extremities,  which  is  probably  due 
to  some  disorder  of  the  vasomotor  mechanism,  resulting  in  a  dila- 
tation of  the  arteries  of  the  affected  area.  During  an  attack  the 
extremity  becomes  bright  pink  in  colour  when  dependent,  and  is 
the  seat  of  excruciating  pain  and  tenderness ;  but  on  raising  it 
above  the  level  of  the  trunk  the  pink  colour  almost  entirely  dis- 
appears, and  the  distressing  symptoms  are  much  relieved.  The 
course  of  the  affection  is  very  chronic,  lasting  many  months  or 
years,  and  being  but  little  influenced  by  treatment.  At  first  only 
a  small  portion  of  the  extremity  is  attacked,  but  gradually  the 
redness  invades  a  wider  and  wider  area,  until,  for  instance,  the 
whole  lower  limb  may  be  involved  as  high  as  the  knee.  The  condi- 
tion may  then  remain  stationary  for  a  long  period.  Subsequently 
it  may  gradually  recede  until  complete  recovery  takes  place ; 
or  some  degree  of  the  affection  may  remain  permanently,  or,  at  any 
rate,  until  the  cases  are  lost  sight  of.  In  many  typical  examples  of 
erythromelalgia  no  evident  pathological  changes  have  been  found, 
but  in  several  recent  cases  thickening  of  the  arteries  has  been 
described,  while  similar  symptoms  are  not  so  very  uncommon  in  gross 
disease  of  the  nervous  system,  whether  of  the  spinal  cord  (such  as 
syringomyelia),  of  the  brain  (as  hemiplegia),  or  of  the  peripheral 
nerves.  Generally  the  distribution  of  the  hyperaemia  has  no  rela- 
tion to  the  nerve-supply  of  the  part,  but  in  rare  cases  it  has  been 
limited  to  the  distribution  of  a  single  nerve. 

In  dealing  with  the  complaint  one  has  to  remember  its  chronic 
course,  and  the  tendency  sometimes  exhibited  for  the  patients  to 
get  gradually  well  without  any  treatment.  It  is  doubtful  whether 
the  duration  of  the  complaint  has  been  actually  shortened  by  any 
method  of  treatment ;  but  since  some  sufferers  seem  to  have  been 
relieved  by  certain  measures,  these  should  be  given  a  trial,  even 
although  they  have  proved  ineffectual  with  others.  Naturally  in 
such  an  obstinate  disorder  the  number  of  remedies  which  have  been 
tried  has  been  almost  innumerable.  The  main  consideration  is  to 
relieve  pain,  the  severity  of  which  is  often  terrible.  The  dependent 
position  and  exertion  nearly  always  increase  the  hyperaeniia  and 
pain,  so  the  patient  should  be  kept  lying  in  the  horizontal  position 


Erythromelalgia.  1231 

with  the  affected  extremity,  usually  a  foot,  raised  ahove  the  level  of 
the  trunk  on  pillows ;  but  owing  to  the  lengthy  duration  of  the 
complaint  the  patient  frequently  refuses  to  endure  this  for  longer 
than  a  few  months.  Cold  applications,  such  as  icebags  or  bathing 
with  cold  water  or  salt  and  water,  usually  afford  some  relief  to 
the  suffering,  while  warmth,  as  would  be  expected,  increases  the 
hyperaemia.  In  exceptional  cases,  however,  warm  baths  or  even 
radiant  heat  have  proved  beneficial,  and  sometimes  cold  has 
aggravated  the  symptoms.  In  this  connection  it  is  of  interest 
to  note  that  erythromelalgia  tends  to  attack  those  persons  whose 
extremities  are  constantly  exposed  to  wet,  such  as  washerwomen 
and  men  who  with  defective  boots  have  to  tramp  the  streets  in  all 
weathers. 

As  in  Raynaud's  disease,  the  employment  of  electricity  has  been 
advocated,  both  the  constant  current  and  faradisation.  The  most 
efficacious  method  seems  to  be  the  immersion  of  the  affected  part  in 
fanidic  baths  for  from  fifteen  to  twenty  minutes  daily.  Pain  can 
sometimes  be  assuaged  by  the  application  of  the  anode  of  the  con- 
stant current  to  the  painful  area,  the  kathode  being  on  some 
indifferent  part.  It  must  be  realised  that  the  measures  indicated 
not  infrequently  fail  to  give  complete  relief,  and  the  administra- 
tion of  anodyne  drugs  becomes  imperative.  Phenazone,  phenacetin 
and  aspirin  should  first  be  tried ;  but  if  these  fail  to  diminish  the 
pain,  opium  or  morphia  must  be  resorted  to.  Where  the  pain  and 
redness  are  confined  to  the  distribution  of  a  single  nerve  a  portion 
of  its  trunk  may  be  excised  if  other  means  are  of  no  avail. 


ALFRED  M.  GOSSAGE. 


REFERENCES. 


Mitchell,  8.  Weir,  and  Spiller,  W.  G.,  Amer.  Journ.  of  Med.  Sci.,  Phila.,  1899, 
CXVIL,  p.  1.  Cassirer,  "  Die  Vasomotorisch-Trophischen  Neurosen,"  Berlin, 
1901.  Osier,  Osier  and  McCrae,  "  System  of  Medicine,"  1909,  VI.,  p.  675.  Barlow, 
Allbutt  and  Rolleston,  "System  of  Medicine,"  2nd  edit.,  1910,  VII.,  p.  149. 


1232 


FACIAL  HEMIATROPHY. 

FACIAL  HEMIATROPHY  is  a  rare  disease,  and  its  pathology,  not- 
withstanding the  fact  that  several  autopsies  have  been  recorded, 
is  still  uncertain.  Hence  its  treatment  remains  symptomatic  and 
empirical.  As  a  rule,  the  atrophy  is  chiefly  limited  to  the  skin  and 
subcutaneous  tissues ;  the  muscles  themselves  are  not  paralysed 
and  are  sometimes  only  slightly  atrophic.  The  appearance  pro- 
duced often  closely  resembles  scleroderma,  with  which  condition, 
indeed,  it  may  be  associated. 

Electrical  treatment  with  the  interrupted  current  may  be  tried, 
but  the  muscles  will  be  found  to  react  well  to  it,  while  its  effect  on 
the  atrophic  cutis  is  problematical.  Local  massage  systematically 
carried  out  is  probably  advantageous.  Rubbing  the  affected  parts 
with  oils  or  liniments  may  be  useful.  Injections  of  tibrolysin  in 
the  neighbourhood  of  the  atrophic  area  might  possibly  be  attended 
with  good  results.  The  appearance  of  the  patient's  face  may  be 
improved  by  paraffin  injections  (Osier  and  Macrae). 

General  nerve  tonics  may  be  administered  empirically.  Walker 
thinks  he  has  seen  improvement  in  cases  of  scleroderma  from  the 
exhibition  of  thyroid  substance,  and  it  might  be  given  a  trial  in 
facial  hemiatrophy. 

S.  A.  KINNIER  WILSON. 

KEFERENCE. 

Aldren  Turner,  article  in  "Allbutt's  System  of  Medicine,"  2nd  edit.,  1910, 
VII.,  p.  167  (bibliography). 


1233 


HYPERTROPHIC   PULMONARY   OSTEO- 
ARTHROPATHY. 

THIS-  is.  ai.  condition  which  occasionally  arises  in  the  course  of 
chronic  ehest  diseases,  especially  of  a  septic  nature,  such  as 
bronchiectasia  or  empyenia.  It  is  characterised  by  an  enlargement 
of  the  bories  of  the  limbs  due  to  deposit  from  the  periosteum.  The 
bones  chiefly  implicated  are  those  of  the  forearms,  hands,  and 
fingers,  and  of  the  legs  and  feet,  in  the  case  of  the  longer  ones 
mainly  at  their  distal  extremities.  In  addition  there  is  always  a 
good  deal  of  thickening  of  the  connective  tissue,  which  is  the  cause 
of  the  associated  clubbing  of  the  fingers  and  toes.  The  joints,  too, 
;uv  sometimes  attacked,  the  synovial  membrane  being  thickened, 
occasionally  with  effusion  of  fluid.  There  is  usually  some  pain  in 
the  affected  parts,  which  becomes  more  severe  in  paroxysms.  The 
condition  is  probably  due  to  septic  absorption,  and  can  only  be 
ameliorated  by  measures  which  render  the  pulmonary  discharges 
aseptic,  or  which  bring  the  suppurative  process  to  an  end,  as  by 
free  drainage  of  an  empyema.  Any  pain  that  arises  may  be 
relieved  by  warm  local  applications,  or  sometimes  by  such  drugs  as 
salicylate  of  soda. 

ALFRED  M.  GOSSAGE. 

REFERENCES. 

Marie,  P.,  Rev.  de  Med.,  Paris,  1890,  X.,  p.  1.  Alexander,  J.  F  .,St.  Bartholo- 
mew's Hospital  Reports,  Lond.,  1906,  Vol.  XLIL,  p.  41. 


S.T. — VOL.  II. 


78 


1234 


INTERMITTENT    CLAUDIC ATION ;     INTERMITTENT 

LIMP. 

INTERMITTENT  CLAUDICATION  (Charcot),  or  intermittent  limp  (Erb1), 
is  regarded,  in  the  great  majority  of  recorded  cases,  as  being  due 
to  obliterative  arteritis,  or  arteriosclerosis,  of  the  smaller  vessels 
of  the  limb  or  limbs  affected.  The  condition  may  be  produced, 
however,  by  mechanical  or  other  pressure  on  one  of  the  main 
arterial  trunks  of  the  limb  at  a  higher  level,  while  Harris 
has  seen  a  typical  case  follow  popliteal  thrombosis.  It  is  not 
necessarily  confined  to  the  lower  extremities,  hence  "dyskinesia 
angiosclerotica "  has  been  proposed  as  a  more  comprehensive 
term.  Recently,  too,  intermittent  claudication  of  the  spinal  cord 
has  been  described  by  Dejerine2;  according  to  him  the  process 
is  one  of  "  meiopragia  "  of  part  of  the  cord,  that  is  to  say, 
insufficient  irrigation  by  the  blood  stream.  The  symptoms  are 
similar  to  those  which  characterise  the  peripheral  condition,  but 
peripheral  vessel  changes  are  conspicuous  by  their  absence. 

Treatment,  to  be  successful,  must  be  directed  to  two  objects, 
viz.,  the  underlying  pathological  condition,  and  its  varying  expres- 
sion ;  it  must,  in  a  word,  be  both  causative  and  symptomatic. 

(1)  The  treatment  of  obliterative  arteritis  or  local  arterio- 
sclerosis is  a  large  subject,  and  the  following  remarks  are  intended 
merely  to  indicate  the  best  methods  (see  also  Arteriosclerosis). 

(a)  Many  cases  are  syphilitic,  but  whether  this  is  so  or  not 
energetic  antisyphilitic  treatment  should  be  adopted  without  fail. 
The  results  are  often  remarkable.  Mercury  should  be  given  by 
inunction  (the  oleate  is  useful)  and  the  iodides  by  the  mouth. 
Sodium  iodide  is  preferable  to  the  potassium  salt,  as  more  likely 
to  reduce  tension  and  less  likely  to  cause  atheroma.  It  may  be 
given  in  small  doses,  not  more  than  10  gr.  three  times  a  day, 
for  three  weeks  at  a  time,  and  then  with  a  break  of  one  week.  The 
writer  can  testify  to  the  value  of  iodipin  (hypodermically  or  in 
capsule).  Teissier3  recommends  iodalose  (a  combination  with 
peptone).  Sodium  bicarbonate  is  an  excellent  drug  for  reducing 
hypertension  ;  the  dose  need  not  exceed  60  gr.  in  the  twenty- 
four  hours.  For  more  rapid  action  it  is  advisable  to  resort  to 
the  nitrites :  Liq.  trinitrini  [U.S.P.  spiritus  glycerylis  nitratis]  in 
minim  or  | -minim  doses,  three  times  a  day,  or  sodium  nitrite  (2  gr.), 


Intermittent  Claudication  ;  Intermittent  Limp.   1235 

or  erythrol  tetranitrate,  in  |-gr.  tabloids.  Other  antispasmodics, 
such  as  belladonna  or  the  bromides,  may  be  helpful.  Mistletoe 
has  been  much  vaunted  recently.  Potain  thinks  that  manganese 
carbonate  (3  to  5  gr.  a  day,  in  pill,  for  a  long  time)  tends  to  soften 
rigid  vessels. 

The  artificial  inorganic  serum  of  Trunecek  has  had  a  mixed 
reception,  but  there  seems  to  be  little  doubt  that  in  certain  cases  its 
hypotensive  action  is  astonishing.  Its  composition  is :  Sodium 
sulphate,  '44  parts  ;  sodium  chloride,  4'92 ;  sodium  phosphate,  '15  ; 
sodium  carbonate,  "20  ;  potassium  sulphate,  *40 ;  distilled  water  to 
make  up  100.  Trunecek  gives  1  cc.  hypodermically,  then  four 
days  later  1J  cc.,  then  2^  cc.,  and  so  on.  Levi  injects  1  cc. 
additional  every  second  day.  Teissier  3  recommends  an  analogous 
powder  in  cachet  every  morning  for  thirteen  consecutive  days. 

(/>)  Suitable  dietetic  treatment  is  of  preponderating  importance 
in  the  cases  under  consideration.  Put  very  briefly,  the  introduction 
of  noxious  substances  must  be  reduced  to  a  minimum,  and  their 
regular  elimination  must  be  encouraged.  Alcohol  is  harmful. 
Tobacco  should  be  forbidden,  unless  denicotinised  (sec  generally 
under  Arteriosclerosis). 

(c)  Gaseous  or  effervescent  baths  are  of  proven  value.     On  the 
amount  of  carbonic  acid  in  the  water,  the  temperature  and  duration 
of  the  bath,  and  the  degree  of  activity  of  its  constituents,  depends 
its  hypertensive  or  hypotensive  effect.     The  merit  of  the  method 
is  the  achievement  of  peripheral  depression  without  acceleration  of 
cardiac  action  (see  generally  under  Hydrology). 

(d)  The  high  frequency  current  may  appear  to  have  fallen  from 
its   high  estate   into  unmerited    disrepute,   for  many   convincing 
clinical  records  have  been  published  of  its  efficiency  in  reducing 
hypertension.     Only  such  cases  should  be  submitted  to  the  treat- 
ment as  are  likely  to  benefit  by  it ;  aortic  and  cardiac  and  coronary 
cases  are  unsuitable.     The  large  solenoid  of  d'Arsonval,  inside  which 
the  patient  is  placed,  is  the  best  apparatus,  but  few  installations  are 
supplied  with  it.     A  seance  should  not  last  longer  than  five  or  six 
minutes  as  a  rule. 

(c)  Much  will  depend,  in  cases  of  intermittent  claudication,  on 
the  patient  leading  a  quiet  life,  with  regular  but  gentle  brain  and 
muscle  exercise,  moderation  in  all  things,  that  is  to  say,  on  the 
intelligent  maintenance  of  a  hygienic  regime  that  does  not  degenerate 
into  valetudinarianism. 

(2)  The  more  definitely  symptomatic  treatment  of  the  disease 
may  briefly  be  noticed.  Hot  foot  baths  or  body  baths,  followed 
by  massage,  often  relieve  temporarily.  Galvanism  to  the  lower 

78—2 


1236  Leontiasis  Ossea. 

extremities  is  very  useful.  Galvanic  baths  are  of  considerable 
value,  especially  where  definite  vasomotor  symptoms  bulk  largely 
in  the  clinical  picture.  Hot  air  baths,  too,  may  reduce  circulatory 
embarrassment.  By  these  means  attacks  of  angina  cruris  can  often 
be  moderated.  The  physiological  value  of  rest  in  this  connection 
cannot  be  over-estimated. 

Whether  surgical  procedures,  such  as  arterio-venous  anastomosis 
or  nerve-stretching,  are  of  any  value  it  is  at  present  impossible 
to  say. 

S.   A.    KINNIER   WILSON. 

REFERENCES. 

1  Erb,  W.,  "  Deutsche  Ztschr.  fur.  Nerveiiheilk."  Leipz.,  1905,  XXIX.,  p.  465, 
ibid.,  1906,  XXX.,  p.  201. 

-  Dejerine,  J. ,  "  Eevue  Neurologique,"  Paris,  1906,  XIV.,  p.  341. 

8  Teissier,  J.,  "  Art£rio-sclerose  et  atheromasie,"  Paris  (Masson),  1908. 


LEONTIASIS  OSSEA. 

VIECHOW  first  called  attention  to  this  condition,  which  is  caused 
by  a  hyperostosis  of  the  bones  of  the  face  and  skull.  It  is  some- 
times associated  with  Paget's  disease  (osteitis  deformans),  but  more 
commonly  the  bony  increase  is  confined  to  the  head.  It  usually 
starts  in  late  childhood  and  progresses  slowly :  during  its  course 
the  various  grooves  and  hollows  of  the  skull  are  filled  up  with  bone, 
so  that  the  eyes  are  forced  from  their  sockets,  nerves  are  compressed 
in  their  grooves  and  foramina,  and  ultimately  paralysed,  and  the 
vessels  are  constricted  by  surrounding  rings  of  bone.  Eventually 
the  patient  becomes  blind,  deaf,  mentally  deficient,  and  generally 
paralysed.  Convulsions  sometimes  occur.  No  treatment  seems  to 
have  any  power  to  arrest  the  progress  of  the  disease  or  to  avert  the 
unhappy  conclusion.  In  the  early  stages  anti-syphilitic  remedies 
should  be  tried  on  the  chance  of  the  symptoms  being  of  syphilitic 
origin,  and  attempts  should  later  be  made  to  alleviate  the  pain 
(caused  by  pressure  on  the  nerves)  by  phenazone,  phenacetin,  or 
morphia. 

ALFRED  M.  GOSSAGE. 


1237 


OSTEITIS   DEFORMANS  (FACET'S   DISEASE). 

THIS  is  a  disease  of  obscure  causation,  in  which  the  bones  are 
enlarged  and  softened  so  that  the  limbs  become  curved,  the  spine 
bent  forward,  and  the  skull  thickened.  It  starts  in  middle  life,  and 
is  usually  associated  with  arterio-sclerosis,  but  in  itself  does  not 
seem  to  influence  the  patient's  general  health,  the  most  marked 
characteristics  being  shortening  of  the  stature  and  deformity  of  the 
limbs.  The  course  of  the  complaint  is  slowrly  progressive,  and 
cannot  be  altered  by  any  treatment.  There  is  usually  some  pain  in 
the  limbs,  which  can  be  best  relieved  by  counter-irritation  of  the 
skin  and  the  internal  administration  of  such  drugs  as  quinine  or 
phena/one.  Some  French  writers  regard  the  disease  as  a  late  effect 
of  congenital  syphilis ;  but  the  evidence  in  favour  of  this  view 
is  not  strong,  and  the  condition  is  not  in  the  least  benefited  by 
anti-syphilitic  drugs. 

ALFRED  M.  GOSSAGE. 

REFERENCE. 
Paget,  Sir  J.,  Med.  Chirurg.  Trans.,  Lond.,  1882,  LXV.,  p.  225. 


OSTEOGENESIS  IMPERFECTA. 

A  LARGE  number  of  the  infants  afflicted  with  this  disorder  are 
born  dead,  with  their  limbs  considerably  deformed  by  intra-uterine 
fractures.  The  condition  is  a  congenital  one,  in  which  the  bones  are 
brittle  and  easily  broken.  Of  the  patients  born  alive  most  die  in 
infancy,  but  some  survive  up  to  adult  life.  The  liability  of  the 
bones  to  fracture  gradually  diminishes  with  advancing  years,  but 
does  not  seem  to  be  influenced  by  any  method  of  ifreatment.  In  the 
management  of  these  cases  it  is  important  to  protect  them  as  far  as 
possible  from  injuries.  Numerous  fractures  are  certain  to  have 
occurred  before  the  child  is  seen,  and  even  with  the  greatest  care 
others  will  take  place.  These  must  all  be  carefully  set  to  avoid 
severe  deformities. 

ALFRED  M.  GOSSAGE. 

REFERENCE. 
Nathan,  P.  W.,  Amer.  Joura.  of  Med.  Sciences,  Phila.,  1905,  CXXIX.,  p.  1. 


I238 


RAYNAUD'S   DISEASE, 

IN  1862  Eaynaud  called  attention  to  a  condition  which  was 
characterised  by  attacks  of  (1)  anaemia  of  the  extremities :  fingers, 
toes,  ears,  etc.,  evidently  caused  by  spasm  of  the  arteries  supplying 
the  parts ;  (2)  cyanosis  and  swelling,  which  usually  followed  the 
attacks  of  local  anaemia,  but  might  occur  independently  of  them  ; 
(3)  gangrene  of  portions  of  the  extremities.  Both  local  syncope 
and  local  asphyxia,  as  Eaynaud  called  them,  as  a  rule,  precede  the 
gangrene,  and  the  latter  only  supervenes  when  one  or  both  of  these 
have  been  severe  and  long  continued.  While  the  anaemia  seems 
clearly  due  to  arterial  spasm,  the  causation  of  the  local  cyanosis  is 
more  obscure  ;  but  there  is  probably  a  regurgitation  of  blood  from 
the  veins,  while  the  arteries  still  remain  constricted  and  the 
circulation  in  the  affected  region  is  at  a  standstill.  Both  anaemia 
and  cyanosis  are  associated  with  a  decrease  of  local  temperature, 
and  may  be  accompanied  by  some  alterations  of  sensation,  such  as 
slight  anaesthesia,  tingling  and  burning  feelings,  and  very  frequently 
severe  pain.  The  degree  of  pain  is  independent  of  the  amount  of 
vascular  change,  and  hence  has  been  regarded  by  many  authors  as  due 
to  some  special  involvement  of  the  nervous  system.  The  paroxysms 
last  from  a  few  hours  to  several  days,  and  in  the  intervals  the 
patient  is  well  except  for  the  results  of  the  last  attack  (e.g.,  loss  of 
tissue  from  gangrene).  In  some  cases  the  attacks  are  associated 
with  epileptic  seizures,  probably  caused  by  spasm  of  the  cerebral 
arteries.  In  others,  especially  those  with  a  history  of  malaria, 
haemoglobinuria  develops,  following  haernoglobinaemia. 

The  common  c^yanotic  swelling  of  the  hands,  which  occurs  in 
many  people  during  cold  weather  and  is  associated  with  chilblains 
is  not  a  paroxysmal  affection  and  has  no  connection  with  llaynaud's 
disease ;  neither  is  the  "dead  finger,''  induced  by  cold  and 
disappearing  with  friction  and  warmth,  necessarily  a  sign  of  this 
complaint,  although  excessive  cold  may  produce  in  the  form  of 
frostbite  all  its  phenomena.  It  is  true  that  the  paroxysms  of  local 
syncope  and  asphyxia  are  more  likely  to  develop  in  cold  weather, 
but  they  may  occur  in  any  season,  and  indeed  may  be  induced  by 
the  application  of  heat,  such  as  washing  the  hands  in  hot  water. 

In  the  treatment  of  Eaynaud's  disease  we  are  confronted  with 
several  problems.  We  wish  to  relieve  and  cut  short  the  attack  from 


Raynaud's  Disease.  1239 

which  the  patient  is  at  the  moment  suffering,  and  next  we  desire 
to  prevent,  if  possible,  further  attacks.  The  methods  of  treatment 
may  be  divided  into  the  general  and  the  local.  Sufferers  are  often 
of  the  neurotic  temperament,  victims  of  hysteria  and  neurasthenia, 
added  to  which  there  seems  a  greater  liability  to  the  paroxysms 
when  the  general  health  is  poor. 

Hence  attempts  should  always  be  made  to  improve  the  general 
condition,  both  physical  and  mental,  by  such  measures  as  open-air 
exercise,  hydrotherapy,  electricity  and  massage.  In  many  of  the 
neurotic  class  mental  worry  is  a  direct  excitant  of  an  attack,  so 
that  they  should  be  protected  as  far  as  possible  from  anything  that 
is  likely  to  cause  emotional  disturbance.  The  greater  frequency 
of  the  paroxysms  in  winter  and  on  exposure  to  cold,  particularly 
damp  cold,  suggest  that  the  winter  should  be  spent  in  a  dry  warm 
climate,  such  as  Egypt  or  Algiers.  The  garments  should  be  warm 
and  of  wool,  and  care  should  be  taken  on  cool  days  to  clothe  the 
extremities  with  loose  warm  coverings,  such  as  woollen  socks  and 
gloves.  It  is  advisable  also  to  cover  the  skin  with  some  fatty 
preparation.  Since  the  condition  is  due  to  a  paroxysmal  narrowing 
of  certain  blood  vessels,  one  would  expect  that  the  vasodilator  drugs, 
like  the  nitrites,  nitroglycerine,  etc.,  would  cut  short  an  attack. 
Occasionally  their  exhibition  seems  to  have  been  successful,  but  in 
the  majority  of  cases  where  they  have  been  tried  they  have  had  no 
effect  on  the  local  vascular  contraction. 

Although  there  can  be  no  doubt  that  some  central  defect  is  the 
cause  of  the  peripheral  manifestations  of  the  disease,  yet  empirically 
we  find  that  much  more  can  be  done  for  the  patient  by  purely 
local  treatment  than  by  general  measures.  Means  which  bring 
about  a  local  dilatation  of  the  arteries  not  only  tend  to  relieve  an 
actual  attack,  but  if  persisted  in  during  the  intervals  seein  to  have 
a  considerable  influence  in  preventing  recurrences.  Of  such  means 
massage  comes  first.  Massage  of  the  extremities,  including  friction 
of  the  fingers  and  toes  from  below  upwards,  induces  an  active 
hypeni'inia  with  rapid  blood  flow.  Such  massage  should  be  per- 
formed daily  for  from  ten  to  twenty  minutes,  care  bei  ng  taken  that 
it  is  thorough,  and  persisted  in  for  many  months  after  the  last 
paroxysm.  The  employment  of  electricity  has  always  been  advo- 
cated, and  Raynaud  himself  advised  the  passage  of  a  galvanic 
current  down  the  back  over  the  spinal  column,  and  also  that  the 
affected  extremities  should  be  treated  with  the  constant  current. 
Further  experience  has  led  to  the  abandonment  of  the  application 
of  the  current  to  the  spine  and  to  its  limitation  to  the  affected 
parts.  The  best  method  is  that  advocated  by  Barlow  in  the  form 


1240  Raynaud's  Disease. 

of  the  electric  bath.  Here  one  electrode  is  placed  on  the  back  and 
the  other  in  a  bath  of  salt  water,  in  which  the  affected  extremities 
are  immersed  for  about  fifteen  minutes  daily ;  meanwhile  a  slowly 
interrupted  constant  current  is  passed,  as  strong  as  the  patient  can 
bear,  and  at  the  same  time  he  is  encouraged  to  move  the  fingers  or 
toes.  After  the  bath  the  limbs  should  be  massaged.  This  treat- 
ment will  often  relieve  a  slight  attack,  and,  if  continued  over  a  long 
period,  may  prevent  recurrence. 

Probably  the  most  efficacious  method  of  putting  an  end  to  an 
actual  paroxysm  is  that  suggested  by  Gushing.  A  Martin's  rubber 
bandage  is  applied  to  the  limb  as  if  to  prepare  it  for  a  surgical 
operation,  and  then  a  tourniquet  kept  on  for  several  minutes  if  the 
patient  can  bear  the  pain.  Following  the  release  of  the  tourniquet 
there  is  a  vasomotor  paralysis  and  the  diseased  part  is  flushed  with 
arterial  blood.  There  seems  no  reason  why  in  case  of  necessity 
this  treatment  should  not  be  carried  out  when  the  patient  is  under 
an  anaesthetic. 

In  many  cases  pain  is  excruciating  and  prevents  the  proper 
application  of  the  above  methods  of  relief.  The  administration  of 
morphia  or  opium  may  then  become  an  absolute  necessity,  but  it 
must  not  be  forgotten  that  in  several  examples  of  this  disease  the 
morphia  habit  has  been  developed.  It  is  advisable,  therefore,  to 
try  at  first  the  effect  of  phenazone  or  phenacetin.  Eadiant  heat 
has  sometimes  helped  in  the  relief  of  pain,  and  also  been  efficacious 
in  hastening  the  termination  of  an  attack;  it  may  thus  be 
employed  when  the  patient  cannot  stand  more  painful  methods 
of  treatment.  Warm  baths  and  hot  opium  stupes  should  also  be 
tried.  During  all  but  the  mildest  paroxysms  the  sufferer  should 
be  kept  in  bed  at  an  equable  temperature  while  more  energetic 
attempts  are  being  made  to  bring  the  vascular  spasm  to  an  end. 

When  the  supervention  of  gangrene  is  certain  it  is  still  advisable 
to  pursue  a  waiting  policy  and  not  to  remove  the  parts  that  are 
apparently  dying.  The  gangrene  is  dry  and  a  distinct  line  of 
demarcation  appears  before  long  ;  besides,  it  is  always  much  less  in 
extent  than  at  first  appeared  probable.  The  separation  of  the 
dead  tissue  is  tedious,  and  should  be  hastened  by  antiseptic  fomen- 
tations. Where  bone  is  involved  the  knife  may  have  to  be  used 
to  trim  the  stump,  and  in  rare  cases  amputation  may  become 
necessary.  The  wounds  heal,  as  a  rule,  without  complication,  and 
so  far  no  case  of  septic  infection  has  been  reported. 

There  is  little  special  to  be  said  concerning  the  treatment  of  the 
more  uncommon  manifestations  of  the  disease,  such  as  epileptic 
seizures  and  hasmoglobinuria.  In  the  reported  cases  the  epileptiq 


Raynaud's  Disease.  1241 

attacks  have  never  been  fatal,  and  it  is  doubtful  whether  they  could 
be  diminished  by  any  means  except  an  improvement  in  the  general 
health.  Of  course  epilepsy  and  Raynaud's  disease  may  be  found 
in  the  same  patient  without  there  being  any  causal  relationship, 
and  the  epilepsy  will  then  require  to  be  treated  in  the  ordinary 
way.  Haemoglobinuria  seems  always  to  follow  exposure  to  cold, 
and  it  rapidly  disappears  if  the  patient  is  kept  at  an  equable 
temperature.  It  is  best  treated,  therefore,  by  rest  in  bed. 
Hsemoglobinuria  is  much  commoner  in  those  cases  of  Raynaud's 
disease  in  which  there  is  a  previous  history  of  malaria.  Although 
quinine  does  not  influence  the  condition  of  the  urine,  it  has  been 
said  to  have  prevented  attacks  of  local  syncope  and  cyanosis  in 
malarial  patients. 

ALFRED  M.  GOSSAGE. 

KEFERENCES. 

I '.itrlow,  SirT.,  Allbutt  and  Bolleston  "  System  of  Medicine,"  2nd  edit.,  1910, 
VII.,  p.  120.  Monro,  T.  K.,  "  Eaynaud's  Disease,"  Glasgow,  1899.  Cassirer, 
"Die  Vasomotorischen-Trophischen  Neurosen,"  Berlin,  1901.  Osier,  Sir  W., 
Osier  and  McCrae,  "System  of  Medicine,"  1909,  VI.,  p.  625. 


1242 


VASOMOTOR    NEUROSES. 

THE  subject  of  this  article  is  not  the  consideration  of  the 
familiar  conditions  associated  with  vasomotor  spasm,  such  as 
Raynaud's  disease,  erythrornelalgia,  etc.,  reference  to  which  will 
be  found  under  their  individual  headings,  but  rather  of  a  very 
definite  group  of  cases  allied  to  epilepsy  on  the  one  hand  and  to 
neurasthenia  on  the  other.  They  have  been  described  by  the 
French  as  affolcment  bulbaire  (literally,  "  bulbar  infatuation "), 
and  are  known  semi-popularly  as  "  nerve  storms,"  more  particu- 
larly in  America.  Sir  William  Gowers  has  drawn  special 
attention  to  their  frequency  and  importance  under  the  term 
"  vaso-vagal  attacks."  Briefly,  whether  they  occur  idiopathically 
or  as  part  and  parcel  of  a  more  general  functional  disturbance  of 
nerve  centres,  they  consist  of  attacks  of  breathlessness,  suffoca- 
tion, palpitation,  cardiac  arrhythmia  ("thudding,"  "racing," 
"fluttering"),  hot  flushes,  cold  waves,  trembling  and  shivering, 
perspiration,  a  sense  of  fear,  of  impending  death  sometimes,  with 
epigastric  sensations  often  superadded.  Some  of  these  symptoms 
occur  in  so-called  "  cardiac  neurasthenia."  In  the  writer's  expe- 
rience the  condition  (in  a  more  or  less  incomplete  form)  is  far 
from  uncommon,  and  fully  deserves  to  be  carefully  separated  from 
the  neurasthenic  tumulus.  The  response  of  many  cases  to 
appropriate  treatment  is  sometimes  remarkable.  The  adjacent 
vasomotor  and  vagal  centres  in  the  medulla  are  the  seat  of  the 
disturbance,  whatever  be  its  nature. 

One  of  the  most  effective  remedies  is  nitro-glycerine  in  one  or  other 
form.  A  favourite  prescription  is  liquor  trinitrini  [U.S.P.  spiritus 
glycerylis  nitratis],  (^,  £  or  1  min.),  liquor  strychninae  (4  min.) 
[U.S.P.  strychnin,  hydrochlorid.,  gr.  ^g],  made  up  with  any  simple 
agents,  three  times  a  day.  It  should  be  continued  for  months  if 
necessary,  and  if  it  does  good.  Its  immediate  effect  on  the  attack  is 
less  potent  than  that  of  amyl  nitrite,  but  its  regular  administration 
is  sometimes  invaluable.  Sodium  nitrite  is  also  of  service.  As 
a  rule,  the  bromides  do  not  realise  expectations  in  these  cases, 
although  a  combination  of  bromide  and  nux  vomica  sometimes 
succeeds.  Bonnier  recommends  vinum  ipecacuanhas  in  small 
doses.  The  prolonged  administration  of  a  good  general  nerve 
tonic,  coupled  with  a  milk  regime,  will  be  found  a  useful  adjunct  to 


Vasomotor  Neuroses.  1243 

specific  treatment.  For  the  actual  attack  inhalations  of  amyl 
nitrite  may  be  tried.  Gowers  advises  the  application  of  chloroform 
externally,  sprinkled  on  lint,  with  oil  silk  over  it  to  prevent 
evaporation,  to  the  pre-cordial,  sternal  or  epigastric  region.  Thus 
the  cardiac  distress,  respiratory  difficulty  or  gastric  discomfort, 
respectively,  may  be  relieved.  Painstaking  attention  to  the 
patient's  general  health,  bodily  functions  and  environment,  will 
be  rewarded  by  the  attainment  of  much-needed  rest  for  the 
nervous  system,  the  basis  on  which  successful  treatment  by  drugs 
must  depend.  A  quiet,  tranquil  life  is  essential. 

S.   A.    KINNIER   WILSON. 

REFERENCES. 

Bonnier,  P.,  "Le  Vertige,"  2nd  edit.,  Paris  (Masson  et  Cie.),  1904. 
Gowers,  Sir  W.  R.  "  The  Borderland  of  Epilepsy,"  London  (Churchill),  1907. 
Levi,  L.,  "La  Presse  Meiicale,"  Paris,  1905,  XIII.,  p.  433. 


1244 


FAMILIAL  DISEASES. 
AMAUROTIC    FAMILY    IDIOCY. 

THIS  condition,  also  known  as  the  Waren  Tay-Sachs'  disease,  is 
due  to  a  progressive  degeneration  of  the  cells  of  every  portion  of  the 
nervous  system  ;  it  is  limited  to  the  Jewish  race. 

It  commences  within  the  first  year  of  life,  and  usually  proves 
fatal  within  the  second  or  third  year.  It  is  evidently  due  to  an 
inherited  defect  in  the  constitution  of  the  ganglion  cells,  and  no 
treatment  that  has  yet  been  discovered  has  had  any  effect  in 
arresting  or  influencing  its  course.  It  has  been  suggested,  owing 
to  its  familial  nature,  that  the  degeneration  might  result  from  some 
substance  ingested  in  the  mother's  milk,  but  no  favourable  effect 
has  been  obtained  by  stopping  breast  feeding. 

Spielmeyer,  Higier  and  others  have  described  as  a  juvenile 
form  of  the  same  disease  a  condition  with  many  similar  symptoms, 
but  it  is  probably  quite  unrelated  to  it ;  it  sets  in  at  a  later  age,  has 
a  more  chronic  course,  and  is  not  limited  to  Jews.  As  in  some 
cases  it  seems  to  develop  on  a  congenital  syphilitic  basis,  vigorous 
anti-syphilitic  treatment  should  be  tried.  This  has  no  influence  on 
the  infantile,  or  Waren  Tay-Sachs,  type. 


GORDON  HOLMES. 


EEFERENCE. 


1  Higier,  H.,  Deutsche  Ztschr.  f.  Nervenheilk.,  Leipz.,   1910,  XXXV1IL, 
p.  388. 


1245 


AMYOTONIA  CONGENITA. 

THIS  form  of  muscular  disease  of  childhood,  known  also  as 
Oppenheim's  disease  from  the  German  neurologist  who  first 
described  it,  is  by  its  morbid  anatomy,  at  least,  closely  related  to, 
or  possibly  identical  with,  the  primary  muscular  dystrophies.  In 
many  cases  the  disease  is  probably  congenital,  in  others  it  is 
acquired  in  early  life.  It  is  said,  however,  to  be  distinguished  from 
the  simple  myopathies  by  a  tendency  to  improve,  and  certain 
children  affected  by  it  have  apparently  recovered  completely. 

The  line  of  treatment  should  be  that  described  for  the  muscular 
dystrophies  ;  the  greatest  benefit  can  be  expected  from  regular  and 
persistent  massage  of  the  muscles,  and  from  encouraging  the  child 
to  use  the  affected  muscles  as  much  as  possible.  A  child  who  is 
unable  to  walk  should  be  allowed  to  crawl  about  the  floor,  and  if 
even  this  is  not  possible  it  should  be  trained  to  use  the  limbs  in 
simple  games. 

General  tonics  should  not  be  omitted  if  there  is  any  indication 
for  their  use,  and  strychnine  has  been  recommended  in  all  cases. 

GORDON  HOLMES. 

REFERENCES. 

Oppenheim,  II.,  "  Monatschr.  f.  Psychiatr.  u.  Neurolog.,"  fieri-,  1900,  VIII., 
p.  232.  Collier,  J.,  and  Wilson,  S.  A.  K,  "  Brain,"  Lond.,  1908,  XXXI.,  p.  1. 


1246 


CHRONIC    DISORDERS    WITH    CEREBELLAR 
SYMPTOMS. 

THERE  are  several  distinct  pathological  conditions  that  produce 
cerebellar  symptoms,  such  as  the  various  forms  of  primary  degenera- 
tion of  the  cerebellum,  cerebellar  disease  associated  with  cerebral 
lesions  or  disease  of  other  portions  of  the  nervous  system,  local 
cerebellar  lesions,  and  spinal  degenerations  involving  the  spino- 
cerebellar  tracts,  of  which  Friedreich's  disease  is  the  best  recognised 
type.  The  grouping  and  relationship  to  one  another  of  these 
different  pathological  processes  cannot  be  considered  here;  but 
as  the  majority  are  primary  degenerations  due  to  intrinsic  or 
inherited  constitutional  defects  which  therapeutics  are  unable  to 
arrest,  the  treatment  of  the  patient  must  become  largely  the 
treatment  of  his  symptoms. 

The  chief  symptoms  of  cerebellar  disease  are  inco-ordination  of 
volitional  movement,  a  disturbance  of  equilibration  in  standing  and 
walking,  static  ataxia,  tremor  and  irregular  movements  of  unsup- 
ported parts  of  the  body,  vertigo,  a  change  in  articulation  and 
affection  of  the  ocular  movements,  generally  in  the  form  of 
nystagmus. 

It  is  usually  the  inco-ordination  of  movement  and  the  affection  of 
gait  that  most  urgently  require  relief;  but,  unhappily,  though 
treatment  may  diminish  these  symptoms,  it  can  rarely  remove 
them.  As  gait  frequently  improves  with  improvement  of  general 
health  and  strength,  attention  should  be  directed  to  this.  The 
inco-ordination  is  frequently  associated  with  feebleness  of  the 
muscles,  and  in  these  cases  massage  of  the  limbs  may  improve  their 
functions.  The  effect  of  strychnine,  iron,  arsenic  and  phosphorus 
should  be  tried.  An  attempt  should  be  made  to  re-educate  the 
movements  that  are  most  ataxic ;  but,  unhappily,  Fraenkel's  exercises 
are  less  efficient  in  cases  where  the  inco-ordination  is  due  to  lesions 
of  the  cerebellar  apparatus  than  in  those  in  which  it  results  from 
loss  of  the  afferent  impulses  to  consciousness  that  control  volitional 
movement,  as  is  the  case  in  tabes  dorsalis. 

GORDON  HOLMES. 


1247 


THE  FAMILY  FORM  OF  MUSCULAR  ATROPHY 
IN  CHILDREN. 

THIS  form  of  progressive  muscular  atrophy  in  children,  known 
also  as  the  Werdnig-Hoffmann  type,  which  sets  in  in  early  childhood, 
is  closely  allied  to  progressive  muscular  atrophy  or  amyotrophic 
lateral  sclerosis  of  the  adult.  It  appears  always  to  be  steadily 
progressive,  though  the  subjects  may  live  till  the  fifth  or  sixth  year. 
No  form  of  treatment  has  been  found  of  any  service  in  arresting  its 
course,  but  massage  and  passive  movements  may  prevent  the 
formation  of  contractures  and  strengthen  the  muscles  that  remain 
capable  of  useful  function. 

GORDON  HOLMES. 


FAMILY    PERIODIC    PARALYSIS. 

NOTHING  is  known  of  the  pathology  of  this  curious  condition  to 
guide  or  suggest  rational  treatment. 

As  severe  exertion,  excitement  and  emotional  disturbances,  as  well 
as  excessive  indulgence  in  rich  foods,  may  induce  an  attack,  the 
patient  should  be  warned  of  the  danger,  and  attempt  to  regulate 
his  life  so  as  to  avoid  them  as  far  as  possible.  As  it  has  been  assumed 
that  the  attacks  are  due  to  the  accumulation  of  some  poison  or  toxin 
in  the  body,  the  administration  of  diuretics  has  been  advised,  and 
their  use  has  apparently  diminished  the  frequency  of  the  attacks 
(Singer).  Large  doses  of  bromide,  given  on  the  first  signs  of  attacks, 
are  said  to  check  them  or  diminish  their  severity.  It  has  been  found 
that  the  application  of  strong  faradism  tends  to  shorten  the  attacks 
when  applied  during  their  course  (Otto  and  Darcourt). 

GORDON  HOLMES. 


1248 


FRIEDREICH'S    DISEASE. 

THE  symptoms  of  Friedreich's  disease,  or  hereditary  ataxia, 
depend  on  a  combined  system  degeneration  of  the  spinal  cord,  due 
to  inherited  defects  in  certain  nerve  tracts  and  cells,  which  is 
steadily  progressive  and  beyond  our  power  to  arrest.  The  course  of 
the  disease  is,  as  a  rule,  slower  the  later  it  appears  in  life. 

But  though  we  are  unable  to  arrest  its  progress,  we  can  often  do 
much  to  relieve  its  symptoms,  when  these  are  not  too  far  advanced. 
It  is  important  to  improve  the  general  health  of  the  patient,  and 
maintain  it  at  as  high  a  level  as  possible.  An  out-door  life  should 
be  recommended,  with  simple  nourishing  food.  Strychnine,  iron, 
arsenic  and  other  tonic  drugs  may  prove  beneficial.  As  the  disturb- 
ance of  gait  is  usually  the  most  serious  symptom,  attention  must  be 
directed  especially  to  the  lower  limbs.  Massage  often  increases  the 
power  of  the  muscles,  and  may  check  any  tendency  to  the  formation 
of  contractures.  If  these  develop  to  a  serious  degree,  tenotomy  may 
be  necessary.  The  most  efficient  means  for  the  treatment  of  ataxia 
are  exercises  for  the  re-education  of  movement,  such  as  have  been 
devised  by  Fraenkel  for  the  treatment  of  tabes  dorsalis ;  but  their 
effect  is  rarely  so  favourable  as  in  this  disease. 

It  must  be  remembered  that  the  power  of  walking  may  deteriorate 
rapidly  if  patients  with  this  disease  are  confined  to  bed  or  pre- 
vented from  getting  about  from  any  cause,  and  this  should  con- 
sequently be  avoided  where  possible.  The  disease  in  itself  rarely 
threatens  life,  though  sudden  death  from  cardiac  failure,  due 
generally  to  myocarditis,  is  not  uncommon;  and  the  patients 
enfeebled  by  inactivity  may  readily  fall  victims  to  intercurrent 
illnesses. 

GORDON  HOLMES. 


1249 

HEREDITARY    SPASTIC    PARAPLEGIA. 

HEREDITARY  spastic  paraplegia,  or  .  primary  lateral  sclerosis,  as 
described  by  Striimpell  and  others,  is  a  rare  affection  due  to  a 
primary  degeneration  of  the  pyramidal  tracts.  Though  it  tends  to 
progress,  some  cases  become  arrested,  and  usually  only  the  lower 
limbs  are  severely  involved.  The  rigidity  of  the  limbs  is  generally 
relatively  greater  and  more  troublesome  than  the  paresis. 

Over-exertion  and  fatigue  must  be  avoided,  as  they  increase  the 
rigidity  and  make  walking  more  difficult  and  awkward ;  many 
cases  improve  with  absolute  rest  for  a  time.  Massage  is  the  most 
valuable  therapeutic  means  we  possess ;  its  use  may  be  advantageously 
preceded  by  hot  baths  or  Turkish  baths,  which  temporarily  diminish 
the  spasms.  Gowers  recommends  gentle  upward  rubbing  rather 
than  kneading  of  the  muscles.  On  the  other  hand,  all  forms  of 
electricity  as  well  as  any  other  form  of  peripheral  irritation,  are  worse 
than  useless,  as  they  reflexly  increase  the  rigidity.  Passive  movements 
must  be  employed  if  there  is  any  danger  of  contractures.  With  the 
exercise  of  reasonable  care  tenotomy  is  rarely  necessary  in  adult  cases. 

Drugs  are  of  little  service  in  the  treatment  of  this  condition ; 
strychnine  should  be  avoided  or  given  only  in  small  doses,  as  it  may 
increase  the  rigidity  and  the  tendency  to  spasms.  When  the  legs  are 
very  rigid  some  relief  may  be  obtained  from  large  doses  of  the 
bromides,  cannabis  indica  or  belladonna,  but  it  is  advisable  to 
administer  these  for  long  periods.  In  the  advanced  stages  of  the 
disease  severe  reflex  spasms  are  often  troublesome,  especially  at 
night,  when  they  may  disturb  sleep  ;  the  same  drugs  often  relieve  this 
symptom,  but  veronal  in  moderate  doses  is  generally  more  effective. 

GORDON  HOLMES. 


HUNTINGDON'S   CHOREA. 

HUNTINGDON'S  CHOREA,  which  is  characterised  by  its  hereditary 
tendency  and  by  irregular  purposeless  movements  resembling  those 
of  Sydenham's  chorea,  associated  with  progressive  mental  deteriora- 
tion, is  due  to  a  diffuse  degenerative  disease  of  the  cerebral  cortex. 
Its  treatment  is  unsatisfactory,  as  no  drugs  or  other  measures  arrest 
its  course.  Arsenic  has  been  most  frequently  recommended  by 
those  who  have  had  most  experience  in  its  treatment,  while 
occasionally  the  bromides,  cannabis  indica  and  other  sedatives  have 

given  relief. 

GORDON  HOLMES. 
S.T. — VOL.  ii.  79 


1250 


THE  MUSCULAR  DYSTROPHIES. 

THE  primary  muscular  dystrophies  are  progressive  diseases  which 
almost  invariably  lead  to  the  complete  crippling  of  the  subjects 
affected  by  them,  though  a  few  instances  of  recovery  have  been 
reported  (Erb,  Marina).  The  different  varieties,  as.  a  rule,  progress 
at  different  rates;  usually  the  forms,  such  as  the  pseudo-hypertrophic, 
which  set  in  at  an  early  age,  progress  the  most  rapidly ;  while  other 
cases  that  appear  at  or  after  puberty  may  leave  the  patient  capable 
of  locomotion  or  even  of  performing  his  occupation  till  after  middle 
life. 

In  such  intrinsic  and  hereditary  diseases  little  can  be  expected 
from  therapeutics,  but  treatment  can  frequently  ameliorate  the 
condition  or  retard  its  progress.  Our  aim  should  be  to  arrest  the 
progress  of  the  primary  degeneration  of  the  muscle  fibres,  and  to 
increase  the  functional  activity  of  the  fibres  that  remain  intact  or 
are  but  little  affected.  As  we  are  not  acquainted  with  any  measures 
that  can  arrest  the  development  of  the  morbid  process,  our  thera- 
peutic efforts  must  be  directed  to  the  latter  aim.  It  is  important 
to  maintain  the  general  health  and  the  nutrition  of  the  patient  at 
as  high  a  level  as  possible  ;  good  food  and  out- door  life  should  be 
adopted,  and  for  the  same  purpose  cod-liver  oil,  iron,  arsenic  and 
other  drugs  may  be  employed.  Strychnine,  especially  by  hypodermic 
injection,  is  favoured  by  many,  and  often  seems  to  have  a  bene- 
ficial result.  On  the  other  hand,  any  tendency  to  adiposity  should 
be  checked  by  regulation  of  the  food-stuffs  and  by  appropriate 
exercises. 

Long-continued  electrical  treatment  by  faradism  or  galvanism 
seems  to  improve  certain  cases.  Massage  of  the  affected  muscles  is 
undoubtedly  more  efficient,  but  it  is  often  necessary  to  persist  in  it 
for  a  long  period  before  any  effect  can  be  observed.  While  over- 
exertion  has  often  a  serious  effect  on  the  progress  of  the  disease, 
a  certain  amount  of  methodical  exercise  is  essential,  as  voluntary 
exercise  is  unquestionably  the  most  efficient  stimulus  to  the 
muscles.  The  patient  should  be  encouraged  to  walk  as  far  as 
he  can  without  fatigue,  while  the  muscles  of  the  trunk  and  upper 
limbs  should  be  exercised  by  gymnastic  exercises  carefully  regulated 
to  bring  into  action  the  weakest  muscles  and  those  most  essential 
in  the  performance  of  the  ordinary  functions  of  the  limbs.  The 


The  Muscular  Dystrophies.  1251 

defects  in  movement  should  be  carefully  analysed  and  the  exercises 
regulated  to  improve  and  strengthen  those  that  are  most  seriously 
affected.  It  is  practically  the  rule  in  all  cases,  but  especially  in 
those  of  the  pseudo-hypertrophic  form,  that  the  power  of  walking 
deteriorates  rapidly  when  a  patient  is  confined  to  bed  for  a  time  by 
an  inter-current  illness  or  in  the  course  of  treatment,  or  if  he  ceases 
to  walk  regularly,  and  it  is  frequently  then  impossible  to  regain 
the  power  that  was  lost  within  a  short  time.  It  is  consequently 
extremely  important  to  keep  the  patient  on  his  feet  as  constantly 
and  as  regularly  as  possible. 

The  Development  of  Contractures,  owing  to  the  excess  of 
fibrous  tissue  in  the  muscles  and  its  shrinkage,  is  one  of  the  most 
serious  features  of  the  disease  ;  these  can  best  be  guarded  against 
by  systematic  active  and  passive  movements  of  the  limbs,  and  by 
massage  of  these  muscles  that  show  any  tendency  to  shorten.  When 
contractures  have  developed,  tenotomy  may  become  necessary,  but 
the  operation  should  be  followed  as  early  as  possible  by  massage  of 
the  muscles,  and  regulated  active  and  passive  movements.  Tendon 
transplantation  has  been  tried  in  a  few  cases  with  reported  good 
effects,  but  the  time  necessary  to  attain  a  useful  result,  and  the 
fact  that  the  transplanted  muscles,  too,  are  usually  affected,  makes 
it  improbable  that  it  can  be  generally  applicable  in  such  a  pro- 
gressive disease.  Further,  as  degenerative  changes  may  supervene 
in  a  muscle  on  section  of  its  tendon,  the  operation  may  not  only  fail 
in  its  aim,  but  may  lead  to  the  serious  weakening  of  muscles  that 
hitherto  had  been  efficient.  Favourable  results  on  the  power  of 
movement  and  utility  of  the  arms  have  been  recorded  from  surgical 
fixation  of  the  scapulae  (Eiselberg,  Raymond).  Instruments  to  fix 
and  support  the  shoulder-girdle  have  been  also  recommended,  and 
may  be  of  considerable  use  in  cases  in  which  the  muscles  of  the 
shoulder-girdle  only  of  the  upper  limbs  are  seriously  involved. 

The  injection  of  muscle  extracts  has  been  repeatedly  tried  without 
definite  benefit.  Thyroid  extract  seemed  to  have  a  beneficial  effect 
in  a  case  treated  by  Rossolimo,  but  others  have  failed  to  attain  any 
result.  No  benefit  has  been  obtained  from  the  use  of  other  organic 
extracts. 

In  the  later  stages  of  the  disease,  when  only  the  prolongation  of 
life  can  be  hoped  for,  it  should  be  remembered  that  the  greatest 
danger  lies  in  pulmonary  complications.  Even  a  slight  attack  of 
bronchitis  may  prove  fatal  owing  to  the  feebleness  of  the  respira- 
tory muscles. 

GORDON  HOLMES. 

79—2 


1252 


MYOTONIA   ATROPHICA. 

THIS  rare  condition,  which  is  characterised  clinically  by  the 
association  of  muscular  atrophy  with  a  slowness  in  the  relaxation  of 
muscles  after  voluntary  contraction,  such  as  characterises  myotonia 
congenita  or  Thomsen's  disease,  is  also  hereditary,  or,  at  least,  may 
occur  in  several  members  of  the  one  generation.  Treatment  is 
helpless  to  arrest  its  course,  and  can  unfortunately  do  little  to 
relieve  its  symptoms.  Massage  to  the  wasted  muscles  should  be  tried, 
and  when  there  is  much  foot-drop  from  wasting  of  the  anterior 
tibial  groups  of  muscles,  a  mechanical  support  may  be  employed  to 
obviate  the  difficulty  in  walking. 

GORDON  HOLMES. 

EEFERENCE. 
Batten,  F.  E.,  and  Gibb,  H.  P.,  "  Brain,"  Lond.,  1909,  XXXII.,  p.  187. 


MYOTONIA  CONGENITA. 

THOMSEN'S  DISEASE  is  characterised  by  an  abnormal  delay  in  the 
relaxation  of  muscles  contracted  voluntarily,  which  diminishes  on 
rapidly  repeated  contraction  ;  it  is  due  to  an  abnormal  state  of  the 
muscle  fibres  only.  This  peculiarity  makes  any  movements  in  which 
muscles  that  have  been  resting  partake  slow,  difficult  and  awkward 
when  first  started. 

No  treatment  has  had  a  favourable  influence  on  the  disease. 
Thomsen,  who  was  himself  a  subject  of  it,  found  he  was  better 
the  more  active  his  life  was,  and  some  patients  have  improved  after 
systematic  gymnastic  exercises. 

GORDON  HOLMES. 


1253 


PERONEAL  MUSCULAR  ATROPHY. 

THE  Charcot-Marie-Tooth  form  of  progressive  muscular  atrophy 
is  due  to  a  degeneration  of  the  ventral  horn  cells  of  the  spinal  cord 
and  of  the  peripheral  nerves,  associated  with  degeneration  of  the 
dorsal  columns,  and  often  of  other  tracts  of  the  spinal  cord,  though 
at  present  we  have  no  definite  evidence  of  the  primary  site  of  the 
disease. 

It  is  often  an  hereditary  disease,  and  no  form  of  treatment  has 
yet  been  found  to  have  any  influence  on  its  course,  so  the  only 
aim  of  therapeutics  can  be  to  diminish  the  symptoms  by  increasing 
the  power  and  functions  of  the  affected  muscles.  For  this  purpose 
massage  is  the  most  efficient  means  we  possess,  but  it  must  be 
persisted  in  for  long  periods.  The  power  of  locomotion  may 
be  improved  by  mechanical  supports  for  the  feet  when  foot-drop , 
which  is  an  almost  constant  symptom,  is  troublesome.  When 
contractures  develop,  tenotomy  may  become  necessary. 

GORDON  HOLMES. 


1254 


DISEASES  CHARACTERISED  BY  DISORDERS 
OF  MUSCULAR  FUNCTION. 

MYASTHENIA  GRAVIS. 

THE  obscurity  of  the  pathogenesis  of  this  disease  has,  up  to  the 
present,  rendered  impossible  the  adoption  of  any  very  satisfactory 
line  of  treatment. 

The  relative  frequency  of  morbid  changes  in  the  ductless  glands, 
especially  the  thymus  and  adrenals,  tends  somewhat  to  confirm  the 
view  that,  possibly,  one  factor  in  the  production  of  myasthenia 
gravis  may  be  some  defect  in  the  balance  of  the  internal  secretions 
of  the  body.  It  is,  therefore,  justifiable  tentatively  to  administer 
extract  of  the  thymus,  thyroid  or  pituitary  glands  or  of  the  ovary. 
Success  has  been  claimed  occasionally  for  one  or  other  of  these, 
but,  in  the  great  majority  of  cases,  no  benefit  results. 

For  the  rest,  the  general  health  of  the  individual  must  be  main- 
tained at  as  high  a  pitch  as  is  possible,  and  for  this  purpose  cod 
liver  oil,  iron,  arsenic  and  nux  vomica  may  be  of  service.  Any 
risk  of  fatigue  must  be  rigorously  guarded  against.  Massage  is 
beneficial  if  not  overdone,  and  the  same  applies  to  galvanism. 

The  diet  should  be  easily  assimilable,  semi-solid,  and  of  a  high 
nutritive  value.  In  more  advanced  cases  the  bulk  of  the  nourish- 
ment should  be  administered  in  the  morning  when  the  muscular 
efficiency  is  at  its  maximum,  and  the  food  itself  must  be  of  such  a 
consistency  as  to  obviate  the  necessity  for  mastication.  Where  the 
power  of  swallowing  is  very  limited,  rectal  feeding  is  probably  to 
be  preferred  to  the  use  of  a  stomach-tube,  in  view  of  the  emotional 
disturbance  and  exhaustion  produced  by  the  latter  (Buzzard). 

Respiratory  failure  may  be  combated  by  artificial  respiration  and 
the  inhalation  of  oxygen,  but  is  always  of  serious  import. 

JAMES    TORRENS. 


1255 


PARAMYOCLONUS    MULTIPLEX. 

A  CONSIDERATION  of  the  treatment  of  this  condition  must  be 
prefaced  by  a  few  words  on  its  nature  and  symptomatology. 

When  Friedreich  described  a  condition  to  which  he  gave  the 
name  "  paramyoclonus  multiplex  "  in  1881,  it  was  supposed  that  a 
new  and  complete  morbid  entity  had  been  discovered.  With 
increasing  knowledge,  however,  it  has  become  abundantly  evident 
that  we  cannot  regard  paramyoclonus  as  other  than  a  symptom 
occurring  under  various  conditions,  and  it  is  preferable  to  em- 
ploy the  term  "myoclonus"  symptomatically,  as  comprising  "the 
totality  of  more  or  less  permanent  morbid  conditions  characterised 
by  rapid,  forced,  abrupt,  inco-ordinate  muscular  contractions, 
rhythmical  or  arrhythmical,  always  affecting  the  same  muscles  and 
resulting  from  the  alternating  contraction  and  relaxation  of  certain 
muscular  groups"  (Vanlair).  Even  with  this  definition  our 
knowledge  of  the  various  forms  of  myoclonus  is  sadly  in  need  of 
revision  and  amplification.  Myoclonus,  paramyoclonus  multiplex, 
Bergeron's  electric  chorea,  Morven's  fibrillary  chorea,  Unverricht's 
familial  myoclonus,  myokymia,  and  Dubini's  disease,  are  conditions 
whose  varying  names  serve  but  to  confuse.  Further,  myoclonus 
is  common  in  epilepsy,  and  movements  analogous  to  myoclonus 
are  of  frequent  occurrence  in  hysteria  and  in  the  maladie  des  tics. 
The  pathology  of  myoclonus  is  unknown,  and  its  treatment  remains 
symptomatic  and  empirical. 

If  we  take  paramyoclonus  multiplex  to  be  a  condition  characterised 
by  violent  clonic  spasmodic  contractions  of  muscles  usually  symr 
metrically  situated,  without  other  disturbance  of  motor  or  sensory 
function,  and  if  we  premise  that  we  are  dealing  solely  with  a 
symptom,  search  for  the  cause  of  which  must  be  undertaken  in 
each  case,  we  may  proceed  to  discuss  its  treatment. 

If  the  condition  is  patently  hysterical,  treatment  along  the  lines 
suggested  for  hysteria  must  be  adopted.  It  is  exceedingly  important 
to  enquire  for  a  history  of  epilepsy,  as  myoclonic  twitchings, 
"regional  convulsions"  (Muskens),  are  of  frequent  occurrence, 
especially  in  the  mornings,  in  patients  who  may  not  as  yet  have 
suffered  from  actual  fits.  Suitable  treatment  as  for  epilepsy  is 
indicated.  If  there  is  reason  to  believe  that  the  myoclonus  is  a 
phenomenon  of  tic,  regulated  exercises  to  the  offending  muscular 


1256  Paramyoclonus  Multiplex. 

groups  is  likely  to  prove  satisfactory.  Should  the  physician  fail  to 
discover  any  etiological  factor  he  must  proceed  empirically.  Electric 
treatment  has  proved  the  most  satisfactory  in  many  instances. 
Strong  galvanic  currents  should  be  applied  to  the  neck  and  back 
(central  galvanisation)  and  the  anode  may  be  placed  on  any 
sensitive  points,  if  these  exist.  Prolonged  static  baths  have  proved 
efficacious  (Delherm).  Spinal  douches  have  also  served  to  reduce 
the  symptoms.  Every  conceivable  nerve  sedative  or  hypnotic  has 
been  tried  by  way  of  internal  medication.  Zinc  valerianate  and 
cannabis  indica,  in  pill  form,  ought  to  be  given  a  trial.  The  bromides 
do  not  appear  to  be  of  much  value.  Vanlair  suggests  repeated  local 
injections  of  cocaine  in  small  doses.  For  that  matter,  the  writer 
has  seen  a  case  apparently  cured  by  repeated  injections  of  aqua 
destillata.  Starr  reports  a  case  cured  by  the  combination  of 
galvanism  to  the  spine,  chloral  and  arsenic.  Speaking  generally, 
local  treatment  seems  to  be  more  satisfactory  than  internal  medica- 
tion, but  it  cannot  be  said  that  the  results  obtained  have  been 
brilliant. 

S.    A.    KINNIER    WILSON. 

REFERENCES. 

Blocq,  P.,  and  Grenet,  H.,  article  "  Myoclonies,"  in  Charcot- Bouchard 
"  Traite  de  M6decine,"  2nd  edit.,  Paris  (Masson),  1905,  X.,p.  416.  Dana,  C.  L., 
"  Journ.  of  Nerv.  and  Ment.  Dis.,"  New  York,  1903,  XXX.,  p.  449.  Meige,H., 
and  Feindel,  E.,  "  Les  Tics  et  leur  Traitement,"  translated  by  S.  A.  K.  Wilson, 
London  (Appleton),  1907.  Vanlair,  "  Revue  de  Medecine,"  1887. 


1257 


DISEASES  OF  OBSCURE  ORIGIN  CHARAC 
TERISED  CHIEFLY  BY  DISORDERS  OF 
MOTION. 

CHOREA. 

THE  term  "  chorea  "  has  been  used  for  more  conditions  than  one. 
The  present  article  does  not  refer  to  Huntingdon's  chorea,  senile 
chorea,  or  post-hemiplegic  chorea,  but  to  ordinary  St.  Vitus'  dance 
as  it  occurs  mainly  in  children  and  adolescents,  particularly  in 
those  who  have  a  personal  and  family  tendency  to  rheumatic  fever 
and  its  effects.  Chorea  in  pregnant  women  is  discussed  elsewhere 
in  Vol.  IV. 

When  St.  Vitus'  dance  is  met  with  in  a  boy  or  girl  the  first  step 
is  to  determine  whether  the  chorea  is  the  chief  or  only  rheumatic 
manifestation  present  or  whether  the  patient  also  exhibits  other 
evidence  of  acute  rheumatism,  especially  bruits  indicative  of 
endocarditis,  a  pericarditic  rub,  pleurisy  with  or  without  effusion, 
acute  tonsillitis,  joint  pains  and  swellings,  or  skin  lesions  such  as 
erythema  multiforme.  If  there  is  endocarditis  the  treatment  of  the 
case  will  be  carried  out  precisely  on  the  same  lines  as  if  the  acute 
rheumatism  and  endocarditis  had  occurred  without  chorea,  with  the 
addition,  perhaps,  of  putting  screens  round  the  patient's  bed  and 
giving  more  aspirin  than  might  otherwise  be  ordered.  The  duration 
of  absolute  rest  in  bed  in  such  a  case  depends  much  more  upon  the 
endocarditis  than  upon  the  chorea. 

It  is  an  important  point  about  chorea  that  if  it  is  uncomplicated 
it  is  not  associated  with  pyrexia,  however  violent  the  movements 
may  be.  So  long  as  there  is  no  pyrexia  and  no  evidence  of 
endocarditis  or  other  complications  of  acute  rheumatism,  the  treat- 
ment may  be  regarded  as  that  of  the  chorea  itself.  Cases  may  be 
divided  up  according  to  the  severity  of  the  movements  into  those 
that  are  mild,  those  that  are  moderate  and  those  that  are  severe. 
It  would  be  unwise,  however,  to  regard  even  a  mild  case  as 
unimportant,  because  without  due  treatment  and  care  the  move- 
ments may  very  readily  become  more  active  and  the  disease 
proportionately  more  severe. 

Medicinal  Measures. — The  best  drug  to  employ  in  all  cases  is 
certainly  aceto-salicylic  acid  (aspirin),  and  it  should  be  given  in  full 
doses.  Whether  the  movements  are  mild,  moderate  or  severe,  one 
should  give  relatively  enormous  doses  at  first ;  if  the  patient  is  about 


1 258  Chorea. 

eight  years  old,  10  gr.  should  be  administered  every  two  hours,  except 
during  sleep,  for  the  first  three  days;  then  10  gr.  every  four  hours  till 
the  end  of  the  week,  after  which  10  gr.  may  be  given  four  times  a  day. 
The  administration  of  the  drug  needs  to  be  continued  for  a  con- 
siderable number  of  weeks  after  the  movements  themselves  have 
ceased,  for  it  would  seem  that  aspirin  merely  minimises  the  move- 
ments or  causes  them  to  cease  without  actually  curing  the  malady 
so  completely  that  it  does  not  at  once  recur  when  the  drug  is 
stopped.  It  is  like  sodium  salicylate  in  relation  to  acute  rheumatic 
joint  pains  in  this  respect.  The  aspirin  has  to  be  continued  for 
almost  the  same  length  of  time  as  the  movements  ordinarily 
continue  when  no  drugs  are  employed  at  all,  namely,  upon  the 
average  about  three  months.  Under  its  influence,  however,  the 
movements  may  cease  entirely  in  a  week  or  two,  and  they  seldom 
continue  for  more  than  eight  weeks,  which  is  something  like  three 
or  four  weeks  less  than  is  their  average  duration  when  other 
remedies  are  employed.  Dr.  Cecil  Wall  was  amongst  the  first  to 
point  this  out,  and  the  writer  can  endorse  his  views.  It  would  seem 
that  aspirin  behaves  as  regards  choreic  movements  more  or  less  as 
potassium  bromide  does  as  regards  epileptic  fits.  It  gets  them 
under  control  but  it  does  not  cure  their  cause.  The  remedy  is  best 
given  as  a  powder  in  cachets ;  children  find  it  difficult  to  swallow 
the  ordinary  tablets.  The  10  gr.  doses  should  be  continued  four  times 
a  day  for  four,  six,  eight,  ten  or  twelve  weeks,  as  the  case  may  be, 
according  to  the  length  of  time  that  elapses  between  beginning  the 
treatment  and  getting  the  movements  under  control,  and  according 
to  the  effect  that  will  be  observed  when  attempts  are  made  first  to 
diminish  and  finally  to  omit  the  remedy. 

Sodium  salicylate,  though  sometimes  employed  instead  of  aceto- 
salicylic  acid,  is  by  no  means  so  good ;  if  there  are  joint  pains  in 
the  case,  or  rheumatic  pyrexia,  these  will  be  benefited  by  sodium 
salicylate,  but  the  chorea  itself  lasts  just  as  long  when  this  drug  is 
given  as  when  no  particular  remedy  is  employed,  and  this  no 
matter  whether  the  doses  are  small,  medium  or  large. 

Bicarbonate  of  soda  is  an  old  remedy  for  rheumatism  which  is 
coming  into  favour  again,  and  there  is  no  reason  why  it  should  not 
be  prescribed  in  chorea  cases  in  addition  to  aspirin,  either  in  the 
same  cachet  or  as  a  separate  mixture. 

Arsenic  was  the  drug  most  usually  employed  in  the  treatment  of 
chorea  until  recently,  and  by  some  it  is  still  preferred  to  anything 
else.  Comparison  between  it  and  aspirin,  however,  is  all  in  favour 
of  the  latter,  and  moreover  some  of  the  worst  cases  of  peripheral 
neuritis  have  occurred  whilst  chorea  was  being  treated  with  medicinal 


Chorea.  1 259 

doses  of  arsenic.  The  ordinary  liquor  arsenicalis  [U.S.P.,  liquor 
potass,  arsenitis]  is  generally  employed,  the  close  being  as  a  rule  a 
small  one,  such  as  2  min.  in  a  mixture  thrice  daily  to  begin  with ; 
the  rule  being  to  increase  this  by  1  min.  every  five  or  six  days  if  it 
is  well  borne,  until  the  patient,  even  though  a  child,  may  be  taking 
as  much  as  10  or  12  min.  three  or  four  times  a  day. 

When  the  movements  have  resisted  arsenic  by  the  mouth 
cacodylate  of  sodium  has  been  given  either  rectally  or  sub- 
cutaneously,  beginning  with  J  gr.  daily  and  increasing  to  twice 
this  amount.  Hypodermic  medication  is  to  be  avoided,  however, 
unless  material  advantage  is  to  be  gained  by  it,  and  this  cannot  be 
said  to  be  the  case  with  sodium  cacodylate. 

Although  the  above  are  the  commoner  remedies  that  are  used  in 
the  treatment  of  chorea,  there  is  a  very  long  list  of  other  prepara- 
tions that  have  been  employed  in  different  cases.  The  difficulty 
is  to  know  whether  they  are  really  beneficial  or  not,  and  the 
probability  is  that  they  have  been  used  chiefly  when  the  cases  were 
either  very  severe  or  very  obstinate,  and  it  is  very  difficult  to  say 
whether  the  relief  that  may  seem  to  have  been  due  to  the  last 
remedy  resorted  to  in  any  prolonged  case  would  not  have  come 
about  spontaneously.  Zinc  salts  were  much  advocated  at  one  time, 
notably  valerianate  of  zinc  given  in  pill  or  powder  form  in  doses 
of  from  ^  to  4  gr.  Hemlock  has  been  tried  on  account  of  its 
sedative  effects  upon  the  nervous  system,  though  its  action  in 
medicinal  doses  of  the  succus  conii  (1  to  2  drachms)  or  of  the  tinctura 
conii  (£  to  1  drachm)  [U.S.P.,  fluid  extract  conii,  mins.  6 — 12]  is 
both  uncertain  and  transient.  Antimony,  particularly  small  doses 
of  the  vinum  antimoniale  [U.S.P.,  vinum  antimonii],  given  in  mixture 
form,  is  beneficial  in  many  maladies,  and  it  may  be  prescribed  along 
with  arsenic.  Quinine  in  small  doses  either  by  itself,  or  in  Easton's 
syrup,  which  contains  f  gr.  of  quinine  sulphate  in  each  drachm, 
or  as  iron  and  quinine  citrate  in  5  to  10  gr.  doses  may  serve  to 
improve  the  patient's  general  tone  and  thereby  assist  in  the  treat- 
ment of  chorea  in  puny  children ;  whilst  cod-liver  oil,  extract  of 
malt  and  iron,  Pamsh's  food  and  tonics  generally  may  be  used  in 
the  treatment  of  chorea  in  the  same  way. 

Belladonna,  especially  the  tincture  in  3  or  4  min.  doses  [U.S.P., 
tinct.  bellad.  fol.  4  or  5  min.],  has  been  advocated  as  a  means  of 
diminishing  the  excitability  of  the  nervous  system  and  thus 
lessening  the  movements  ;  whilst  in  America  particularly  cimicifuga 
has  a  reputation  for  benefiting  chorea,  though  it  is  seldom 
employed  in  this  country. 

When  the  movements  become  more  than  moderately  violent  the 


1 260  Chorea. 

question  of  the  use  of  stronger  sedatives  or  even  of  hypnotics  may 
arise.  Choreic  patients,  however,  usually  sleep  well  even  though 
their  movements  are  violent  during  the  day  ;  hypnotic  remedies 
should  not  lightly  be  resorted  to  therefore.  If  they  should  be 
necessary,  however,  those  which  do  least  harm  are  probably 
chloralamide  in  doses  of  from  10  gr.  upwards  ;  bromides,  particularly 
potassium  bromide  or  a  combination  of  10  to  15  gr.  of  sodium  or 
ammonium  bromide,  with  ^  to  1  drachm  of  syrup  of  chloral  hydrate 
as  a  draught  at  night,  to  be  repeated  if  necessary,  will  often  not 
only  produce  sleep  but  also  afford  material  relief  to  the  violence  of 
the  movements  next  day ;  whilst  trional  has  also  been  advocated  in 
doses  of  3  to  10  gr.  three  times  a  day  or  in  a  larger  single  dose 
at  night-time.  It  can  only  be  in  rare  cases,  however,  that  such 
potent  remedies  will  be  required.  Still  less  will  the  physician 
resort  to  opium  or  morphia,  and  it  is  only  when  the  movements  are 
phenomenally  violent  that  chloroform  inhalations  will  be  thought 
of.  Cannabis  indica,  lobelia,  physostigmine,  thyroid  extract  and 
curare  have  all  been  employed,  but  seeing  that  they  are  such  potent 
remedies  they  are  to  be  avoided  whenever  possible  in  children. 

Rest- — Best,  especially  to  the  mind,  is  most  important  in  the 
successful  treatment  of  chorea ;  the  patients  are  nearly  always  active- 
minded,  the  majority  being  almost  too  keen  upon  their  school  work 
whether  they  are  high  in  their  classes  or  not;  indeed  over-pressure  at 
school  is  one  of  the  chief  factors  in  bringing  out  choreic  movements 
in  children  who  are  predisposed  to  acute  rheumatic  symptoms, 
especially  when  there  has  been  some  final  exciting  cause,  such  as 
competition  for  a  prize,  a  fright,  or  other  excessive  stimulation  of 
the  brain.  Opinions  differ  as  to  whether  the  patients  should  be 
kept  strictly  in  bed  or  not,  but  there  can  be  no  doubt  about  the 
necessity  of  their  being  kept  away  not  only  from  school  but  also 
from  school  friends,  from  books  of  study,  from  exciting  narratives, 
and  from  the  various  excitements  that  are  almost  necessarily 
associated  with  visits  from  other  children,  relatives  and  strangers. 
If,  in  a  mild  case,  it  is  possible  for  the  child  to  live  quietly  in  a 
sunny  garden,  there  is  no  reason  for  confinement  to  bed  in  the 
house,  but  in  towns,  especially  amongst  the  poorer  classes,  it  is 
almost  impossible  to  ensure  absence  of  mental  and  physical  excita- 
tion unless  the  child  is  put  to  bed.  The  severe  cases  must  be  kept 
there  until  the  violence  of  the  movements  subsides,  the  danger  of 
self -injury  by  striking  some  part  against  a  hard  portion  of  the  bed 
being  minimised  by  surrounding  the  patient  with  banked  up  pillows, 
by  bandaging  cotton- wool  over  the  hands  and  other  parts  that  are 
particularly  liable  to  injury,  and  if  need  be  by  having  soft  cushions 


Chorea.  1261 

on  the  floor  lest  by  the  violence  of  the  movements  the  child  becomes 
bodily  ejected  from  the  bed.  So  violent  may  the  movements  be 
sometimes  that  it  is  a  physical  impossibility  for  the  patient  to  feed 
himself,  and  it  may  even  be  very  difficult  indeed  for  the  nurse  to 
hold  a  feeding  cup  in  contact  with  the  lips  without  running  con- 
siderable danger  of  injuring  the  mouth  or  soft  parts  near  it.  Nasal 
feeding  becomes  necessary  in  violent  cases  of  this  kind,  and 
material  relief  is  sometimes  obtainable  from  the  use  of  large  linseed  or 
other  poultices  applied  to  the  trunk  as  hot  as-ean  be  borne.  Fortu- 
nately, if  a  case  is  not  already  of  this  degree  of  violence  when  first 
seen,  the  adoption  of  the  aspirin  treatment,  together  with  ordinary 
quietude,  seldom  fails  to  alleviate  the  severity  of  the  movements 
without  the  attack  becoming  worse.  When  it  is  impossible  for  the 
child  to  have  a  room  to  itself  it  is  wise  to  prevent  it  from  seeing 
what  is  going  on  in  the  rest  of  the  apartment  by  screening  off  the 
cot  or  bed. 

Diet. — A  choreic  patient  should  be  fed  well  but  at  the  same  time 
upon  simple  food.  Milk  and  bread  and  butter  should  constitute  the 
chief  part  of  the  dietary,  at  any  rate  to  begin  with,  and  if  there  is  any 
rheumatic  complication,  especially  joint  pains,  it  is  advisable  to 
continue  with  milk  diet  for  two  or  three  weeks  at  least  before  this  is 
increased.  Uncomplicated  chorea  also  improves  better  upon  a  milk 
and  bread  and  butter  diet  than  when  fish,  meat,  potatoes  and  vege- 
tables are  allowed  early,  provided  always  that  the  patient  will  take  a 
sufficiency  of  the  simpler  foods.  Milk  puddings  of  any  kind,  ripe 
fruits,  whether  fresh  or  cooked,  are  also  to  be  allowed  in  ordinary 
cases,  and  after  the  first  two  or  three  weeks,  if  the  violence  of  the 
movements  has  abated,  eggs,  fish  and  meat  may  be  allowed  in 
ordinary  quantities,  even  though  the  chorea  has  not  entirely  ceased. 
Alcohol  is  contra-indicated  so  far  as  the  chorea  itself  is  concerned, 
though  it  may  sometimes  be  ordered  in  spite  of  the  chorea  if  there 
is  a  severe  heart  lesion  at  the  same  time. 

The  bowels  need  no  particular  attention  in  chorea  beyond  what 
they  receive  in  the  case  of  other  sick  children.  There  is  no  need 
to  be  alarmed  if  a  motion  is  delayed  for  two  days.  If  there  is  no 
action  for  longer  than  this  a  simple  glycerine  suppository  may  be 
used  or  a  small  soap  and  water  enema  given,  but  it  is  unwise  to 
resort  to  purgatives  if  they  can  be  avoided.  Their  use  is  apt  to 
necessitate  their  continuance.  Constipation  has  an  exaggerated 
importance  attached  to  it  as  a  cause  of  increased  violence  of  choreic 
movements,  though  naturally  it  would  be  unwise  to  allow  the 
patient  to  go  many  days  without  taking  minimum  steps  towards 
ensuring  an  evacuation. 


1 262  Chorea. 

Nursing  is  one  of  the  most  important  factors  in  the  treatment 
of  a  severe  case.  Skill  is  required  in  keeping  the  patient  clean  ;  it 
may  be  impossible  for  the  child  to  sit  upon  a  bed-pan,  chamber  or 
commode,  owing  to  the  violence  oi  the  movements,  in  which  case 
the  motion  has  to  be  passed  as  best  it  may  be  into  towels  placed 
under  the  child  in  bed ;  similar  difficulty  may  occur  with  the  urine, 
and  it  may  not  be  at  all  easy  to  keep  the  skin  quite  clean.  Feed- 
ing may  be  easy  in  mild  cases,  but  the  inconsequent  twists  and 
squirms  and  jerkingj^of  a  severe  case  may  make  it  very  difficult  to 
convey  each  spoonful  safely  to  the  patient's  mouth,  and  each  meal 
may  require  a  great  deal  of  patience  on  the  nurse's  part  and  take  a 
long  time  in  the  giving. 

Blistering  of  the  precordia  is  often  resorted  to  in  cases  of  acute 
rheumatic  endocarditis ;  but  when  the  latter  is  associated  with 
chorea  the  irresponsible  movements  of  the  latter  are  so  liable  to 
lead  to  damage  even  of  the  healthy  skin  that  blistering  is  contra- 
indicated. 

Convalescence. — When  there  is  no  cardiac  or  other  rheumatic 
complication  most  choreic  patients  have  no  period  of  convalescence 
in  the  ordinary  sense ;  as  soon  as  the  movements  cease  the  child  is 
generally  to  all  intents  and  purposes  well.  If  confinement  to  bed 
has  been  long,  however,  a  change  of  scene  and  air  is  to  be  recom- 
mended before  school  work  is  begun  again,  and  extract  of  malt  and 
iron  or  other  tonic  remedy  may  be  employed.  Small  doses  of  arsenic 
may  be  very  beneficial  at  this  stage.  The  change  should  be  to  a  quiet 
rather  than  to  an  exciting  place,  either  to  the  country  or  to  a  sea- 
side resort,  where  there  are  good  sands  to  play  upon.  The  question 
of  a  place  of  residence  may  arise,  and  in  this  connection  there  can 
be  no  doubt  that  some  districts  are  much  more  saturated  with 
rheumatic  cocci  than  others  are.  London  as  a  whole  is  as  full  of 
acute  rheumatism  and  its  effects  as  any  other  place,  and  children 
who  have  a  disposition  to  suffer  from  chorea  or  any  other  manifes- 
tation of  acute  rheumatism  should,  whenever  possible,  be  taken  out 
of  London  to  live  elsewhere ;  even  quite  close  to  London  there  are 
many  places  upon  sandy  or  upon  chalky  soil  where  acute  rheu- 
matism is  much  rarer  than  it  is  in  London  itself,  though  at  no 
place  will  the  child  be  absolutely  immune.  It  is  an  old  observation 
that  a  susceptible  child  may  become  choreic  as  the  result  of  visiting 
a  chorea  patient.  It  used  to  be  said  that  this  was  due  to  one  child 
imitating  the  other,  but  it  is  much  more  likely  that  it  is  due  to  the 
chorea  being  actually  caught  as  the  result  of  a  susceptible  child 
having  stayed  in  surroundings  full  of  the  rheumatic  cocci.  Be 
this  as  it  may,  it  is  unwise  for  children  with  acute  rheumatic 


Chorea.  1 263 

tendencies  to  associate  with  others  who  have  acute  rheumatism  or 
chorea. 

Electrical  treatment  has  been  advocated  by  some,  and  all  varieties 
of  electricity  have  been  employed,  though  none  with  any  benefit  that 
can  be  laid  stress  upon. 

Special  baths  and  spa  treatment  have  sometimes  been  advocated, 
but  they  are  not  indicated  unless,  perhaps,  in  a  very  few  cases, 
during  convalescence,  and  then  they  are  treatment  for  the  con- 
valescence rather  than  for  the  chorea  itself. 

Massage  will  seldom  if  ever  be  recommended  in  the  acute  stages 
of  the  malady,  but  in  patients  whose  general  nutrition  suffers  during 
an  attack  or  in  those  in  whom  the  movements,  obstinately  resisting 
treatment,  persist  in  a  mild  degree  for  months,  careful  massage  of 
the  ordinary  rubbing  type  may  be  prescribed  with  much  benefit ; 
passive  movements  of  the  limbs  and  of  each  joint  may  be  employed 
at  the  same  time  with  a  view  to  improving  the  tone  of  the  muscles 
and  preventing  any  risk  there  may  be  of  contractures  from  long 
rest  in  bed. 

A  fatal  case  of  chorea  occurs  now  and  then,  but  it  will  nearly 
always  be  found  that  the  fatal  ending  is  not  due  to  the  chorea 
itself  so  much  as  to  other  rheumatic  manifestations,  particularly 
myo-,  peri-  and  endocarditis  of  malignant  intensity.  Most  cases 
get  well  within  three  months  and  many  within  much  less  time  than 
this  when  excitement  is  avoided  ;  partial  or  complete  rest  is  insisted 
on,  fresh  air  and  sunshine  are  allowed,  and  the  feeding  is  simple 
but  generous.  When  aspirin  is  used  in  large  doses  for  the  first 
three  days  and  in  smaller  doses  during  the  succeeding  weeks  the 
duration  of  the  attack  is  shortened  upon  the  average  by  a  month  or 
more,  though  it  is  most  important  to  continue  with  the  remedy  for 
some  while  after  the  movements  have  ceased. 

HERBERT  FRENCH. 


1264 


OCCUPATION  NEUROSES  AND  CRAFT  PALSIES. 

THE  occupation  neuroses,  or  fatigue  spasms,  must  be  distinguished, 
on  the  one  hand,  from  the  craft  palsies,  which  are  mostly  local 
muscular  wastings  produced  by  certain  trades,  and,  on  the  other 
hand,  from  the  symptoms  of  pain  and  cramp  that  may  be  amongst 
the  early  symptoms  of  the  onset  of  a  grave  nervous  disease,  such  as 
hemiplegia,  syringomyelia,  etc. 

OCCUPATION  NEUROSES. 

These  are  a  group  of  functional  disorders,  whose  most  prominent 
symptoms  are  spasm  or  cramp,  pain,  tremor  and  weakness.  These 
disorders  are  peculiar  to  adults,  and  are  found  associated  with  many 
occupations,  the  chief  of  which  is  writing.  Besides  writer's  cramp, 
similar  symptoms  are  met  with  in  telegraphists,  piano  and  violin 
players,  tailors,  cobblers,  milkers,  compositors,  cigarette  makers, 
smiths,  barbers,  and  in  several  other  occupations  in  which  the  same 
movements  are  constantly  repeated.  Miners'  and  mountaineers' 
nystagmus,  clarionet  players'  and  glass-blowers'  spasm  of  the  lips 
also  belong  to  the  occupation  neuroses.  The  cramp  is  never  met 
with  during  the  learning  stages  of  writing  or  of  the  trade  concerned, 
and  occurs  only  when,  after  long  and  constant  practice,  the  repeti- 
tion of  the  movement  has  become  automatic  ;  it  is  therefore  not 
muscular  in  origin,  but  central,  due  to  breaking  down  of  lines  of 
resistance  between  the  co-ordinating  and  association  centres  con- 
cerned in  the  movements,  and  it  is  therefore  rest  for  the  brain  that 
is  called  for,  by  total  cessation  of  the  special  movements  causing 
the  spasms.  Other  points  *that  go  to  prove  the  neurotic  origin  of 
the  complaint  are  the  frequency  of  the  occurrence  of  other  neuroses 
or  psychoses  in  near  relatives  of  the  sufferer. 

Writer's  cramp,  indeed,  may  be  hereditary,  or  several  members 
of  the  same  family  may  suffer.  The  earlier  treatment  is  begun  the 
more  chance  there  is  of  arresting  or  curing  the  disease ;  but  if  this 
is  of  long  standing  and  the  spasm  is  no  longer  strictly  limited  to 
the  particular  movements,  such  as  of  the  hand  in  writing,  but  is 
beginning  to  be  felt  in  other  movements  of  the  same  muscles,  the 
disease  is  practically  impossible  to  cure  unless  total  rest  from  the 
affected  movements  is  observed.  Writing,  then,  with  the  right 
hand  must  be  totally  given  up  for  at  least  six  months,  and  mean- 


Occupation  Neuroses  and  Craft  Palsies.      1265 

while  may  be  practised  with  the  left  hand.  It  is  true  that 
occasionally  the  spasm  may  spread  to  the  left  hand  ;  should  this  he 
the  case,  however,  the  patient  is  no  worse  off  than  if  he  had  never 
tried  to  use  the  left  hand.  If  the  right  hand  can  thus  be  rested 
completely  from  all  writing  for  six  months,  or,  better  still,  for  longer, 
it  may  be  possible  to  effect  a  cure,  and  the  writing  may  again  be 
taken  up  by  the  right  hand  ;  moreover,  the  spasm  may  never  return, 
in  spite  of  a  considerable  amount  of  writing  work  being  done.  This 
good  result  will  be  the  more  likely  if  spasm  and  not  neuralgic 
pain  and  tenderness  is  the  prominent  symptom.  Again,  the 
prognosis  will  be  better  if  the  trouble  has  appeared  during  a  tem- 
porary mental  stress  or  anxiety,  such  as  domestic  sickness,  financial 
worries,  etc.  If  these  difficulties  are  satisfactorily  surmounted, 
there  will  be  less  tendency  for  the  neurosis  to  recur.  . 

If  the  patient  is  unable  to  give  up  writing  altogether,  or  if  the 
symptoms  are  slight  and  not  fully  developed,  various  treatments 
may  be  adopted  with  a  view  to  lessening  the  spasm.  Firstly,  as  the 
disorder  affects  especially  those  who  use  a  steel  pen  and  cultivate  a 
cramped  and  copper-plate  style  of  writing,  in  which  the  hand  rests 
upon  the  little  finger  and  the  pen  is  gripped  low  down,  alterations 
must  be  adopted  to  produce  a  freer  style  of  writing,  in  which  the 
pen  is  merely  held  between  the  fingers  and  thumb,  and  the  letters 
are  formed  by  movements  imparted  to  the  pen  by  the  larger 
muscles  of  the  forearm  and  arm,  rather  than  by  the  intrinsic 
muscles  of  the  hand.  A  stylographic  pen  or  pencil  should,  if 
possible,  be  substituted  for  the  steel  nib,  or  if  the  latter  is  essential, 
a  stout  cork  penholder  must  be  used.  Various  styles  of  holding  the 
pen  may  be  adopted  as  a  change,  such  as  holding  it  between  the 
first  and  second  fingers,  and  care  must  be  taken  that  the  arm  rests 
comfortably  on  a  smooth  and  polished  table. 

Other  mechanical  devices  which  are  sometimes  of  great  service 
are  Nussbaum's  bracelet,  and  a  ring  attachment  to  the  pen  through 
which  the  index  finger  may  be  slipped.  The  ring  should  be  f  inch 
in  width,  and  of  such  a  diameter  as  to  fit  the  finger  closely  and 
comfortably,  and  it  should  be  firmly  fixed  to  the  side  of  the  pen- 
holder about  3  inches  from  the  point  of  the  pen.  The  object  of 
this  device  is  to  prevent  the  pen  from  slipping  from  the  grasp 
during  writing,  and  also  to  avoid  the  necessity  for  continual  tonic 
contraction  of  the  first  dorsal  interosseus  and  opponens  muscles,  and 
thus  lessening  the  tendency  to  fatigue  spasm.  The  bracelet  is  of  ser- 
vice in  holding  the  spread-out  fingers  together,  and  thus  diminishing 
the  tendency  towards  irregular  spasmodic  movements  of  the  fingers, 
causing  the  pen  to  be  either  lifted  off  the  paper  or  the  point  driven 

S.T. — VOL.  n.  80 


1266     Occupation  Neuroses  and  Craft  Palsies. 

through  the  page.  A  quill  pen  has  been  recommended,  but  its 
shaft  is  too  small,  though  a  quill  nib  may  be  used  on  a  cork 
penholder. 

Local  treatment  to  the  hand  and  arm  by  massage  and  Swedish 
gymnastic  exercises,  graduated  against  resistance,  may  be  extremely 
useful,  and  sometimes  also  galvanic  arm-baths.  The  electrode 
should  not  be  stroked  over  the  hand  and  forearm  muscles,  but  both 
electrodes  should  be  dipped  into  the  two  ends  of  an  arm-bath 
sufficiently  long  to  take  the  forearm  and  hand  with  the  fingers 
straight  out.  Warm  water  without  any  salt  should  be  placed  in  the 
bath  to  a  depth  just  sufficient  to  cover  the  forearm,  and  a  steady 
constant  current  of  about  30  milliamperes  sent  through  the 
bath.  Of  this  current  about  one-third,  as  a  rule,  passes  through 
the  tissues  of  the  patient.  If  this  method  is  tried  it  should  be 
persisted  in  daily  ;  it  is  likely  to  be  of  more  use  in  the  neuralgic 
cases. 

Possibly  suggestion  plays  the  chief  part  in  the  cure  in  some 
cases.  When  these  methods  fail  and  rest  from  writing  is  impos- 
sible, either  the  left  hand  must  be  trained  to  do  the  work  or  else  a 
typewriter  must  be  substituted  for  the  writing  by  hand.  This, 
however,  is  often  impossible  for  lawyers'  clerks  and  others  who 
have  to  do  engrossing  and  copper-plate  writing.  Giving  up  the 
employment  is  the  only  other  alternative. 

Next  to  writer's  cramp,  telegraphist's  cramp  is  perhaps  the 
most  important ;  here,  again,  as  with  writing,  the  disease  does  not 
show  itself  in  the  learning  stages,  but  develops  only  after  some 
years  of  constant  practice  and  familiarity  with  sending  messages. 
In  the  present  form  of  machine  used  the  operator  learns  to  send 
the  dots  and  dashes  of  the  Morse  code  by  listening  to  the  noise 
that  the  key  makes  as  it  is  depressed  and  released.  This  is  a 
greater  strain  upon  the  attention  than  watching  the  movements  of 
a  needle,  as  in  the  older  types  of  sending  machines. 

The  cramp  shows  itself  by  inability  to  perform  correctly  the 
proper  spacing  of  the  dots  and  dashes,  and  certain  combinations 
will  be  found  more  difficult  at  first  than  others,  varying  with 
individuals,  but  eventually  extending  to  all  letters,  so  that  the 
rapidity  of  the  operator  is  greatly  diminished,  and  the  work 
ultimately  becomes  impossible. 

A  contributing  factor  in  the  development  of  telegraphist's  cramp 
is  the  operator's  method  of  working  with  the  instrument  on  the 
edge  of  the  table,  so  that  the  arms  are  not  supported.  If  the  right 
arm  can  be  rested  upon  a  table,  one  element  of  strain  is  thus 
removed,  and  the  left  hand  should  be  used,  if  possible,  in  order  to 


Occupation  Neuroses  and  Craft  Palsies.     1267 

rest  the  right.  As  in  writer's  cramp,  so  also  in  this  form  and  in 
other  occupation  neuroses,  nervous  heredity,  nerve  strain,  and 
worry  play  an  important  part.  Nerve  tonics,  such  as  the  glycero- 
phosphates,  iron,  arsenic  and  strychnine,  should  be  thoroughly  tried, 
and  bromide  may  be  added  with  advantage  if  neurasthenic  sym- 
ptoms, such  as  irritability,  lack  of  power  of  concentration  and 
sleeplessness,  are  present.  If  the  latter  symptom  is  severe  and 
amounts  to  actual  insomnia,  veronal  (in  7-gr.  doses)  should  be 
given  in  addition  nightly,  the  dose  being  gradually  diminished  and 
then  the  drug  withdrawn. 

The  terms  hammerman's  cramp,  smith's  cramp,  or  hephsestic 
hemiplegia  as  it  has  been  called,  have  been  applied  to  more  than 
one  disorder,  including  apoplexy  from  cerebral  haemorrhage.  Actual 
fatigue  spasm  may  attack  the  right  arm  in  men  who  have  to  deliver 
repeated  blows  with  a  hammer  in  their  work.  The  triceps  becomes 
weakened  by  this  movement,  and  the  sufferers  instinctively  hold 
the  arm  adducted  to  the  side  to  help  them  in  the  blow.  Tremor  of 
the  arm  may  be  very  marked,  and  the  triceps  which  is  weak  in 
delivering  a  blow  may  appear  quite  strong  in  holding  the  arm 
firmly  extended  against  resistance,  this  inconsistency  proving  the 
disorder  to  be  functional.  Further  symptoms  of  functional  hemi- 
plegia and  hemi-anaesthesia  may  develop,  and  prolonged  treatment 
and  massage  and  faradism,  with  plenty  of  encouragement,  is 
required.  Rest  from  work  in  this  stage  is  necessary  for  a  time. 

CRAFT  PALSIES. 

Various  forms  of  neuritis  and  consequent  muscular  atrophy  may 
result  from  pressure  on  nerves  and  muscles  in  certain  occupations 
and  trades ;  hence  the  term  occupation  neuritis  has  been  applied  to 
these  cases,  which  must  be  distinguished  from  occupation  neuroses. 
Thus  the  pressure  of  a  trowel  in  gardening  or  the  constant  use  of- a 
scrubbing-brush  may  cause  atrophy  of  the  thenar  muscles,  usually 
without  any  anaesthesia.  House  painters,  too,  may  get  similar  atrophy 
from  pressure  of  the  brush-handle  and  partly  from  the  toxic  action 
of  the  lead  rubbed  in.  Atrophy  of  all  the  intrinsic  muscles  of  the 
hand  may  also  be  met  with  in  ironers,  scrubbers,  plate  polishers, 
joiners,  etc.,  or  this  form  of  atrophy  may  result  from  the  pressure 
of  the  handle  of  a  walking-stick  or  similar  support  in  persons 
suffering  from  some  permanent  weakness  of  a  leg,  such  as  old 
poliomyelitis.  If  the  cause  9f  such  atrophy  is  recognised  in  time, 
recovery  may  ensue  on  the  cessation  of  the  cause  of  the  pressure, 
aided  by  faradism  applied  in  the  form  of  a  wave-current. 

Ulnar  paralysis  may  occur  in  oarsmen,  glass  workers,  and  in 

80—2 


1268     Occupation  Neuroses  and  Craft  Palsies. 

wood  engravers  and  telephone  operators  from  the  ulnar  nerve 
being  pressed  on  through  leaning  the  elbow  on  a  high  table  or  desk 
while  at  work.  In  such  cases  it  is  usually  mostly  a  motor  paralysis, 
with  muscular  wasting  of  the  interossei  and  ulnar  flexors  of  the 
fingers  and  wrist,  with  little  or  no  sensory  symptoms  beyond  some 
pain  at  the  elbow  and  slight  pins  and  needles  on  the  inside  of  the 
hand  and  little  finger.  In  order  to  effect  a  cure  the  cause  should 
be  recognised  early,  and  the  faulty  position  must  be  corrected,  and 
if  possible  the  arm  be  given  as  complete  a  rest  as  possible. 

Electricity  in  the  form  of  the  faradic  wave-current  is  perhaps 
here  the  best  stimulus  to  the  regeneration  of  the  muscular  tissue. 
With  one  flexible  electrode  wrapped  round  the  fingers  and  the  other 
fixed  round  the  forearm  immediately  below  the  elbow,  this  form  of 
current  is  produced  by  slowly  sliding  the  secondary  coil  to  and  fro 
over  the  primary,  so  as  to  produce  alternately  tetanisation  and 
relaxation  of  the  muscles. 

Similarly,  paralysis  of  the  long  thoracic  nerve  may  occur  through 
violent  muscular  strain  of  the  serratus  magnus  and  scalenus  medius 
in  the  act  of  swimming,  especially  with  the  side-stroke,  and  the 
musculo-spiral  nerve  may  also  be  damaged  in  the  upper  arm  by 
violent  contraction  of  the  triceps  muscle. 

Actual  atrophy  of  muscles  continually  engaged  in  prolonged 
heavy  work  may  occur  without  any  pressure  upon  the  nerve-trunk 
supply  of  the  muscle.  Such  wasting  of  the  deltoid  and  triceps  may 
be  seen  occasionally  in  smiths,  whose  occupation  necessitates  the 
frequent  wielding  of  a  heavy  hammer.  Cessation  of  the  harmful 
trade  is  the  only  possible  remedy  in  these  cases,  followed  by 
massage  and  faradism  as  above  described. 


WILFRED  HARRIS. 


KEFEREXCES. 


Oppenheim,  H.,  "Text-book  of  Nervous  Diseases,"  5th  edit.,  English  transla- 
tion by  A.  Bruce,  1910,  II.,  p.  1268.  Gowers,  Sir.  W.  E.,  "  Manual  of  Dis.  of 
Nerv.  Syst.,"  2nd  edit.,  1893,  II.,  p.  710. 


1269 


PARALYSIS  .AGITANS. 

OUR  present  uncertainty  as  to  the  etiology  of  this  disease 
necessarily  handicaps  us  severely  in  our  attempts  at  the  allevia- 
tion of  its  symptoms.  The  brain,  the  spinal  cord,  and  even  the 
muscles,  all  in  turn,  have  been  accused  of  being  the  seat  of  the 
primary  pathological  process.  The  fact,  however,  that  the  dis- 
tribution of  the  symptoms  is  usually  unilateral  at  the  onset, 
points  to  the  conclusion  that  we  have  to  do  with  an  essentially 
cerebral  affection,  and  that  the  inconstant  changes  described  by 
various  observers  in  the  vessels  or  nerve-cells  of  the  spinal  cord, 
or  in  the  muscle  fibres,  must  be  regarded  as  accidental  concomi- 
tants of  the  disease,  not  its  primary  cause. 

Although  causing  the  patient  considerable  discomfort,  and  in 
its  later  stages  producing  muscular  rigidity,  paralysis  agitans  is 
not  a  fatal  disease.  The  motor  disability  which  supervenes  is  not 
due  to  paralysis,  but  results  from  two  other  factors,  tremor  and 
rigidity.  There  are  also  certain  vasomotor  symptoms,  such  as 
sudden  subjective  sensations  of  heat  or  cold  passing  through  the 
body,  which  may  call  for  alleviation.  In  the  later  stages  of  the 
disease  the  patient  often  complains  of  restlessness  and  of  a  curious 
difficulty  in  finding  a  comfortable  position  in  bed.  In  such  cases 
a  specially  hard  mattress  is  preferable  to  a  soft  one,  enabling  the 
patient  to  change  his  position  with  less  difficulty. 

Kecognising,  then,  that  cure  is  out  of  the  question  and  that  our 
treatment  must  be  frankly  symptomatic,  let  us  consider  what 
remedial  measures  are  at  our  disposal. 

Worry,  excitement,  business  anxiety  and  strenuous  mental  exer- 
tion all  tend  to  aggravate  the  symptoms ;  therefore  a  quiet,  restful 
mode  of  life,  if  this  can  be  arranged,  is  advisable.  If  the  patient's 
means  admit  of  his  going  occasionally  to  some  one  or  other  of  the 
climatic  or  balneo-therapeutic  resorts  which  he  may  fancy,  care 
should  be  taken  to  ensure  that  he  is  not  overwhelmed  by  strenuous 
physical,  electrical  or  balneological  treatment,  all  of  which  measures, 
if  too  zealously  pushed,  may  only  aggravate  his  discomfort.  Gentle 
passive  movements,  however,  sometimes  alleviate  the  rigidity.  So, 
also,  do  warm  baths  and  mild  galvanic  baths  in  certain  cases. 
Strong  massage,  faradic  electricity,  and  gymnastic  exercises,  on  the 
other  hand,  in  my  experience,  usually  aggravate  the  disease. 


1270  Paralysis  Agitans. 

Amongst  the  drugs  which  have  been  employed,  that  which  has 
hitherto  produced  the  greatest  beneficial  results  is  hyoscine.  By  its 
means,  tremor  and  restlessness  are  often  appreciably  diminished, 
and  the  patient  tends  to  sleep  better.  We  may  commence  with 
^<kj  gr.  of  the  hydrobromide  morning  and  evening,  gradually 
increasing  to  T£Q  gr-  or  even  ^  gr.  If  the  drug  is  left  off  for 
a  week  or  so  once  a  month,  the  results,  on  the  whole,  are  better 
than  if  it  is  administered  continuously  for  long  periods ;  more- 
over, toxic  symptoms  are  less  likely  to  supervene.  Other  drugs 
belonging  to  this  same  group  (duboisine,  scopolamine,  hyoscya- 
mine)  act  in  a  similar  fashion.  Drugs  which  induce  sweating 
commonly  aggravate  the  disease.  In  severe  cases,  when  sleep  is 
much  interfered  with,  we  may  be  justified  in  administering  heroin 
or  morphine  hypodermically. 

I  have  seen  many  cases  in  which  the  blood  pressure  was  abnormally 
low,  in  marked  contrast  to  the  senile  facies,  and  in  such  patients  I 
have  found  occasional  benefit  from  the  administration  of  pituitary 
extract  in  full  doses,  in  combination  with  hyoscine.  It  should  be 
noted  that  pituitary  extract  has  comparatively  little  pharmacological 
effect  if  given  by  the  mouth.  It  should  be  administered  hypo- 
dermically. 

PURVES  STEWART. 


1 27 1 


TETANY. 

THIS  symptom  of  recurrent  attacks  of  muscular  spasm,  affecting 
especially  the  limbs,  abdominal  and  respiratory  muscles,  is  often 
associated  with  considerable  pain.  Its  causes  are  very  various,  and 
consequently  the  treatment  must  be  not  only  symptomatic,  but  also 
directed  towards  the  primary  disease.  Many  varieties  of  tetany  are 
toxic-infective  in  their  origin  ;  it  may  occur  after  or  during  the  course 
of  diphtheria,  typhoid  and  many  other  infections,  and  in  certain 
districts  it  has  been  described  as  both  endemic  and  epidemic  at  certain 
seasons  of  the  year.  Shoemakers  and  tailors  suffer  not  unfrequently, 
probably  owing  to  absorption  of  some  toxin  from  the  leather  or  cloth 
handled.  Total  removal  of  the  thyroid  gland  may  be  followed  by 
tetany,  which  is  then  of  very  serious  prognosis ;  it  is  said  to  be  due 
to  the  removal  of  the  parathyroids,  which  in  man  are  buried  in  the 
thyroid.  Consequently  treatment  with  parathyroid  substance  (2 
or  8  gr.  daily)  will  be  necessary.  Tetany  may  also  be  combined 
with  either  myxcedema  or  exophthalmic  goitre,  scleroderrnia,  etc. 
I  have  seen  chronic  tubercular  peritonitis  associated  with  tetany. 
In  suckling  women  tetany  is  not  rare  if  the  lactation  is  prolonged 
unduly  or  the  woman  is  run  down  in  health.  Trousseau  named 
this  form  Nurse's  contracture.  The  lactation  must  be  given  up 
and  tonics  administered.  One  of  the  most  dangerous  forms  of 
tetany  is  that  found  with  excessive  dilatation  of  the  stomach.  Gastric 
lavage  is  here  a  special  danger,  and  fatal  results  have  occasionally 
occurred.  The  tetany  in  these  cases  is  thought  to  be  due  to  absorbed 
toxins  from  the  stomach.  Lavage  of  the  stomach  must  be  avoided 
in  such  cases,  and  if  the  weight  is  falling  in  spite  of  careful  diet- 
ing, rectal  feeding  must  be  employed  for  a  few  days,  with  daily 
subcutaneous  injections  of  £  pint  of  saline,  followed  by  gastro- 
enterostomy. 

If  the  pain  of  the  spasms  is  severe,  bromides,  morphia,  or  chloral 
hydrate  must  be  given  (see  also  Tetany  in  Children,  p.  1272). 

WILFRED  HARRIS. 


1272 


TETANY   IN    CHILDREN. 

THE  treatment  of  tetany  is  based  on  its  probable  origin  in  a 
toxaemia  of  gastric  or  intestinal  causation.  Impaired  nutrition, 
notably  that  associated  with  rickets,  is  a  predisposing  factor.  The 
poison  acts  on  and  induces  hyper-excitability  of  the  nerve  cells  in 
the  bulb  and  the  anterior  cornua,  the  efferent  nerves  and  the  muscles. 
The  hypotheses  that  the  affection  depends  on  an  excess  of  lime  salts 
in  the  diet  or  a  deficiency  thereof  in  the  brain,  blood  and  muscles 
may  be  disregarded.  Apparently  the  toxic  body  is  a  product  of 
microbial  activity  or  of  imperfect  digestion.  Tetany  is  most  common 
at  six  to  eighteen  months  of  age,  a  period  of  life  when  rickets  is 
developed  and  infants  are  often  erroneously  fed.  It  is  generally 
associated  with  chronic  dilatation  of  the  stomach  or  chronic  diar- 
rhoaa,  occasionally  with  chronic  dilatation  of  the  colon.  It  is  rare 
in  acute  diarrhoeal  affections,  for  the  poison,  if  formed,  is  rapidly 
eliminated. 

Preventive  treatment  includes  suitable  diet,  warm  clothing  and 
the  ordinary  measures  of  general  hygiene.  Dilatation  of  the  stomach, 
so  apt  to  occur  in  rachitic  infants,  must  be  guarded  against  by 
limiting  the  size  of  the  meals  and  giving  food  which  is  not  liable 
to  undergo  gaseous  fermentation  in  the  stomach. 

Active  measures  include  elimination  of  the  poison,  reduction  of 
the  hyper-excitability,  and  treatment  of  the  underlying  cause.  The 
condition  of  the  alimentary  tract  must  receive  attention.  In  the 
ordinary  case,  dependent  on  chronic  intestinal  catarrh,  an  initial 
dose  of  castor  oil  or  calomel  should  be  prescribed,  and  subsequently 
drugs,  such  as  bismuth  or  benzo-naphthol.  For  gastric  disturbance 
either  alkalies  or  hydrochloric  acid  are  required.  Mild  diuretics 
assist  elimination. 

For  the  reduction  of  hyper-excitability  rest  in  bed  in  a  dark 
room,  complete  quiet,  hot  baths  and  chloral  are  required.  In 
bad  cases  a  bath  at  95°  to  105°  F.  should  be  given  every  six  hours. 
Sometimes  the  chloral  must  be  given  per  rectum  in  doses  of  5  to 
10  gr.,  in  an  ounce  of  water,  every  six  hours  or  even  more  fre- 
quently, according  to  its  retention,  its  effects  and  the  severity  of 
the  cramps.  In  milder  cases  in  infants  chloral  (1  gr.  for  each 
three  months  of  life  up  to  one  year  of  age),  is  given  alone  or  with 
double  the  quantity  of  sodium  bromide,  in  a  drachm  of  syr.  aurantii 


Tetany  in  Children.  I273 

or  syr.  mori,  every  three  to  six  hours.  Bromides  alone  may  be 
sufficiently  sedative  for  mild  attacks.  In  very  bad  ones  chloroform 
up  to  complete  anaesthesia  should  be  utilised  as  a  temporary  measure 
until  the  chloral  has  time  to  act. 

As  soon  as  the  alimentary  tract  is  in  a  healthy  state  and  the 
spasms  have  subsided,  the  rickets  or  other  underlying  factor  present 
must  be  treated.  It  should  not  be  assumed  that  the  child  is  cured 
as  soon  as  the  cramps  have  ceased,  for  the  tendency  thereto,  a  con- 
stitutional state  known  as  spasmophilia,  persists  and  recurrence  is 
not  uncommon  (see  also  article  on  Tetany,  p.  1271). 

EDMUND  CAUTLEY. 


1274 


MENTAL  DISEASES, 

GENERAL  CONSIDERATIONS. 

THE  treatment  of  mental  disorder  is  unfortunately  not  solely  a 
medical  matter.     With  it  are  involved  social  and  legal  considera- 
tions which,  looming  large  in  the  popular  and  forensic  minds,  have 
most  seriously  interfered  with  the  therapeutic  art  in  this  branch  of 
medicine.    But  a  few  generations  ago  and  amongst  the  most  civilised 
nations  the  mentally  afflicted  patient  was  regarded  as  one  possessed 
and  therefore  as  one  to  be  dealt  with  on  a  penal  system.     That  this 
state  of  affairs  has,  at  least  in  this  and  other  civilised  countries, 
been  swept  away  is  due  to  the  efforts  of  members  of  the  medical 
profession,  and  we  believe  that  there  is  no  brighter  record  on  the 
pages  of  our  therapeutic  annals  than  that  which  compares  the  vile 
horrors  of  a  not  remote  past  with  the  humanitarian  methods  of 
to-day.     The  progress  made,  though  less  rapid,  is,  in  the  saving  of 
life  and  the  shortening  of  illness,  .comparable  to  that  of  abdominal 
surgery.      But  while  these  magnificent  strides  have  been  made  pro- 
gress has  been  retarded  to  an  appreciable  extent  by  certain  legal 
and  social  developments.     About  the   middle  of  the  last  century 
there  arose  a  popular  and  sentimental  agitation  fomented  by  literary 
scaremongers.      It  was  alleged  that  the  liberty  of  the  subject  was 
endangered  and  that  but  too   often   inconvenient   relatives    were 
immured  or  "put  away"  within  asylums  and  there,  though  sane, 
were  compelled  to  pass  the  remainder  of  their  days.     Under  the 
influence  of  this  agitation  legislation  was  carried  through  which, 
without  doubt,  though  it  might  be  expected  successfully  to  protect 
the  liberty  of  the  sane  individual,  rendered  it  necessary  to  bring 
every  insane  individual  within  the  purview  of  the  law  and  to  pre- 
vent treatment  outside  that  purview.     The  result  has  been  that  for 
the  most  part  the  treatment  of  the  insane  or,  as  we  should  prefer 
to  put  it,  of  the  mentally  disordered  has  been,    as  a  matter  of 
obligation,  carried   on   in  asylums,  and  so  has  been  fostered  the 
popular  notion  that  the  lunatic  must  be  under  lock  and  key,  that 
"  treatment "  consists  in  his  being  immured  in  an  asylum  from 
which  he  is  not  to  be  allowed  to  "  escape,"  that  he  may  thus,  with 
the  lapse  of  time,  get  well  or  not  without  any  medical  intervention, 
and  that  mental  disorder  is  a  thing  apart  from  other  branches  of 


Mental  Diseases.  1275 

medicine  and  by  no  means  to  be  treated  on  the  same  lines  as  are 
disorders  of  that  which  is  called  the  body  as  distinct  from  that 
which  is  called  the  mind.     The  social  and  legal  stigmata  which 
attach  to  that  which  too  often  is  regarded  as  a  conviction  of  lunacy 
operate  on  therapeutics  most  seriously  in  that  patients  are  only  as 
a  last  resort  brought   under    treatment  ;    everything  except  sub- 
mission to  proper  treatment  is  done  to  postpone  the  moment  when 
the  patient  is  "  put  away,"  that  moment  being,  as  a  rule,  determined 
at  the  stage  when  the  patient  has  become  a  nuisance  to  society  or 
dangerous  to  himself.     This  attitude  has  led  to  the  treatment  of 
patients   being   neglected   during   the   recoverable   stage  of   their 
illness,  and  it  is  not  to  be  wondered  at  that  the  prognosis  of  fully 
developed  mental  disorders  is  regarded  by  many  medical  men  with 
pessimism  when  we  appreciate  the  chronic  nature  of  the  malady 
they  are  called  upon  to  treat.     We  find  enormous  institutions  in 
which  are  herded  large  numbers  of  persons  of  unsound  mind  under 
the  care  of  medical  staffs  which  are  absurdly  inadequate  in  number, 
where  that  individual  attention  which  is  so  important  in  this  class 
of  case  is  perforce  absent  and  where  the  advent  of  degradation  in 
mental  level,  be  it  slow  or  rapid,  is  regarded  with  fatalistic  resigna- 
tion.    If  this  state  of  affairs  may  be  considered  as  an  important 
factor  in  combating  our  therapeutic  efforts  it  is  also  to  be  remarked 
that  by  general  consent  and  in  all  grades  of  society  the  presence  of 
a  "  lunatic  "  in  a  family  is  regarded  with  feelings  other  than  those 
aroused  by  other  forms  of  illness.      Sympathy  and  a  desire  to  help 
to  the  utmost  are,  to  the  credit  of  our  race,  in  a  large  majority  of 
cases  present,  but   there   is   intermixed   with   these  praiseworthy 
emotions    a  curious   half -deprecating   attitude  of   shamefacedness 
and  a  dislike  to  admitting  the  fact  that  the  patient  is  mentally 
affected.     No  one  objects  to  having  had  in  person  or  to  having  a 
relative  who  has  had  appendicitis,  while  a  reputation  for  "  nervous 
breakdowns  "  seems  even  to  enhance  the  interest  of  an  otherwise 
uneventful  and  colourless  life,  but  a  history  of  insanity,  recognised 
as  such,  is  referred  to  with  bated  breath,  or,  indeed,  as  is  too  often 
the  case,  suppressed  altogether.    The  almost  necessary  consequence 
of  this  is  that  the  earlier  symptoms  are  set  down  to  anything  rather 
than  to  mental  illness ;  that  the  patient  is  subjected  to  the  schemes 
and  devices  of  ignorant  persons,  charlatans  and  crochet-mongers 
and  that  time  of  extreme  value  is  wasted. 

To  neutralise  these  various  circumstances  which  untowardly 
militate  against  the  treatment  of  mental  disorder  at  that  very 
time  when  it  is  not  firmly  established,  various  schemes  have  been 
suggested.  In  part  it  has  been  hoped  to  educate  the  public  and  in 


1276  Mental  Diseases. 

part  to  mitigate  the  rigour  of  the  law.  There  can  be  but  little 
doubt  that  the  establishment  of  mental  hospitals  or,  better  still,  of 
special  wards  in  general  hospitals,  would  have  a  remarkable  effect 
in  persuading  patients  and  their  friends  that  mental  disorders  are 
to  be  treated  on  the  same  lines  as  are  those  diseases  which  are 
termed  physical  or  "  bodily,"  that  it  is  desirable  that  advice  should 
be  sought  at  the  earliest  moment  and  that  there  is  no  reason  to 
despair,  at  least  in  many  cases,  of  the  ultimate  issue.  But  to 
inaugurate  reform  on  these  lines  it  is  necessary  that  the  law  should 
be  modified,  or,  if  not  modified,  that  everything  should  be  done  in 
a  spirit  which  realises  that  some  of  its  provisions  have  become 
antiquated  and  that  at  its  base  is  not  the  fundamental  principle 
that  a  patient  is  to  be  treated,  but  the  principle  that  the  liberty  of 
the  subject  is  to  be  jealously  guarded.  To  the  medical  profession 
it  is  plain  that  the  result  is  that  the  treatment  of  our  patients  is 
rendered  difficult  or  impossible,  while  there  is  probably  not  one  of 
us  who  has  ever  known  of  an  authentic  case  where  a  sane  person 
has  been  wrongfully  detained.  Provision  for  the  early  treatment  of 
mental  disorder  among  the  poor  is  practically  non-existent,  and  it 
must  fall  to  many  of  us  to  watch  cases  gradually  drifting  from  bad 
to  worse  until  the  day  at  length  arrives  when  no  course  is  open  to 
the  relatives  but  to  send  the  patient  to  an  asylum ;  the  absence  of 
such  provision  is  a  crying  scandal,  and  its  establishment  would,  we 
believe,  save  many  useful  citizens  who  now  encumber  the  ground 
at  our  asylums.  Among  the  well-to-do  the  early  treatment  of 
insanity  can  be  carried  on  in  the  patient's  home,  a  medical  man's 
house  or  nursing  home,  but  section  316  of  the  Lunacy  Act,  1890, 
has  always  to  be  borne  in  mind.  In  framing  this  section  our  legis- 
lators no  doubt  had  what  they  considered  to  be  the  good  of  the 
majority  in  mind,  whereas  the  physician  working  in  this  branch  of 
medicine  at  once  appreciates  that  to  obey  the  letter  of  the  law  all 
too  often  inflicts  a  cruel  and  unnecessary  wrong  upon  a  patient 
without  the  smallest  compensating  advantage.  Section  316  of  the 
Lunacy  Act,  1890,  runs  as  follows  : 

"Every  person  who,  except  under  the  provisions  of  this  Act, 
receives  or  detains  a  lunatic,  or  alleged  lunatic,  in  an  institution  for 
lunatics,  or  for  payment  takes  charge  of,  receives  to  board  or  lodge, 
or  detains  a  lunatic  or  alleged  lunatic  in  an  unlicensed  house,  shall 
be  guilty  of  a  misdemeanour,  and  in  the  latter  case  shall  also  be 
liable  to  a  penalty  not  exceeding  fifty  pounds." 

The  question  must  here  arise  as  to  what  a  "lunatic  "  is.  The 
Lunacy  Act,  1890,  defines  as  follows  :  "  '  Lunatic '  means  an  idiot 
or  person  of  unsound  mind."  If  every  person  who  presents 


Mental  Diseases.  I277 

symptoms  of  mental  disorder  is  to  be  regarded  as  a  "  lunatic,"  and 
such  is  tlie  law,  and  if  no  such  person  is  to  be  received  for  treat- 
ment by  those  skilled  in  the  therapeutic  art  unless  he  or  she  is 
legally  certified  as  a  "  lunatic,"  the  Act  plainly  becomes  an  engine 
of  ridiculous  tyranny.  In  Scotland  the  Lunacy  Commissioners 
have,  in  a  recent  report,  officially  expressed  an  opinion  that  those 
perform  a  useful  function  who  receive  such  patients  as  it  is  not 
desirable  to  certify,  even  though  they  present  symptoms  of  mental 
disorder.  In  the  suggestions  which  we  shall  hereinafter  make 
with  regard  to  the  treatment  of  the  mentally  disordered  we  shall 
not  contrast  that  which  is  sometimes  called  "asylum  treatment" 
with  treatment  which  may  elsewhere  be  instituted,  for  we  are  of 
opinion  that  there  should  in  fact  be  no  such  contrast.  It  is  too 
often  held  that  an  asylum  is  less  a  place  for  the  treatment  of 
acute  insanity  than  one  for  harbouring  the  chronically  insane  and 
demented,  but  we  hold  most  strongly  to  the  opinion  that  an  asylum 
should  be  primarily  a  mental  hospital  at  which  treatment  should 
be  carried  on  with  the  care  and  attention  to  detail  which  mark  the 
administration  of  our  general  hospitals. 

The  practical  problem  which  will  confront  the  medical  man  and 
the  relations  of  the  patient  is  as  to  how  the  patient  is  best  to  be 
treated  and  where,  and  it  is  to  the  latter  part  of  this  problem  we 
propose  now  to  address  ourselves.  The  financial  resources  of  the 
patient  to  a  large  extent  govern  the  situation.  If  the  number  of 
nurses  can  be  unlimited,  if  the  largest  part  of  the  time  of  a  medical 
man  can  be  secured,  and  if  a  certain  part  of  the  patient's  house  can 
be  set  aside  for  his  own  exclusive  use,  it  may  be  quite  possible  to 
treat  the  patient  who  is  acutely  ill  at  home.  The  expense  involved 
is  naturally  very  great,  and  the  patient  cannot  in  this  way  be  so 
completely  withdrawn  from  home  influences  as  if  he  was  housed 
elsewhere.  If  adequate  medical  attendance  and  nursing  cannot  be 
obtained  at  home,  or  if  the  patient  cannot  there  be  properly 
secluded,  an  alternative  lies  in  his  removal  to  the  house  of  some 
skilled  person  willing  to  receive  him.  Noisiness  and  violence  on 
the  part  of  the  patient  is  perhaps  the  chief  bar  to  reception  into  a 
private  house,  while  the  treatment  of  a  marked  case  of  paranoia 
outside  an  asj'lum  is  difficult.  If  delusions  of  suspicion  and  perse- 
cution are  pronounced  a  homicidal  tendency  should  be  suspected, 
and  such  a  tendency  is  clearly  best  controlled  in  an  institution.  So, 
too,  in  the  case  of  a  suicidal  patient  it  is  best  that  he  should  be  in 
an  institution  where  the  possibilities  of  an  attempt  at  self-destruc- 
tion are  carefully  guarded  against.  In  addition  to  these  indications 
against  treatment  in  a  private  house  it  must  be  borne  in  mind  that 


1278  Mental  Diseases. 

unremitting  medical  attention  and  nursing  involve  an  expenditure 
which  cannot  often  be  borne,  and  when  this  is  the  case  a  choice 
must  be  made  from  among  a  large  number  of  licensed  institutions 
where  expenses  are  less  owing  to  the  large  number  of  patients 
received.  In  cases  of  chronic  insanity  the  disposal  of  the  patient 
must  depend  on  the  severity  of  the  symptoms.  In  some  mild  cases 
there  is  no  reason  why  the  patient  should  not  live  at  home,  but  in 
severe  cases  institutional  treatment  is  more  desirable  than  treat- 
ment in  single  care,  for  there  is  a  wider  range  of  society,  of  work  and 
of  amusement  to  be  found  within  the  walls  of  a  well-regulated 
institution.  When  it  has  been  decided  that  it  is  desirable  that  the 
patient  should  be  certified  and  the  objection  of  the  relatives  to  such 
a  course  has  been  overcome,  the  process  of  certification  or  legal 
recognition  of  the  person  as  of  unsound  mind  has  to  be  effected. 

Certification. — The  most  usual  method  whereby  certification  is 
executed  is  by  a  reception  order  made  upon  the  presentation  of 
a  petition  supported  by  medical  certificates.  Forms  may  be 
obtained  from  Shaw  &  Sons,  Fetter  Lane,  E.G.  The  petition 
consists  of  an  application  which  is  made  by  a  near  relative  of  the 
patient  and  contains  particulars  concerning  the  history  of  the 
patient.  If  a  near  relative  is  not  available  the  petition  may  be 
signed  by  someone  else,  but  in  this  case  it  must  be  explained 
why  the  petition  is  not  presented  by  a  near  relative  or  connection. 
This  petition  is  presented  with  the  medical  certificates  to  a 
magistrate,  having  special  jurisdiction  in  such  matters,  who  there- 
upon makes  an  order  for  the  reception  of  the  patient  into  the  asylum, 
hospital  or  house  which  has  been  selected.  It  is  to  be  remembered 
that  it  is  not  necessary  that  the  magistrate  should  see  the  patient, 
nevertheless  the  decision  rests  with  him.  Two  medical  certificates, 
signed  by  two  registered  practitioners,  are  required  and  contain  the 
facts  observed  by  the  practitioners  at  the  time  of  their  examination 
of  the  patient  and  facts  communicated  to  them  by  others.  One  of 
the  certificates  should,  whenever  practicable,  be  under  the  hand  of 
the  usual  medical  attendant  of  the  patient.  Each  of  the  practi- 
tioners must  personally  examine  the  patient  separately  from  the 
other  and  the  examination  must  not  have  occurred  more  than  seven 
clear  days  before  the  presentation  of  the  petition.  Neither  practi- 
tioner may  be  the  father  or  father-in-law,  mother  or  mother-in-law, 
son  or  son-in-law,  daughter  or  daughter-in-law7,  brother  or  brother- 
in-law,  sister  or  sister-in-law,  partner  or  assistant  of  the  other. 
The  following  cannot  sign  the  certificate  :  The  petitioner,  the 
superintendent,  proprietor,  or  medical  attendant  of  the  asylum, 
hospital  or  house  to  which  the  patient  is  to  go;  any  person 


Mental  Diseases.  1279 

interested  in  the  payments  on  account  of  the  patient;  or  the 
husband  or  wife,  father  or  father-in-law,  mother  or  mother-in-law, 
son  or  son-in-law,  daughter  or  daughter-in-law,  brother  or  brother- 
in-law,  sister  or  sister-in-law,  partner  or  assistant  to  any  of  the 
foregoing  persons. 

In  some  cases  it  is  desirable  that  the  patient  should  forthwith  be 
placed  under  care  and  the  above  procedure  may  be  made  shorter  by 
the  use  of  the  urgency  order.  In  this  case  the  authority  to  receive 
the  patient  is  given  by  a  near  relation  or  connection  of  the  patient, 
and  need  only  be  accompanied  by  one  medical  certificate  drawn  up 
by  a  practitioner  who  has  seen  the  patient  within  two  clear  days 
before  his  reception  at  the  house  or  institution  in  which  he  is  to  be 
detained.  The  ordinary  papers  must  then  be  completed  within  a 
week  from  date  of  order.  Such  are  by  far  the  most  common 
methods  in  vogue,  and  it  is  unnecessary  here  to  detail  those  by 
which  lunatics  wandering  at  large,  or  persons  of  property,  or 
persons  not  properly  cared  for,  can,  by  the  order  of  a  justice,  or 
by  order  of  two  Commissioners  in  Lunacy,  or  by  the  process  of 
inquisition,  be  brought  under  care.  It  may  however  be  remembered 
that  in  the  case  of  pauper  patients  only  one  medical  certificate  is 
necessary  and  all  arrangements  have  to  be  made  through  the 
relieving  officer.  In  Scotland  and  Ireland  the  procedure,  though 
substantially  the  same,  differs  in  a  few  details. 

AVe  propose  now  to  pass  to  those  medical  aspects  of  the  treatment 
of  mental  disorder  which  are  our  chief  concern.  The  present 
classification  of  mental  disorder,  although  vastly  improved  in  recent 
years,  is  not  perfect,  and  to  deal  with  therapeutics  on  the  basis  of 
that  classification  would,  we  believe,  lead  to  much  reiteration.  It 
has  seemed  to  us  better  for  our  purpose  to  select,  for  the  most  part, 
groups  of  symptoms  and  to  endeavour  to  indicate  the  treatment 
proper  to  them.  In  the  first  instance  we  shall  discuss  at  length 
prophylaxis  and  the  treatment  of  the  important  groups  which  pass 
under  the  terms  "  mania  "  and  "  melancholia."  and  thereafter  pass 
to  those  whose  etiology  or  symptomatology  suggest  separate 
consideration. 

Prophylaxis. — A  due  consideration  of  the  problems  involved  in 
the  prophylaxis  of  mental  disorder  would  in  itself  necessitate  works 
of  enormous  magnitude  upon  biological,  pathological  and  sociological 
subjects.  Here  we  can  alone  deal  with  some  of  the  proximate  and 
most  obvious  factors  which  appear  to  tend  to  the  production  of 
morbid  mental  states. 

Among  the  matters  of  special  importance  upon  which  the  medical 
man  is  occasionally,  but  far  too  infrequently,  consulted,  is  that  of 


1280  Mental  Diseases. 

the  marriage  of  persons  whose  family  or  personal  histories  contain 
evidence  of  a  neurotic  inheritance.  The  problem  as  to  whether  the 
advice  of  the  physician  should  always  be  thrown  into  the  scale 
against  such  unions  or  whether  the  advice  should  be  modified  by 
special  circumstances  is  as  yet  not  solved,  and  we  propose  here  to 
offer  only  a  few  general  rules,  wbich  we  trust  may  be  of  some  assist- 
ance in  particular  cases.  It  is  plain  that  persons  who  are  presently 
insane,  and  to  a  less  degree  those  who  have  been  insane,  are  not 
persons  who  are  the  most  suitable  for  the  procreation  of  children  ; 
but  again  it  is  equally  plain  that  to  deny  marriage  to  one  who 
is  perfectly  healthy  because  his  family  history  reveals  a  case  or  two 
of  insanity  would  be  over-cautious  and  certainly  quite  idle.  We 
believe,  however,  that  under  the  circumstances  mentioned  here 
below  it  is  wise  and  right  to  advise  that  marriage  should  not  take 
place.  A  family  history  which  shows  many  members  of  the  family 
to  have  been  insane  or  neurotic,  and  especially  if  such  insanity  has 
broken  out  in  successive  generations,  centra-indicates  the  procreation 
of  children,  and  a  fortiori  is  this  the  case  if  such  defect  occurs  in  the 
family  histories  of  both  parties.  Epileptic,  diabetic  or  pronounced 
alcoholic  family  histories  should  in  the  same  way  act  as  an  objection 
to  matrimony.  The  presence  of  gross  stigmata  of  degeneration  in 
either  male  or  female,  and  all  the  more  if  the  stigmata  are  observed 
in  both  parties,  the  fact  that  one  of  the  parties,  has  had  or  has 
epilepsy,  or  has  shown  symptoms  of  certain  types  of  mental  dis- 
order, or  has  not  completely  recovered  from  an  attack,  so  that  he 
or  she  is  occupying  a  lower  mental  level  than  was  occupied  before 
the  attack,  are  all  centra-indications.  It  is  for  the  moment 
undecided  as  to  when,  if  ever,  the  risks  of  paternal  or  maternal 
syphilis  become  extinguished,  and  we  can  only  affirm  that  children 
should  certainly  not  be  procreated  until  the  long  period  of  treatment 
prescribed  by  our  present  day  knowledge  has  been  safely  passed  and 
there  are  no  evidences  of  the  disease  being  present.  On  the  other 
hand,  there  are  cases  in  which  it  does  not  appear  to  us  that  we 
have  sufficient  justification  in  advising,  without  hesitation,  against 
marriage.  Defective  family  history  on  one  side  only,  if  limited  to 
a  single  member  or  a  distant  relation,  with  a  sound  family  history 
on  the  other  side,  need  not  compel  us  to  advise  against  marriage. 
In  the  case  of  the  individual  who  has  had  one  attack  of  insanity 
the  future  circumstances  of  the  married  state  should  be  considered. 
If  they  are  such  that  a  life  of  comparative  peace  is  likely,  that  work 
need  not  be  pushed  to  the  breaking  point  of  the  individual,  and  that 
early  and  intelligent  treatment  can  be  instituted  and  carried  out  on 
the  slightest  signs  of  any  relapse,  then,  again,  we  cannot  absolutely 


Mental  Diseases.  1281 

recommend  that  marriage  should  not  take  place.  Further,  if  the 
attack  of  insanity  appeared  to  be  due  not  so  much  to  the  inherent 
weakness  of  the  individual  as  to  the  exceptional  stresses  to  which 
he  was  subject,  and  if  such  stresses  can  in  the  future  be  avoided,  we 
need  oppose  no  bar.  There  is  but  little  doubt  that  to  a  large  extent 
the  salutary  weeding  out  of  weakly  individuals  which  is  effected  in 
accord  with  the  so-called  law  of  the  survival  of  the  fittest  has  -been 
hindered  by  the  advance  of  civilisation  and  knowledge.  There  are 
said,  in  certain  quarters,  to  be  signs  of  racial  degeneracy  or,  at  any 
rate,  that  a  larger  proportion  of  weaklings  is  nowadays  kept  alive 
than  was  formerly  the  case.  If  this  is  so,  there  can  be  but  little 
question  that  it  will  become  necessary  for  the  community  closely  to 
enquire  into  the  hygienic  conditions  of  the  stock  from  which  future 
generations  of  citizens  are  to  be  reared.  In  the  meanwhile,  we  are 
of  opinion  that  it  is  desirable  in  the  relatively  small  field  in  which 
our  work  lies  to  direct  our  advice  against  those  unions  from  which 
disaster  to  the  contracting  parties  and  to  their  offspring  is  almost 
certain  to  ensue. 

The  education  of  the  individual  has  a  very  distinct  bearing  upon 
the  prophylaxis  of  mental  disorder.  Here,  again,  civilisation  and 
science  have  evolved  a  scheme  of  education  which,  while  in  some 
respects  admirable,  is  less  Spartan  than  of  yore,  and  has  led  to  the 
production  of  a  type  of  child  who,  precocious  in  knowledge,  is 
deficient  in  self-control.  Intellectual  abilities  are  rightly  highly 
esteemed,  but  their  educational  cultivation  at  the  expense  of  that 
which  is  known  as  "  character  "  is  to  be  deprecated.  It  is  of  the 
greatest  importance  that  the  child,  especially  the  one  that  comes 
from  a  neurotic  stock,  should  be  tended  from  all  sides  and  not  only 
from  the  intellectual  or  only  from  the  physical.  Steady  growth  in 
all  directions  should  be  promoted  and  tendencies  towards  the  pro- 
digious curbed.  A  process  of  slow  and  equal  growth  is  likely  to 
result  in  a  stable  period  of  maturity,  whereas  early  brilliancy  too 
often  leads  later  to  enfeeblement  and  even  to  intellectual  extinction. 
The  intellectual  education  of  the  neurotic  child  may,  as  a  rule, 
be  postponed  for  a  year  or  two  beyond  the  time  at  which  it  is 
customary  for  education  in  this  country  to  commence,  and  the  time 
may  very  well  be  spent  in  the  country,  where  he  may  learn  the 
rudiments  of  some  manual  craft.  When  at  length  intellectual 
education  is  commenced  it' is  of  great  importance  that  the  pro- 
gress of  the  child  should  not  be  forced  or  his  faculties  spurred 
in  the  pursuit  of  prizes  and  scholarships.  During  the  period  of 
puberty  the  child  should  be  especially  keenly  watched,  and  work  and 
play  so  regulated  that  no  undue  fatigue  occurs.  There  is  probably 

S.T. — VOL.  ii.  81 


1282  Mental  Diseases. 

no  age  too  early  ior  the  inculcation  of  self-restraint,  of  obedience 
to  proper  authority  and  a  due  regard  for  the  claims  of  others. 
Observation  of  many  patients  cannot  but  make  us  feel  that  from 
the  want  of  such  education  ill-regulation  of  life  ensues  and,  as  a 
further  sequence,  a  mental  instability  which  renders  the  patient 
prone  to  fall  a  victim  to  the  adventitious  causes  of  mental  disorder. 
It  is,  unfortunately,  not  infrequently  the  case  that  the  neurotic 
child  is  educated  by  the  neurotic  parent  in  a  neurotic  family 
atmosphere,  and  that  as  a  consequence  the  child  who,  under 
other  circumstances,  would  have  grown  into  a  normal  adult,  has 
just  those  characteristics  markedly  developed  which  should  have 
been  pruned  away,  and,  in  the  feebleness  of  its  will  power  and  the 
unrestrained  strength  of  its  emotions,  pursues  modes  of  life  which 
tend  to  mental  disorder.  It  is  of  course  clear  that  under  these 
circumstances  the  physician,  on  those  rare  occasions  upon  which  it 
is  thought  desirable  to  seek  his  advice,  should  recommend  removal 
from  home  to  the  charge  of  those  fitted  by  character  and  training 
for  the  judicious  handling  of  the  young. 

To  any  person,  whether  a  child,  a  juvenile,  or  an  adult,  in  whom 
there  is  a  neurotic  diathesis  certain  simple  rules  of  life  should  be 
recommended.  Food  should  be  plain  and  plentiful,  and  it  should 
be  sought  to  keep  the  patient's  weight  at  a  few  pounds  in  excess  of 
the  amount  proper  to  the  age  and  sex.  A  decrease  of  weight, 
especially  if  it  is  rapid,  is  to  be  regarded  with  particular  suspicion. 
So  far  as  is  possible  the  digestion  must  be  kept  in  order  and 
regularity  of  the  bowels  maintained.  Milk  is,  as  a  rule,  the  best 
drink  for  neurotic  persons  and  they  are,  for  the  most  part,  better 
without  alcohol.  Meals  should  not  be  hurried.  A  larger  and  larger 
proportion  of  the  population  daily  hurries  from  a  hasty  breakfast  to 
its  work,  bolts  a  scamped  lunch,  and,  thoroughly  tired  at  the  end  of 
the  day,  hastens  back  to  a  meal  for  which  the  appetite  has  been 
robbed  by  fatigue.  It  is  not  surprising  that  from  among  those  who 
live  this  life  comes  a  large  proportion  of  the  dyspeptic  and  the 
nervous.  Work  should  be  carried  on  between  regulated  hours,  and 
the  day  should  be  so  mapped  out  that  the  meals  can  be  taken  quietly 
and  in  peace.  So,  too,  the  practice  of  working  late  into  the  night 
should  be  discountenanced,  for  it  is  a  fruitful  source  of  insomnia. 
For  the  neurotic  holidays  are  of  great  importance,  and  the  attempt 
to  continue  work  when  body  and  mind  are  jaded  is  only  too  likely 
to  end  in  breakdown.  Such  comparatively  simple  rules  as  these 
should  be  the  constant  theme  of  the  physician  in  the  presence  of 
his  neurotic  patients.  They  can  hardly  be  inculcated  too  often,  for 
it  is  in  their  breach  that  lie  the  most  potent  causes  of  mental  dis- 


Mental  Diseases.  1283 

order,  yet  it  must  not  be  forgotten  that  there  may  be  a  danger  that 
the  patient  may  be  trained  into  a  hypochondriacal  valetudinarian, 
and  the  utmost  tact  must  be  used,  while  advising  regularity  of  life, 
to  avoid  this  extreme. 

At  this  point  it  is  important  to  insist  upon  due  regard  being  paid, 
both  by  the  patient  and  by  the  physician,  to  early  symptoms. 
These  are  but  too  frequently  overlooked,  though  there  can  be  no 
doubt  that  it  is  in  their  early  recognition  that  the  best  hope  of  the 
patient  lies.  A  falling  body  weight,  an  appetite  which  is  becoming 
poor,  sleep,  the  amount  of  which  is  becoming  shorter  and  its  quality 
lighter,  are  all  notable  phenomena  in  a  neurotic  individual.  Inability 
to  attend  properly  to  work  or  even  to  play,  restlessness,  irritability, 
and  slight  changes  of  conduct,  should  be  noted  and  call  for  immediate 
treatment,  but  it  is  too  often  the  case  that  not  till  alteration  of  con- 
duct has  eventuated  in  some  gross  breach  of  manners  or  morals 
that  the  relations  are  sufficiently  aroused  to  take  action  and  to  seek 
advice.  If,  however,  the  relations  are  sufficiently  wideawake  or  if 
the  patient  has  had  a  previous  attack  and  knows  the  character  of 
the  prodromata,  then  there  is  much  hope  that,  on  their  appearance, 
timely  treatment  may  avert  a  further  development.  The  patient 
should,  where  it  is  possible,  at  once  give  up  work  and  rest,  while  it 
must  be  sought  to  improve  the  appetite  and  promote  sleep.  With 
such  simple  measures  health  is  often  restored  in  the  course  of  a 
few  weeks,  whereas  if  the  patient  had  drifted  on  a  breakdown  would 
have  resulted  which  would  have  laid  the  patient  aside  for  many 
months,  passed  perhaps  in  an  asylum,  and  with  serious  risk  of 
permanent  mental  disablement. 

MAURICE  CRAIG  and  E.  D.  MACNAMARA. 


81—2 


1284 


MANIA. 

THERE  are  but  few  cases  of  mania  in  which  prodromata 
are  wholly  absent,  and  as  treatment  at  this  stage  may  do  much 
to  lessen  the  severity  of  the  coming  attack  it  is  of  supreme 
importance  to  recognise  them.  Unfortunately,  in  most  cases,  these 
prodromal  symptoms  are  not  recognised  by  friends  and  relations 
as  evidences  of  illness,  and  the  patient  is  not  brought  under  the 
notice  of  the  physician  until  a  further  and  much  more  marked 
stage  has  been  reached.  The  early  stages  of  exhilaration  and 
excitement  may  very  probably  lead  the  patient  into  paths  of 
conduct  in  which  the  incitements  to  an  agitated  disquietude  are 
powerful,  so  that,  entering  upon  a  vicious  circle,  the  condition 
of  the  patient  rapidly  becomes  worse.  At  this  stage  he  has 
probably  become  intolerable  to  society  and  the  physician  is  called 
in  to  lend  his  aid  in  effectuating  legal  restraint.  But  whether  the 
patient  comes  under  care  at  the  earliest  or  at  later  stages  of  the 
disease,  the  therapeutic  measure  of  first  importance  is,  so  far 
as  is  possible,  to  put  the  patient  in  such  circumstances  that 
incitation  to  excitement  is  reduced  to  a  minimum.  The  presence 
of  relations  and  friends,  transparently  solicitous,  almost  always 
ignorant  and  often  tactless,  should  be  forbidden,  and  excuses  that 
the  patient  will  be  more  worried  by  their  absence  than  by  their 
presence  may  safely  be  ignored,  for  experience  teaches  us  that  this 
is  simply  not  the  case  in  conditions  of  acute  mental  disorder.  In 
the  case  of  the  master  or  the  mistress  of  a  house  it  is  inevitable 
that  while  at  home  he  or  she  cannot  be  restrained  from  interest 
and  participation  in  the  affairs  of  home  life,  and  this  is  true, 
though  perhaps  to  a  less  extent,  of  other  members  of  a  family.  It 
follows  that  removal  from  home  is  imperative.  The  room  in  which 
the  patient  is  to  be  nursed  should  be  large,  airy  and  quiet.  The 
fewer  objects  in  the  room  which  may  excite  attention  the  better,  so 
that  pictures,  ornaments  and  unnecessary  pieces  of  furniture  should 
be  conspicuous  by  their  absence.  Wall-papers  and  hangings  should 
be  of  some  neutral  tint,  and  blinds  should  be  so  arranged  that, 
while  air  is  not  excluded,  the  bright  light  of  the  sun  is  tempered. 
If  the  patient  should  become  violent  it  obviously  becomes  yet  more 
imperative  that  there  should  be  nothing  in  the  room  which  he  can 
use  as  a  missile  or  as  a  means  of  attack  upon  others,  or  with  which, 


Mania.  1285 

in  his  impulsiveness,  he  might  damage  himself.  Although  patients 
of  this  class  are  but  little  inclined  to  suicide  or  to  premeditated 
assaults  on  bystanders,  yet,  nevertheless,  they  should  be  watched 
day  and  night,  for  impulsive  acts  of  violence  are  not  uncommon 
whereby  they  may  injure  themselves  or  others.  Tearing  of  clothes, 
smashing  of  furniture,  masturbation  and  the  handling  of  faeces,  are 
all  acts  which  may  be  expected  and  should  be  guarded  against. 
At  this  stage  it  may  be  convenient  to  point  out  that,  though  the 
patient  should  be  guarded  against  the  assault  of  others  and  pre- 
served from  accidental  injury  to  himself,  yet  that  this  is  but  badly 
effected  by  mechanical  means  of  restraint.  Such  means  may 
readily  convert  moderate  excitement  into  extreme  fury,  which  not 
only  renders  supervision  and  nursing  doubly  difficult,  but  increases 
those  very  symptoms  it  is  sought  to  abate  and  induces  an  exhaustion 
from  which  the  patient  but  slowly  recovers.  Mechanical  means 
of  restraint  further  tend  to  produce  a  false  sense  of  security 
and  a  relaxation  of  that  close  attention  on  the  part  of  the  nurse 
which  is  all-important.  To  reduce  the  sensory  incitements  to 
motor  activity  to  a  minimum,  rest  in  bed  is  of  supreme  importance. 
In  the  great  majority  of  cases  submitted  to  this  procedure  agitation 
is  notably  reduced,  the  patient  is  taught  to  recognise  the  fact  that 
he  is  seriously  ill,  his  vital  forces  are  spared  to  do  their  utmost 
in  combating  further  deterioration  of  nervous  tissues,  circulation 
and  nutrition  are  in  general  facilitated,  and  nursing,  in  place 
of  being  a  perpetual  struggle,  approximates  to  that  necessitated 
by  an  acute  infective  process,  in  which  the  patient's  temperature 
chart,  his  pulse  rate,  his  respiration  rate,  the  occasions  upon  which 
his  bowels  are  opened  and  the  amount  of  water  passed,  are  all  duly 
noted  and  recorded,  his  skin  is  kept  clean  and  active  by  frequent 
ablutions,  food  is  given  regularly  and  frequently,  while  all  the  time 
he  is  being  subjected  to  a  kindly  and  tactful  discipline  which 
is  directed  to  the  removal  of  all  sources  of  disquietude.  From  the 
onset  it  may  happen  that  the  patient  will  take  kindly  to  this  form 
of  treatment,  but,  on  the  other  hand,  he  may  prefer  to  get  up  and 
restlessly  to  wander  about  his  room.  In  a  large  number  of  such 
cases  the  patient  can  be  induced  by  kindly  persuasion  to  return 
to  his  bed  after  a  short  interval,  but  in  others  the  patient  persists 
in  aimlessly  walking  about,  and  when  this  is  the  case  he  should 
on  no  account  be  forcibly  kept  in  bed,  for  fruitlessly  to  struggle 
against  superior  force  is  even  more  wearing  and  exciting  than 
to  walk  about.  Persistence  in  this  line  of  treatment  is  likely 
in  a  few  days  to  eventuate  in  the  patient's  submission,  and  it  will 
then  be  found  that  as  time  goes  on  he  will  become  more  and  more 


1286  Mania. 

peaceful,  motor  restlessness  will  diminish,  and  there  will  be  less 
and  less  need  for  perpetual  management.  We  do  not  wish  it  to  be 
supposed  that  we  are  vaunting  this  mode  of  treatment  as  a  panacea. 
There  are  cases,  though  but  few  in  number,  in  which  it  is  impos- 
sible, without  the  exercise  of  nocuous  and  unwarrantable  restraint, 
to  keep  a  patient  in  bed,  and  in  which  excitement  is  rather  increased 
than  diminished  by  persistence  in  this  line,  but  we  strenuously  urge 
not  only  that  this  line  of  treatment  has  been  empirically  found 
to  be  the  best,  but  that  it  is  far  more  in  accord  with  our  present  day 
knowledge  of  the  pathology  of  the  nervous  system  that  that  system 
should,  when  diseased,  be  treated  as  are  the  other  systems  of  the 
body,  and  not,  as  heretofore,  on  wholly  opposite  lines.  To  excite 
an  already  pathologically  excited  patient  by  travel  or  change 
of'  scene  or  social  gaiety,  in  the  hope  of  "  distracting  his  mind," 
is  to  place  upon  the  neurons  already  labouring  under  the  stress 
of  exhaustion,  or  of  toxines,  or  of  both,  additional  burdens  which 
they  are  in  no  position  to  bear.  As  an  adjuvant  to  rest,  fresh  air 
is  of  very  great  importance,  and  if  suitable  provision  can  be  made 
for  the  accommodation  of  the  patient's  bed  in  the  open-air,  the 
good  effects  of  the  treatment  will  be  notably  increased.  It  is  of 
course  not  desirable  that  the  bed  should  so  be  placed  that  the 
multitude  of  impressions  received  from  without  becomes  greater 
than  when  the  patient  is  confined  to  his  room,  but  with  a  system 
of  screens  this  can  be  prevented,  and  it  will  be  found  that  the 
restlessness  of  mind  and  body  characteristic  of  the  syndrome 
becomes  diminished,  sleep  improves,  the  appetite  becomes  better, 
anaemia  becomes  less  marked,  the  functions  of  the  alimentary  tract 
are  better  performed,  and  flesh  is  put  on. 

Combined  with  rest  in  bed,  or  in  some  cases  substituted  for 
it,  balneation  holds  a  prominent  place.  The  temperature  of  the 
bath  should  be  from  94°  to  98° F.  The  length  of  time  the  patient 
is  kept  in  it  may  be  on  the  first  day  from  half  an  hour  to  an  hour, 
and  this  time  may  be  increased  as  the  days  go  on  until  he  spends 
the  greater  part  of  the  day,  or  at  least  several  hours,  in  the  bath. 
At  times  patients  have  been  kept  in  their  baths  for  days,  weeks, 
and  even  months,  and  the  combination  of  the  effects  of  the  complete 
rest  and  of  the  bath  has  appeared  to  be  productive  of  greater  good 
than  could  be  expected  from  either  mode  of  treatment  separately. 
For  the  first  few  days,  and  even  in  some  cases  for  longer,  it  is 
desirable  to  apply  to  the  head,  while  the  patient  is  in  the  bath, 
a  compress  wrung  out  in  ice-cold  water  or  an  ice-bag.  The 
patient  should  be  so  supported  that  there  is  no  danger  of  his 
mouth  and  nose  slipping  below  the  surface  of  the  water.  Among 


Mania.  1287 

other  hydrotherapeutic  measures  may  be  mentioned  daily  baths, 
preceded  by  a  thorough  shampoo  of  the  skin,  and  in  some  cases 
the  wet  pack  is  of  value.  The  patient  is  placed  in  a  sheet  which 
has  been  damped  with  water  at  a  temperature  of  about  50° F.  and 
which  is  loosely  laid  over  and  about  him,  while  over  this  is  placed 
a  blanket.  The  patient  may  be  kept  in  such  a  pack  for  from 
ten  to  twenty  minutes,  and  a  sedative  effect  is  often  obtained. 
The  cold  plunge  and  the  cold  douche  have  been  rightly  abandoned 
in  the  treatment  of  acute  mania. 

It  is  to  be  remembered  that  in  a  large  number  of  cases  in  which 
the  syndrome  of  mania  occurs  the  patient's  "  bodily  "  health  has 
for  some  time  been  deteriorating,  and  that  with  this  deterioration 
there  has,  in  all  probability,  been  much  loss  of  weight.  The 
extreme  restlessness  of  the  early  and  acute  stage,  during  which  the 
activities  of  mind  and  body  know  no  pause,  still  further  depletes 
the  tissues,  and  a  still  more  marked  decrease  in  weight  occurs.  It 
is  plain  that  to  meet  this  condition  the  body  must  be  sustained 
by  an  ample  supply  of  good  food.  In  many  cases  there  is  little 
or  no  difficulty  in  getting  a  patient  suffering  from  acute  mania 
to  take  food,  and,  in  almost  all,  such  difficulty  as  exists  can  be 
met  successfully  by  the  attentive  persuasion  of  a  skilled  nurse, 
while  it  is  but  rarely  that  forced  feeding,  such  as  is  described 
under  the  article  on  melancholia,  has  to  be  resorted  to.  Food  may 
be  very  varied,  but  whereas  the  patient  is  apt  to  bolt  it  and 
in  consequence  its  preparation  for  the  stomach  by  efficient  mas- 
tication is  defective,  it  should  be  given  in  a  finely  divided  form. 
At  least  3  pints  of  milk  should  be  given  during  the  twenty- 
four  hours,  and  in  each  draught  of  milk  one  or  two  eggs  may 
be  beaten  up.  The  ordinary  three  meals  a  day  should  consist 
of  minced  meats  and  milk  puddings,  with  a  liberal  supply  of  fresh 
or  stewed  fruits,  care  being  exercised  in  the  exhaustion  cases,  lest 
diarrhoaa  should  be  produced.  These  meals  should  be  supple- 
mented by  smaller  feeds,  administered  between  the  larger,  or,  on 
the  other  hand,  the  patient  may  sometimes  with  advantage  be  put 
upon  regular  two-hourly  feeds ;  but  in  any  case  a  treatment  of 
super-alimentation  should  be  pursued  until  the  patient's  normal 
weight  has  been  regained,  and  only  then  very  slowly  relaxed  until 
the  patient  shows  definite  mental  improvement. 

The  medicinal  treatment  of  the  maniacal  syndrome  consists 
in  the  administration  of  sedative  and  hypnotic  drugs.  It  is, 
however,  eminently  desirable  to  be  restrained  in  the  use  of 
medicines,  seeing  that  these  are  one  and  all  liable  to  produce 
toxic  effects.  Rest  in  bed,  fresh  air,  hydrotherapeutic  measures 


1288  Mania. 

and  feeding,  are  all  more  reliable  and  safer  measures.  Opium 
is  occasionally  employed,  but  on  the  whole  there  seems  to  be 
a  widespread  objection  to  its  use  in  mania,  for  in  the  acute  stage 
it  is  apt  to  increase  the  incoherence  and  agitation  ;  nevertheless,  in 
extreme  cases  accompanied  by  much  physical  exhaustion,  and  also 
later,  when  the  excitement  is  abating,  its  good  effects  are  obvious. 
When  opium  is  given  it  should  be  given  in  the  form  of  the  tincture, 
commencing  with  from  5  to  10  min.  [U.S.P.  3  to  6  min.] ,  and 
gradually  increasing  the  dose.  It  is,  of  course,  to  be  remembered 
that  the  dose  must  be  diminished  and  the  drug  gradually  withdrawn 
so  soon  as  its  desired  effect  has  been  produced  or  when  it  has 
become  plain  that  no  further  good  can  be  expected  from  its  con- 
tinued administration.  The  bromides  may  occasionally  exercise  a 
sedative  influence,  but  they  are  often  most  disappointing.  With 
the  bromide  salt  chloral  may  be  given,  but  during  its  administra- 
tion the  heart  must  be  carefully  watched.  Paraldehyde,  sulphonal 
and  veronal  are  among  the  most  useful  hypnotics.  Hyoscine  and 
Hyoscyamine  are  at  times  useful  and  lessen  both  motor  restlessness 
and  activity  in  the  processes  of  cerebration.  It  must  be  remembered 
that  both  drugs  are  powerful  poisons  and  that  they  must  be 
administered  in  the  smallest  quantities,  Hyoscine  Hydrochloride 
or  Hydrobromide  in  T^Q  to  200  Sr->  and  Hyoscyamine  from  Ja  to 
xio  8r-  doses.  Beyond  the  serious  syncopal  symptoms  which  may 
supervene  upon  a  large  dose  of  either  of  these  drugs,  it  is  to  be 
remembered  that  they  are  apt  to  give  rise  to  hallucinations 
especially  in  just  those  cases  of  acute  mania  in  which  there  is  the 
most  need  for  the  drug. 

It  will,  unfortunately,  only  too  often  be  found  that,  directly 
the  more  acute  symptoms  have  passed  off,  the  relatives  of  the 
patient  become  desirous  of  removing  him  from  medical  care,  and 
by  this  course  not  only  is  recovery  retarded,  but  sometimes 
a  relapse  is  caused.  On  no  account  should  convalescence  be 
hurried,  and  it  .should  only  be  by  the  easiest  stages  that  the  patient 
is  returned  to  a  normal  routine  of  life.  When  there  has  been  no 
sign  of  mental  symptoms  for  a  month  and  when  the  patient's 
general  health  has  become  satisfactory  and  his  weight  has  again 
reached  the  normal,  a  change  may  be  advised  and  the  patient  sent 
to  some  quiet  country  resort,  where  he  may  enjoy  some  mild  and 
unexciting  change  in  occupation.  Life  in  the  open-air  combined 
with  such  games  as  croquet  or  golf,  or  such  an  occupation  as 
gardening,  contribute  to  restore  appetite  and  sleep.  After  a  mouth 
of  this  sort  of  life  a  period  of  travel,  bereft  of  the  bustling  aspects 
which  too  often  makes  hard  labour  of  a  modern  tour,  may  be 


Mania.  1289 

> 

suitably  recommended,  and  after  this  the  patient  may  return 
to  his  home  and,  later,  to  the  business  occupation  of  his  life. 
It  must  be  borne  in  mind  that  the- period  of  excitement  will  be 
followed  by  a  phase  of  depression  in  the  maniacal  depressive  cases. 
It  is  plain  that  we  are  now  prescribing  a  course  of  treatment  which 
can  only  be  applicable  to  persons  of  means,  but  for  others  we  would 
lay  it  down  that  the  longer  the  period  of  treatment  in  an  asylum  or 
mental  hospital  the  better ;  the  disasters  following  upon  too  early 
removal  are  so  many  and  so  serious  that  a  general  rule  such  as  this 
is  wise.  Of  course,  wherever  it  is  possible,  we  would  counsel  change 
of  scene  before  the  patient  returns  to  his  ordinary  avocations. 

The  treatment  of  so-called  acute  delirious  mania  does  not 
markedly  differ  from  that  of  acute  mania.  Inasmuch  as  the 
constitutional  symptoms  are  even  more  marked  and  the  patient 
soon  falls  into  a  typhoidal  state,  skilful  nursing  and  feeding 
are  of  the  utmost  importance.  Food  should  be  given  every 
two  or  three  hours  during  the  night  as  well  as  during  the 
day,  and  should  consist  chiefly  of  milk  and  eggs,  to  which  may 
be  added  such  carbohydrate  and  proteid  foods  as  can  be  mixed  with 
the  milk.  Stimulants  may  be  required,  and  there  need  be  no 
hesitation  in  giving  brandy,  port  wine  or  stout.  In  some  cases 
the  violent  restlessness  of  the  patient  is  such  that  it  becomes 
well-nigh  impossible  to  do  anything  for  him,  and  he  can  only 
be  fed  forcibly  with  the  assistance  of  several  nurses.  Under 
these  circumstances  it  may  be  desirable  to  administer  chloroform, 
and  while  the  patient  is  under  its  influence  the  bowels  may 
be  opened  with  an  enema,  the  stomach  washed  out  and  then 
replenished  with  food,  to  which  may  have  been  added  some 
hypnotic  drug,  and  the  patient  may  be  washed  and  put  to  bed, 
where  he  may  obtain  some  hours'  sleep.  The  prolonged  hot 
bath  has  been  alleged  by  continental  authorities  to  be  of  signal 
service,  but  should  be  used  with  caution. 

MAURICE  CRAIG  and  E.  D.  MACNAMARA. 


I2QO 


MELANCHOLIA. 

IN- the  treatment  of  melancholia,  as  in  the  treatment  of  mania, 
attention  to  the  surroundings  of  the  patient  is  of  prime  import- 
ance. The  patient  should  be  placed  in  as  peaceful  an  environment 
as  it  is  possible  to  find,  and  in  all  but  the  very  mildest  cases 
it  is  necessary  that  he  should  be  removed  from  his  habitual 
surroundings ;  for  the  cares  of  home,  and  it  is  with  the  cares  and 
not  with  the  comforts  that  the  patient's  mind  is  filled,  the  contrast 
between  his  present  misery  and  his  past  happiness,  and  contact 
with  relations  and  friends  all  militate  against  a  reduction  in  the 
number  of  those  impinging  irritants  which  are  harmful  to  such  a 
patient.  The  "  rousing  treatment,"  whereby  by  voyages  or  an 
unceasing  round  of  distraction  and  physical  activity  the  patient's 
depleted  energies  were  yet  further  exhausted,  is  fortunately  passing 
out  of  vogue  and  indeed  possesses  as  little  justification  as  did 
the  indiscriminate  bleeding  of  earlier  generations.  The  body, 
invariably  in  an  enfeebled  and  wasted  state  and  still  further  worn 
by  the  ceaseless  and  all  engrossing  misery  of  the  mind,  patently 
pleads  for  rest,  and  the  plea  should  be  no  more  disregarded  than 
it  is  in  the  case  of  any  other  exhausting  malady.  Best,  especially 
in  bed,  is,  in  the  early  stages,  undoubtedly  the  best  treatment  for 
patients  who  exhibit  the  syndrome  of  acute  melancholia.  Where 
possible  it  is  highly  desirable  that  treatment  should  be  carried  on  in 
the  open-air,  and  that  the  patient  should,  in  this  respect,  be  treated 
exactly  as  is  the  patient  suffering  from  tuberculosis.  Improve- 
ment in  physical  health  is  in  this  way  accelerated,  the  patient's 
appetite  becomes  larger,  sleep  becomes  longer  and  deeper,  the 
temperature  rises  to  the  normal  and  the  circulation  of  blood 
improves,  while,  on  the  mental  side,  it  will  be  found  in  most  cases 
that  restlessness,  anxiety  and  anguish  of  mind  are  diminished. 
Rest  in  bed  has  the  further  advantage  of  rendering  attempts  at 
suicide  less  feasible,  though  it  must  not  be  forgotten  that  patients 
have  been  known  to  conceal  in  the  bedding  weapons  which  they 
have,  when  the  watch  has  been  relaxed,  used  upon  themselves, 
while  under  the  cover  of  their  bedclothes  some  have  attempted  to 
strangle  themselves.  Where  continuous  rest  in  the  open-air  is 
impracticable  care  should  still  be  taken  that  as  much  fresh  air  is 
admitted  to  the  sick  room  us  can  possibly  be  obtained. 


Melancholia.  1291 

In  the  acute  stage  of  the  illness  the  visits  of  friends  are  always 
harmful,  and  the  various  symptoms  become  worse  after  the  inter- 
view. Where  relations,  often  out  of  distrust  of  those  in  whose 
hands  they  have  placed  the  patient,  insist  upon  exercising  their 
right  of  seeing  him,  they  should  be  counselled  that  conversation 
should  be  short,  upon  general  topics  and  not  upon  such  as  may  in 
any  way  further  arouse  the  apprehensions  of  the  patient.  There 
are  many  lay  persons  who  regard  themselves  in  this,  as  in  other 
branches  of  medicine,  as  endowed  with  some  peculiar  faculty  in  the 
therapeutic  art,  and  who  especially  seek  opportunities  of  exercising 
'their  powers  in  those  cases  where  the  morbid  changes  are  recondite. 
Such  will,  when  visiting  a  patient,  take  the  opportunity  of  practis- 
ing their  peculiar  method,  and  often  to  the  very  great  harm  of 
the  sufferers.  In  the  later  stages  the  visits  of  relations  may  be 
allowed,  but  only  tentatively,  and  must  be  at  once  stopped  if  there 
is  any  evidence  that  the  effect  has  not  been  good.  In  a  similar  way 
correspondence  is  almost  always  bad  for  a  patient.  To  write  a 
letter  is  often  a  wearisome  labour,  and  especially  when  its  com- 
position becomes  a  matter  of  hours  duration,  as  it  does  in  the 
exhausted  condition  in  which  the  patient  is  ;  while  it  is  but  rarely 
that  the  reception  of  even  the  most  judiciously  worded  letter  does 
not  produce  an  exacerbation  of  the  patient's  symptoms  lasting  for 
several  days. 

The  next  object  of  urgent  importance  to  which  treatment  must 
be  directed  is  so  carefully  to  watch  the  patient  that  any  attempt  at 
suicide  may  be  prevented,  for  the  golden  rule  that  every  melan- 
cholic patient  is  a  potential  suicide  must  never  for  an  instant  be 
forgotten.  The  attention  of  the  nurse  must  be  continuously 
directed  to  this  point,  and  he  or  she  must  be  so  frequently  relieved 
that  there  may  be  no  chance  of  this  attention  becoming  tired  and 
therefore  relaxed.  Unless  a  sufficient  number  of  nurses  can  be 
provided  it  is  undesirable  that,  the  patient  should  be  treated  else- 
where than  at  an  institution.  Care  should  be  taken  that  the 
patient  is  deprived  of  every  possibly  lethal  weapon,  and  all  cutting 
instruments  such  as  scissors  or  knives  should  be  searched  for  and 
removed.  Drugs  should  not  be  kept  in  the  patient's  room.  Hand- 
kerchiefs, pieces  of  clothing,  of  string  or  of  tape,  may  be  used  for 
purposes  of  strangulation,  the  flames  of  candles,  fires  and  gas- 
burners  may  be  used  for  the  purpose  of  setting  alight  to  clothing, 
and  various  articles  such  as  pieces  of  glass  or  china  may  be 
swallowed  with  a  view  to  causing  serious  intestinal  lesions.  Patients 
not  uncommonly  seize  opportunities  of  throwing  themselves  from 
heights,  and  special  care  is  required  on  those  occasions  when 


1292  Melancholia. 

it  may  be  necessary  for  them  to  ascend  or  descend  staircases,  while 
the  windows  of  their  rooms  should  be  jealously  guarded,  and  so 
blocked  that  the  lower  sashes  can  only  be  opened  to  a  slight  extent. 
On  no  account  must  a  patient  be  allowed  to  go  to  the  water-closet  by 
himself,  and  it  is  perhaps  best  that  motions  should  be  passed  into 
the  pan  of  a  commode  in  the  bedroom,  where  their  amount  and 
character  can  be  better  noted.  Food  should  be  so  prepared  that 
the  use  of  a  knife  is  unnecessary. 

Feeding  is  always  a  matter  of  great  difficulty  in  the  treatment  of 
melancholic  patients,  for  to  the  patient  himself  the  taking  of  food 
is  an  insufferable  nuisance.  The  sensibility  of  his  organs  of  taste 
is  diminished,  his  alimentary  tract  is  performing  its  work  ill  and 
sluggishly,  he  is  too  preoccupied  with  sorrow  to  think  of  food,  he 
is  afraid  of  being  poisoned,  or  he.  is  desirous  of  mortifying  himself, 
while  there  may  very  probably  be  present  a  hope,  the  only  one  of 
the  melancholic,  that  death  by  starvation  will  be  a  welcome  release. 
Nevertheless,  food,  abundant  in  quantity  and  substantial  in  quality, 
must  be  regularly  administered.  Happily,  in  most  cases  this  is 
effected  by  patient  persuasion  on  the  part  of  the  nurse,  and  it  is 
but  comparatively  rarely  that  forcible  feeding  has  to  be  resorted  to. 
At  least  3  pints  of  milk  should  be  given  during  the  twenty-four 
hours,  and  to  some  of  this  may  be  added  eggs  or  some  miscible 
carbohydrate  or  nitrogenous  foodstuff,  while,  if  the  milk  has  been 
skimmed,  cream  may  be  added  to  it.  No  special  dietary  is 
indicated,  though  in  cases  where  the  blood  pressure  is  high  the 
meat  foods  should  be  reduced  in  quantity,  and  the  only  important 
point  to  insist  upon  is  that  the  patient  should  have  a  large  quantity 
of  good  food.  Some  patients  will  not  trouble  to  raise  the  food  from 
the  plate  to  the  mouth,  and  in  these  cases  the  nurse  must  give  the 
food  with  a  spoon,  while  in  others  the  opposition  on  the  part  of  the 
patient  is  such  that  recourse  has  to  be  had  to  forced  feeding,  and 
the  food  is  placed  in  the  oesophagus  or  stomach  by  means  of  the 
nasal  or  oesophageal  tubes.  The  patient  should  be  laid  upon  a 
mattress  on  the  floor  and  be  securely,  though  with  the  utmost 
gentleness,  held  by  nurses  so  that  he  cannot  interfere  with  the 
operations  of  the  physician,  and  the  nasal  tube  (sizes  9  or  10), 
previously  lubricated,  is  then  passed  through  one  or  other  nostril 
into  the  cesophagus.  If,  as  occasionally  happens,  the  tube  is  passed 
into  the  larynx,  cough  or  dyspnoea  are  at  once  set  up,  and  the  tube 
must  be  partially  withdrawn  and  again  passed.  In  the  case  of  the 
oesophageal  tube  it  is  necessary  that  a  gag  should  be  used,  and 
this  constitutes  the  great  objection  to  its  use,  as  there  is  risk  of 
damage  to  the  teeth.  To  the  other  end  of  the  tube,  whether 


Melancholia.  1293 

cesophageal  or  nasal,  a  large  glass  funnel  is  attached,  and  into  this 
the  foodstuffs  are  poured.  These  should  consist  of  milk,  eggs, 
soups,  powdered  meats,  vegetable  extracts,  cream,  and  such  carbo- 
hydrate foods  as  can  be  readily  passed  through  the  variety  of 
tube  selected  in  the  particular  case.  Patients  should  be  fed  three 
or  four  times  a  day,  and  if  there  is  a  tendency  to  vomiting,  an  act 
sometimes  artificially  excited  by  the  patient,  the  amount  passed  in 
should  be  about  \  or  f  pint ;  in  other  cases  the  quantity  may  be  rather 
more  than  a  pint.  The  tube  should  be  treated  as  carefully  as 
the  teat  of  a  baby's  feeding  bottle  and  should  be  thoroughly  washed 
and  disinfected  after  each  time  of  use.  Tentative  efforts  should 
constantly  be  made  to  feed  the  patient  by  more  natural  methods, 
and  it  not  unfrequently  happens  that  after  one  forced  meal  the 
patient  is  willing  to  feed  himself  adequately. 

It  is  surprising  that  considering  the  dirty  state  of  the  tongue 
and  the  pronounced  constipation  with  which  melancholic  patients 
are  invariably  affected  there  is  in  general  so  little  complaint  of 
gastro-intestinal  disorder.  Such  an  aspect  of  the  tongue  and 
condition  of  the  bowels  as  would  usually  be  an  indication  for  some 
strict  dietetic  regime,  in  the  melancholic  syndrome  only  indicates 
the  giving  of  large  quantities  of  substantial  food.  Nevertheless, 
the  condition  of  the  tongue  should  not  be  neglected,  for  it  is  at  least 
possible  that  the  syndome  is  in  some  cases  the  result  of  a  chronic 
intoxication,  the  place  of  generation  of  the  poison  being  the 
alimentary  tract.  The  first  indication,  then,  is  to  secure  a  regular 
action  of  the  bowels.  In  some  cases  this  may  be  done  by  getting 
the  patient  to  take  an  adequate  amount  of  water,  a  fluid  he  has 
probably  recently  neglected,  while  in  others  the  drugs  most  usually 
found  useful  are  calomel,  cascara  sagrada,  the  saline  purgatives 
and  castor  oil.  Enemata  are  not  unfrequently  necessary,  especially 
in  those  cases  in  which  there  is  some  degree  of  obstruction  owing 
to  impaction  of  hardened  fseculent  matter.  While  there  can  be  no 
doubt  as  to  the  desirability  of  relieving  the  bowels,  the  neutralisa- 
tion or  counteraction  of  the  supposed  poisons  and  the  destruction 
of  the  micro-organisms  which  possibly  make  them  is  rather  more 
debateable.  Given  the  poison  or  the  micro-organism  or  both,  such 
drugs  as  salicylate  of  bismuth,  salol,  sodium  sulpho-carbolate  or 
beta-naphthol  may  be  ordered  or  the  stomach  or  large  intestine 
may  be  washed  out,  or  the  lactic  acid  bacillus  may  be  given. 
Hydro  therapeutic  measures  may  in  some  cases  be  found  to  improve 
the  enfeebled  nutrition  of  the  patient,  but  it  should  not  be 
forgotten  that  the  reaction  of  such  is  often  slow,  and  that 
the  indiscriminate  use  of  the  cold  douche  may  provoke  internal 


1294  Melancholia. 

congestions.  Nevertheless,  the  cold  douche,  especially  following 
upon  the  hot  one,  has  its  place  in  mild  cases  and,  during  the  stage 
of  convalescence,  in  bad  cases.  Douches  at  moderate  temperatures, 
packs  and  warm  baths  have  a  soothing  and  hypnotic  effect,  and 
may  therefore  be  given  at  night.  In  any  case,  however,  washing 
for  cleansing  purposes  should  be  strictly  enforced  and  the  emunctory 
functions  of  the  skin  fully  utilised.  About  many  melancholic 
patients  there  is  an  odour  which  is  peculiar  to  insane  persons,  and 
which  is  strongly  suggestive  that  some  extraordinary  process  of 
elimination  through  the  skin  is  being  carried  on. 

Electricity  has  not  proved  of  much  use  in  the  treatment  of 
mental  disorder  in  general  nor  of  melancholia  in  particular.  Some 
have  recommended  that  a  mild  faradic  current  should  be  applied  to 
the  limbs  once  a  day.  Our  experience  favours  the  use  of  the  static 
varieties  of  electricity.  There  is  no  objection  to  a  few  such  appli- 
cations being  made  and,  if  any  good  seems  to  ensue,  to  their  being 
continued.  Similarly  massage  may  occasionally  be  found  to  be  of 
some  value,  but  in  the  majority  of  cases  in  the  acute  stages  it  is 
disagreeable  to  the  patient  and  unproductive  of  any  other  result. 
In  later  stages,  when  convalescence  has  set  in,  both  electricity  and 
massage  have  their  place  in  improving  the  general  nutrition  of  the 
patient. 

The  fact  that  occasionally  patients  presenting  the  syndrome  of 
melancholia  are  seemingly  benefited  by  being  attacked  by  some 
non-mental  illness  has  suggested  a  line  of  treatment  whereby  some 
comparatively  harmless  malady  is  induced  in  the  hope  that  its 
occurrence  may  abate  the  mental  symptoms.  For  instance,  a  con- 
dition of  hyperthyroidism  has  been  induced  by  the  administration 
of  large  doses  of  thyroid  extract.  The  initial  dose  may  consist  of 
10  gr.  taken  three  times  a  day,  and  this  may  be  increased  up  to  15 
or  20  gr.  by  the  fourth  or  fifth  .days  of  treatment.  During  the 
next  few  days  the  dosage  is  gradually  reduced  so  that  10  gr.  three 
times  a  day  is  given  on  the  eighth  day.  The  patient  is  kept  in  bed, 
for  his  body  weight  is  rapidly  reduced  and  his  mental  symptoms 
initially  exaggerated,  while  the  pulse  rate  may  be  quickened  and 
the  temperature  unduly  lowered.  At  the  end  of  the  week  the 
patient  is  ill  with  hyperthyroidism,  and  the  ordinary  routine  treat- 
ment for  melancholia  being  instituted  it  is  hoped  that  a  more  rapid 
improvement  in  mental  symptoms  will  follow  than  would  have  been 
the  case  if  thyroid  had  not  been  given.  We  ourselves  regard  this 
mode  of  treatment  with  suspicion. 

While  we  urge  that  rest  in  bed  is  of  the  first  importance  in  the 
treatment  of  melancholia,  especially  in  cases  of  maniacal  depressive 


Melancholia.  I295 

insanity  and  the  exhaustion  psychoses,  yet  we  are  quite  willing  to 
admit  that  there  are  eases  in  which  it  appears  to  do  harm  rather 
than  good.  In  such  cases  we  would  urge  that  the  amount  of 
exercise  taken  should  be  moderate  in  amount  and  should  stop 
short  of  exhausting  the  patient.  So  long  as  mental  disorder  was 
regarded  as  a  thing  apart  from  neuronic  disorder  so  long  was  it 
approximately  reasonable  to  endeavour  to  reduce  the  mind  to  order 
by  violent  action  of  the  body ;  the  practice  was  in  fact  an  extension 
of  the  ascetic  doctrine.  At  present  there  is  a  general  consensus  of 
opinion  that  the  proper  expression  of  mentality  depends  upon  the 
healthy  performance  of  the  functions  of  the  neuronic  systems  and 
that,  so  far  as  our  present  knowledge  goes,  there  is  no  reason  for 
treatment  of  the  functional  disorders  of  the  nervous  system  upon 
principles  other  than  those  which  govern  us  throughout  thera- 
peutics. If,  then,  we  find  that  the  patient's  restlessness  or  the 
profundity  of  his  depression  is  in  fact  increased  by  his  being  in 
bed  we  may  permit  of  short  walks  taken  in  the  open-air,  or  even 
perhaps  of  some  such  light  work  as  can  be  found  in  gardening  or 
in  regulated  gymnastic  exercises  or  drill.  When  the  acute  stages 
have  passed  off  exercise  will  in  any  case  be  indicated,  but  such 
exercise  as  is  appropriate  to  a  patient  recovering  from  a  serious 
illness.  At  first  the  amount  should  be  limited  to  an  hour  or  so  a 
day  and  should  consist  in  walking,  a  period  of  repose  immediately 
succeeding,  but  as  the  days  go  on  the  time  may  be  increased  and 
the  character  of  the  exercise  may  be  varied,  mild  games  such  as 
croquet,  lawn  tennis  and  golf  being  permitted. 

There  has  of  recent  years  been  introduced  a  somewhat  portentous 
but  useful  term,  "  psychotherapy."  It  is  employed  to  denote  the 
organised  use  of  the  therapeutic  powers  inherent  in  the  action  of  a 
healthy  mind  upon  one  diseased.  These  powers  have,  since  the 
dawn  of  history,  been  known  and  utilised,  but  generally  by  those 
who  have  sought  to  endow  them  with  mystic  significance,  and  they 
are  even  now  very  largely  exploited  by  members  of  the  numerous 
bodies  whose  creeds  consist  of  a  curious  jumble  of  bad  metaphysics, 
bad  science  and  infinite  credulity.  In  acute  cases  of  mental  dis- 
order appeals  addressed  to  the  reason  with  a  view  to  inducing  the 
patient  to  restrain  himself  or  to  take  a  more  hopeful  view  of  things 
appear  perfectly  futile,  or  if  they  produce  an  effect  it  is  but 
momentary.  Nevertheless,  conversational  intercourse  with  the 
patient  should  be  conducted  as  if  it  were  with  a  sane  individual. 
It  is  often  surprising  how  much  patients  remember,  when  they  are 
recovered,  of  what  has  been  said  to  them  and  of  what  has  been  done 
to  them,  and  how  often  too  they  acknowledge  an  influence  to  have 


1296  Melancholia. 

been  exerted,  the  effect  of  which  certainly  did  not  immediately  or 
obviously  show  itself.  Bearing  this  in  mind,  the  physician's 
attitude  should  be  one  of  assured  hopefulness,  and  even  in  the 
presence  of  the  most  convinced  despair  he  should  point  to  a  happy 
issue  ;  he  should  be  ready  with  those  approximate  explanations  of 
symptoms,  often  to  him  absurdly  platitudinous,  which  even 
mentally  sound  patients  delight  in,  and  he  must  above  all  things 
exercise  an  infinite  patience.  To  listen  to  the  eternally  reiterated 
moaning  of  the  depressed  individual  and  to  meet  every  insane 
assertion  by  a  reasoned  statement  of  the  facts  as  they  appear  to 
the  healthy  understanding,  and  to  do  this  with  a  show  of  real 
interest,  is  to  practise  an  art  of  the  greatest  difficulty.  We  believe 
that  it  can  only  be  practised  by  those  whose  show  of  interest  is 
founded  upon  a  real  interest  of  the  most  intense  character  and 
whose  will  is  immovably  and  hopefully  directed  to  the  effectuation 
of  the  recovery  of  the  patient.  Tactfulness  by  no  means 
necessarily  presumes,  as  is  too  often  thought,  entire  acquiescence 
in  another's  views,  but  rather  in  the  endeavour  to  present  reason- 
able views  in  a  light  attractive  to  the  patient.  To  "  humour  "  the 
patient  is  to  pander  to  his  unhealthy  delusions,  while  to  flatly  con- 
tradict them  is  to  raise  in  him  a  revolt  against  a  contradiction  of 
personal  experiences  which  are  very  real  to  him  and  to  induce  in 
him  a  distrust  of  the  person  who  contradicts.  The  primary  duty 
of  the  physician  is  to  endeavour  to  persuade  the  patient  that  he  is 
a  sick  man,  and  it  is  therefore  absurd  to  adopt  those  too  common 
subterfuges  by  which  it  is  sought  to  introduce  the  doctor  to  the 
patient  as  somebody  whom  he  is  not.  From  the  outset  the 
physician  should  assert  his  position  and  definitely  lay  it  down  that 
he  is  there  for  the  purpose  of  endeavouring  to  alleviate  symptoms. 
It  not  unfrequently  happens  that  it  is  a  relief  to  a  patient  to  learn 
that  he  is  ill,  and  it  is  plainly  an  enormous  step  in  advance  when 
he  has  been  further  persuaded  to  submit  himself  to  treatment. 
Throughout  the  illness  the  same  discriminating  attitude  should  be 
adopted,  and  whatever  the  development  of  symptoms  it  must  be 
sought  to  explain  to  the  patient  that  his  hallucinations,  delusions 
and  aberrations  of  conduct  are  due  to  illness  and  must  accordingly 
so  be  treated.  The  instillation  of  faith  and  the  assurance  of  hope 
are  the  keynotes  of  psychotherapy,  whether  the  processes  adopted 
are  called  by  that  name  or  by  some  other  of  a  religious  connotation. 
In  the  case  of  those  suffering  from  the  syndrome  of  melancholia 
who  are  sleepless  or  agitated,  sedatives  and  hypnotics  will  be 
indicated.  In  certain  cases,  where  there  is  much  restlessness, 
potassium  bromide,  especially  in  full  doses,  notwithstanding  its 


Melancholia.  1297 

depressive  action,  is  of  considerable  use,  but  it  should  be  given 
very  tentatively,  and  of  course  at  once  dropped  if  it  has  an  effect 
opposite  to  the  one  desired.  The  bromides  may  also  be  given  in 
combination  with  chloral  as  a  hypnotic  draught  at  bedtime  when 
the  patient  is  settled  for  the  night.  The  various  preparations  of 
opium  sometimes  have  a  most  striking  effect  in  producing  calm. 
The  tincture  of  opium  or  a  liquid  preparation  of  one  of  the 
alkaloids,  given  by  the  mouth,  are  the  best  for  our  purpose.  At 
the  commencement  the  tincture  may  be  given  in  doses  of  from 
5  to  7  min.  [U.S.P.  3  to  5  min.]  three  times  a  day,  and  this 
amount  may  be  increased  from  day  to  day  by  2  or  3  rain.,  until 
20  or  30  min.  [U.S.P.  12  to  18  min.]  are  being  taken  three 
times  a  day.  The  dosage  arid  length  of  time  during  which  the 
drug  is  to  be  administered  will  depend  upon  the  effect  produced, 
and  when  a  condition  of  increased  restfulness  has  been  obtained 
tentative  efforts  may  be  made  to  reduce  the  quantity  given.  In 
practice  it  is  found  that  in  these  cases  there  is  but  little  danger  of 
inducing  a  habit,  and  where  this  has  unfortunately  been  established 
it  has  been  where  the  drug  was  administered  hypodermically,  or 
without  due  medical  supervision.  Codeine  similarly  used  will 
sometimes  be  found  to  give  better  results  than  opium.  Among  the 
most  useful  hypnotics  in  melancholia  are  paraldehyde,  amylene 
hydrate  and  the  more  soluble  forms  of  veronal.  Such  little 
soluble  drugs  as  sulphonal  are,  in  the  constipated  state  of  the 
patient's  bowels,  rather  dangerous,  and  indeed  may  produce 
disastrous  symptoms. 

Where  there  is  a  notable  rise  in  the  blood  pressure  it  may  be 
lowered  by  the  administration  of  such  drugs  as  trinitrin,  erythrol 
tetranitrate  and  sodium  nitrite.  Erythrol  tetranitrate  may  be 
given  at  first  in  doses  of  \  gr.  three  times  a  day,  the  amount  being 
increased  so  that  at  the  end  of  a  week  2  or  3  gr.  are  being  given. 
With  the  lowering  of  the  blood  pressure  it  will  be  found  that  some 
of  the  mental  symptoms  are  alleviated,  perhaps  only  temporarily, 
but  at  times  permanently. 

The  injection  subcutaneously  or  into  the  bowel  of  sterilised 
normal  salt  solution  in  quantities  of  \  to  1J  pints  daily,  or  on 
alternate  days,  has  been  much  recommended.  It  is  hoped  that  by 
this  method  urinary  excretion  may  be  increased,  that  toxic  sub- 
stances retained  in  the  organism  may  be  diluted  or  their  elimination 
promoted  and  that  in  this  way  auto-intoxication  may  be  diminished. 

As  the  acute  symptoms  pass  off  and  as  convalescence  becomes 
established  the  rtf/iine  under  which  the  patient  has  been  living 
may  be  very  cautiously  and  gradually  relaxed.  The  patient  should 

S.T. — VOL.  ii.  82 


Melancholia. 

by  this  time  have  learnt  that  his  inclination  to  suicide  represents  a 
morbid  symptom  and  should  have  been  urged,  on  feeling  any  such 
inclination,  at  once  to  report  it  to  his  nurse  or  doctor.  The  con- 
finement to  bed  which  may  have  lasted  for  weeks  or  months  may 
be  exchanged  for  rest  on  a  sofa  or  in  an  easy  chair,  while  the 
amount  of  exercise  taken  is  gradually  increased  and  made  more 
interesting  in  character.  At  last,  when  the  mental  state  of  the 
patient  is  as  it  was  before  he  became  ill,  when  his  sleep  is  normal 
in  amount  and  quality,  when  his  appetite  is  good  and  his  bowels 
regular  and  his  body  weight  has  reached,  or  preferably  surpassed, 
the  standard  appropriate  to  his  age  and  height,  he  may  be  sent 
away  for  a  few  weeks'  sober  travel.  It  should  not,  however,  be  for 
several  months  that  the  patient  returns  to  his  work,  properly 
prepared  on  the  slightest  recurrence  of  his  previous  symptoms  to 
report  himself  to  his  medical  attendant. 

MAURICE   CRAIG  and  E.  D.  MACNAMARA. 


EXHAUSTION  PSYCHOSES. 

THE  symptoms  exhibited  by  patients  suffering  from  the 
exhaustion  psychoses  are  varied.  There  may  be  confusion, 
mania,  melancholia,  stupor,  or  katatonia,  while  hallucinations 
are  often  a  marked  feature.  Treatment  will  therefore  vary 
somewhat  according  to  the  syndrome  present,  but  whereas  the 
morbid  state  is  essentially  due  to  exhaustion  it  is  to  remedying 
that  condition  that  the  physician  should  direct  his  attention.  The 
principal  indications  are  to  improve  the  nutrition  of  the  body  by 
rest  and  good  feeding.  The  patient  should  be  put  to  bed,  and,  in 
most  cases,  a  stay  there  of  two  or  three  months  will  not  be  found 
excessive.  Too  early  abandonment  of  this  method  of  treatment  is 
very  apt  to  result  in  a  relapse,  and  in  any  case,  when  it  has  been 
decided  that  the  patient  should  get  up,  a  careful  watch  should  be 
kept  on  the  pulse  rate,  and  upon  the  mental  condition,  so  that  if 
the  first  is  unduly  accelerated  and  there  is  any  indication  of  the 
return  of  the  more  acute  symptoms  the  patient  should  be  returned 
to  bed.  Food  as  substantial  and  in  as  large  quantities  as  the 
stomach  can  tolerate  should  be  given,  and  if  the  patient  should 
refuse  food,  speedy  recourse  must  be  had  to  its  administration  by 
the  tube.  Suicidal  attempts  must  be  guarded  against,  as  these 
patients  are  apt  to  be  very  impulsive.  Aperients  are  commonly 
necessary  and  may  be  combined  with  intestinal  antiseptics,  such 
as  salol,  sodiurn-sulpho-carbolate  or  bismuth  salicylate,  for  it  is  of 
importance  to  endeavour  to  avoid  a  condition  of  auto-intoxication 
consequent  upon  abnormal  fermentations  occurring  in  the  alimentary 
tract.  In  cases  of  mental  excitement  or  motor  restlessness  the 
bromides  or  preparations  of  opium  or  hyoscine  or  hyoscyainine 
may  be  employed,  while  sleep  is  best  procured  by  the  use  of  such 
drugs  as  veronal,  hedonal,  paraldehyde  or  amylene  hydrate.  The 
wet  pack  or  the  warm  bath  at  night  are  also  at  times  of  service, 
and  careful  attention  to  the  skin  is  important.  In  all  cases  any 
cause  for  the  exhaustion,  menorrhagia,  dysentery,  etc.,  should  be 
treated. 

It  is  more  obvious  in  these  cases  than  in  any  other  class  of 
mental  disorder  that  treatment  directed  towards  "rousing"  and 
"distracting"  the  patient  is  fundamentally  wrong,  and  it  will  not 
infrequently  be  found  that  the  misplaced  energy  of  friends  has 

82—2 


1300  Exhaustion  Psychoses. 

converted  a  mild  case  into  one  in  which  the  damage  is  irreparable. 
Here  also  the  extreme  importance  of  early  treatment  cannot  be  too 
much  insisted  upon.  On  the  recovery  of  the  patient  it  will  be  the 
duty  of  the  physician  to  point  out  to  the  patient  the  harmful 
character  of  the  conditions  which  brought  about  the  illness  and  to 
insist  that  in  future  the  simple  rules  of  life  outlined  in  the  section 
on  Prophylaxis  (p.  1279)  should  be  adhered  to. 

Among  the  exhaustion  psychoses  may  be  placed  the  insanities  of 
pregnancy,  parturition  and  lactation,  though  there  may  be  some 
doubt  whether  the  insanity  which  occurs  in  the  first  half  of 
pregnancy  can  rightly  be  so  classed.  Treatment  must  be  carried 
out  on  the  lines  indicated  above.  The  prognosis  of  speedy  recovery 
in  those  cases  which  occur  early  in  pregnancy  is  so  good  that, 
unless  the  symptoms  are  such  that  it  is  quite  impossible  to  keep 
the  patient  at  home,  it  is  not  necessary  that  she  should  be  sent 
away.  It  is,  however,  essential  that  the  patient  should  be  relieved 
from  the  worries  incidental  to  the  management  of  a  household,  and 
that  she  should  be  carefully  tended  by  skilled  persons.  So  also  the 
disorder  which  occurs  at  or  shortly  after  parturition  may  be  of 
brief  duration  and  is  analogous  to  the  delirium  of  an  intoxication  ; 
under  such  circumstances  removal  from  home  is  hardly  necessary. 
The  question  of  abortion  may  sometimes  be  raised,  and  whereas 
neither  the  induction  of  premature  labour  nor  natural  labour  result 
in  anything  more  than  a  temporary  lull  in  the  symptoms,  recourse 
to  this  measure  may  be  deemed  inadvisable  unless  indicated  on 
other  grounds. 

MAURICE    CRAIG  and  E.  D.  MACNAMARA. 


1301 


PSYCHOSES  ASSOCIATED  WITH  CHANGES   IN  THE 
THYROID  GLAND. 

IN  these  psychoses  the  mental  symptoms  appear  to  be  a  result  of 
changes  in  nutrition,  brought  about  by  imperfections  in  the 
functions  of  the  thyroid  gland.  In  one  variety  there  are  conditions 
in  which  there  is  but  little  doubt  that  the  functions  of  the  thyroid 
are  performed  inadequately,  and  to  which  the  term  "  hypothyroidism  " 
has  been  applied,  and  in  a  second  variety  there  are  conditions  to 
which  the  term  "hyperthyroidisin"  has  been  applied,  and  in  which 
it  is  possible  that  there  is  an  over-activity  of  the  gland.  Associated 
with  hypothyroidism  is  niyxoedema,  while  it  is  at  any  rate  a 
tenable  hypothesis  that  exophthalmic  goitre  is  dependent  upon 
hyper  thyroidism . 

In  rnyxo3dema  there  is  usually  a  retardation  of  the  mental 
processes,  but  it  occasionally  happens  that  states  of  excitement  or 
depression  occur,  with  which  may  be  coupled  anxiety,  restlessness, 
delusions  of  persecution  and  insomnia.  Treatment  consists,  as  in 
the  other  manifestations  of  myxoedema,  of  the  administration  of 
preparations  of  thyroid  gland,  and  among  these  the  most  convenient 
and  efficacious  are  tablets  and  tabloids.  It  has  been  alleged  that 
tliyro-iodine  is  the  active  principle,  but  the  state  of  our  knowledge 
is  not  yet  so  far  advanced  that  its  use  can  be  recommended  in 
preference  to  that  of  preparations  of  the  entire  gland.  It  is  highly 
desirable  that,  whatever  the  preparation  selected,  the  initial  doses 
should  be  small,  and  that  such  symptoms  as  increased  frequency  of 
the  pulse  rate,  increased  frequency  of  the  respiration  rate,  restless- 
ness, anorexia,  loss  of  weight,  gastro-intestinal  disturbance, 
rheumatic  pains,  insomnia  and  cutaneous  eruptions,  which  are 
indications  of  over-dosage,  should  be  carefully  looked  for,  and,  if 
present,  that  the  dose  should  be  proportionately  diminished.  The 
administration  of  the  drug  should  not  be  pressed  with  the  view  of 
obtaining  a  speedy  effect,  for  troublesome  symptoms  may  in  this 
way  be  rapidly  produced.  A  long  course  of  treatment  rather  than 
large  dosage  produces  the  best  effects,  and  directly  the  symptoms 
are  abated  an  effort  may  be  made  to  reduce  the  amount  of  the 
gland  which  is  to  be  taken.  A  continuance  of  administration  must, 
however,  be  maintained,  and  it  is  as  a.  rule  unwise  ever  wholly  to 
discontinue  the  use  of  the  gland.  At  the  commencement  of  the 


1302  Thyroid  Gland  Psychoses. 

treatment  it  is  as  well  that  the  patient  should  be  confined  to  his 
bed,  and  this  is  especially  the  case  if  the  more  severe  symptoms 
of  mental  disorder  are  present  or  if  the  heart  is  in  any  way  weak. 

It  is  not  uncommon  to  find  that  exophthalmic  goitre  is  accom- 
panied by  mental  symptoms.  Restlessness,  irritability  and  abulia, 
although  important  symptoms,  are  seldom  regarded  as  of  mental 
character,  though  maniacal  and  melancholic  symptoms  attract 
attention  at  once  and  somewhat  seriously  aft'ect  the  prognosis.  In 
severe  cases  it  is  necessary  to  keep  the  patient  in  bed  and  at  the 
same  time  to  give  a  liberal  diet  with  plenty  of  milk  and  cream. 
Cod- liver  oil  or  malt  should  be  given,  while  it  may  occasionally  be 
found  that  the  bromides  or  belladonna  are  of  service.  Removal  of 
a  part  of  the  gland  or  a  diminution  of  the  amount  of  blood 
supplied  to  it  by  ligation  of  the  thyroid  arteries  has  been 
practised,  but  such  operations  are  liable  to  be  attended  by  sudden 
death.  An  attempt  at  rational  treatment  by  the  administration  of 
the  serum  of  the  blood  *>r  of  the  milk  of  dethyroidectomised  goats 
and  sheep  has  been  made,  and  it  has  appeared  to  us  that  in  some 
cases  this  method  of  treatment  has  been  productive  of  good 
results.  Antithyroidin  Moebius  may  be  given  in  doses  of 
10  min.  three  times  a  day,  and  the  dose  may  be  gradually 
increased  until  about  30  min.  are  given  at  each  administration. 
Thyroidectine  prepared  from  the  dried  blood  of  dethyroidectomised 
animals  may  be  given  in  doses  of  5  gr.  three  times  a  day  and  be 
gradually  increased.  Rodagen,  which  is  a  substance  consisting 
of  the  dried  milk  of  dethyroidectomised  goats,  may  be  given  in 
doses  of  75  to  150  gr.  thrice  daily,  and  of  this  class  of  preparation 
this  is  perhaps  productive  of  the  happiest  results.  Cases  have  been 
reported  in  which  large  doses  of  these  substances  have  been 
followed  by  symptoms  suggestive  of  myxoedema,  but  this  has  never 
happened  in  our  experience. 

MAURICE   CRAIG  and  E.  D.  MACNAMARA. 


1303 


TOXIC  PSYCHOSES. 

RENAL  inadequacy  is  frequently  accompanied  by  some  degree  of 
mental  ineptitude,  and  it  occasionally  happens  that  more  pro- 
nounced symptoms  occur.  States  of  excitement,  states  of  depres- 
sion, of  stupor,  profound  disorientation,  hallucinations  and 
pronounced  insomnia,  constitute  the  most  prominent  of  these 
symptoms.  Treatment  must,  of  course,  be  directed  towards 
combating  the  uraemia  from  which  the  patient  is  suffering,  and 
the  patient  being  put  on  a  special  diet  and  being  kept  in  bed,  and 
other  emunctory  organs  being  stimulated  to  perform  those 
functions  properly  performed  by  the  kidneys,  the  symptoms  soon 
pass  away.  Indeed,  the  rapidity  of  the  relief  afforded  by  these 
methods  is  often  of  material  assistance  in  the  formation  of  a 
diagnosis  in  obscure  cases. 

Similarly  in  diabetes  the  melancholic  syndrome  occasionally 
makes  its  appearance.  Here,  too,  treatment  must  be  on  the  lines 
proper  to  the  essential  character  of  the  disease.  In  gout  the 
irritability  of  the  patient  is  a  well-known  mental  phenomenon. 
Some  patients  are  liable,  perhaps  prior  to,  or  perhaps  during  an 
articular  attack,  to  present  symptoms  of  depression. 

Among  the  important  toxic  psychoses  are  to  be  mentioned  those 
occurring  with  acute  infective-  processes.  The  fever,  which  is  an 
almost  invariable  accompaniment  of  the  infections,  may  very 
rapidly  produce  delirium  and  this  delirium  may  pass  into  mania, 
but  the  commonest  psychoses  connected  with  the  infections  are 
found  at  subsequent  stages,  and  are  not  dependent  upon,  or  at  any 
rate  coincident  with,  the  pyrexia.  The  syndrome  characteristic  of 
the  exhaustion  psychoses  is  the  most  common.  There  may, 
however,  be  a  condition  of  mental  enfeeblement  which  becomes 
more  and  more  pronounced,  and  of  which  the  prognosis  is  bad. 
Some  of  these  psychoses  appear  to  be  dependent  upon  changes  in 
the  brain  ensuing  upon  a  polio-encephalitis,  but  in  others  the 
anatomical  changes  accompanying  the  morbid  processes  are 
unknown.  Those  symptoms  which  arise  in  the  initial  stages  of  the 
infections,  and  which  are  coincident  with  a  high  degree  of  fever, 
should  be  treated  as  is  the  delirium  which  is  the  more  common 
accompaniment  of  these  states.  The  patient  is  of  course  in  bed, 
and  hydrotherapeutic  measures,  such  as  the  continuous  bath  or  the 


1304  Toxic  Psychoses. 

wet  pack  or  cold  sponging,  are  of  prime  importance,  while  the 
strength  must  be  maintained  by  the  administration  of  such  food 
as  the  patient  is  capable  of  assimilating.  The  condition  of  the 
cardio-vascular  system  must  be  continuously  observed,  and  nocuous 
action  of  the  toxins  upon  it  must  be  met  by  the  administration  of 
stimulants,  and  the  use  of  alcohol  should  not  be  sparing.  In  the 
case  of  mental  symptoms  which  appear  during  convalescence,  or 
when  the  patient  is  supposed  to  have  been  restored  to  a  normal 
state  of  health,  treatment  must  depend  on  the  particular  syndrome 
present,  and  it  should  be  borne  in  mind  that  the  post-febrile 
disorders  are  only  slowly  recovered  from.  The  most  important 
point  which  we  would  urge  now  is  that  in  no  infective  process 
should  the  stage  of  convalescence  be  unduly  shortened  and  that 
ample  time  should  be  allowed  for  the  restitution  of  those  delicate 
nervous  structures  which  have  been  subjected  to  the  harmful 
action  of  the  poison. 

MAURICE   CRAIG  and  E.  D.   MACNAMARA. 


1305 


DEMENTIA  PR^ECOX. 

THE  diagnosis  of  this  affection  may  be  difficult  in  the  earliest 
stages.  It  is  true  that  in  persons  who  display  certain  traits 
of  character,  for  instance,  affected  piousness,  impulsiveness, 
emotionalism,  precocious  scepticism  and  cynicism,  and  who  come 
of  a  neurotic  stock,  the  appearance  of  more  acute  symptoms  may  be 
anticipated  and  appropriate  prophylactic  treatment  may  in  good 
time  be  instituted,  but  as  a  rule  it  is  not  until  the  hebe- 
phrenic,  katatonic  or  paranoid  symptoms  have  shown  themselves 
that  the  patients  come  under  skilled  observation.  If  the  presence 
of  the  affection  is  suspected  before  the  outbreak  of  serious 
symptoms  the  patient  should  live  strictly  in  accordance  with  the 
hygienic  rules  laid  down  elsewhere,  should  be  educated  to  some 
handicraft  or  simple  outdoor  occupation,  and  his  moral  develop- 
ment most  carefully  tended  ;  but  if  the  acute  symptoms  are 
present  it  will  become  of  the  first  importance  that  the  general 
nutrition  should  be  improved,  for  it  will  be  found  as  a  rule  that 
the  patient  is  run  down,  that  his  weight  is  less  than  it  was  and  that 
sleep  is  bad. 

It  is  desirable  that  at  any  rate  at  first  the  patient  should  be  con- 
fined to  his  bed,  the  length  of  his  sojourn  there  depending  upon 
the  conditions  of  his  nutrition.  At  times  this  measure  eventuates  in 
some  alleviation  of  the  symptoms,  and  at  any  rate  when  the  more 
acute  symptoms  have  somewhat  subsided  the  influence  of  a  kindly 
though  firm  discipline  is  not  without  effect,  and  peculiarities  of 
conduct,  shorn  of  their  grosser  characteristics,  become  less 
marked.  In  asylums  and  even  in  their  own  homes  such  persons 
may  display  activities  of  considerable  use  in  the  humble  roles 
assigned  to  them. 

MAURICE   CRAIG  and  E.  D.  MACNAMARA. 


1306 


THE   MENTAL    ASPECTS    OF    HYSTERIA. 

THOUGH  a  preliminary  discussion  as  to  the  pathogeny  of  this 
disorder  might  be  of  value  in  clarifying  our  notions  as  to  the 
character  of  treatment  to  be  pursued,  the  space  at  our  disposal 
is  sufficient  only  for  a  few  remarks  on  those  symptoms  which 
are  patently  of  a  mental  nature.  A  condition  of  what  we  may  call 
hyper-suggestibility  has  been  put  forward  as  explanatory  of  the 
phenomena  of  the  affection,  and  we  are  willing  to  agree  that 
hyper-suggestibility  is,  at  any  rate,  a  very  prominent  feature  in  the 
production  of  individual  symptoms.  The  suggestions  are  some- 
times auto-  and  sometimes  heterogenetic,  but  the  problem,  to  our 
minds,  only  arises  at  this  point  and  may  be  summed  up  in  the 
inquiry  as  to  why  suggestions,  whether  from  within  or  without, 
produce  in  certain  individuals  effects  which  are  uncommon  and 
morbid.  It  is  a  mere  truism  to  observe  that  the  patients  are 
suggestionable,  and  it  is  as  much  in  the  interpretation  put  upon  the 
suggestion  as  upon  the  hyper-sensitive  condition  of  affectivity 
that  we  would  seek, an  explanation.  There  are  mentally  disordered 
persons  who  are  perpetually  being  disturbed  by  the  slights  which 
they  fancy  are  being  put  upon  them  by  those  who  are  not  even 
thinking  about  them  at  all,  and  there  are,  similarly,  persons  who 
are  perpetually  disturbed  by  the  obtrusion  into  the  field  of  their 
consciousness  of  sensations,  somehow  "  suggested  "  to  them,  which 
are  not  so  obtruded  upon  the  consciousness  of  the  normal  individual. 
That  this  covers  the  whole  psychic  and  somatic  ground  upon  which 
the  symptoms  and  signs  of  hysteria  become  manifest,  we  do  not 
pretend,  but  we  do  assert  that  from  the  therapeutic  point  of 
view  it  is  as  well  so  to  regard  it.  Both  prophylactic  and  curative 
treatment  must  be  based  on  the  hypothesis  that  the  appearance 
and  disappearance  of  symptoms  depend  fundamentally  upon  the 
"character"  of  the  individual.  We  have  never  known  the 
phenomena  of  hysteria  to  appear  in  persons  in  whom  has  been 
developed  the  faculty  of  self-control,  nor  do  we  know  any  soil  more 
favourable  for  the  development  of  symptoms  than  that  type  of 
character  best  exemplified  by  the  term  "  spoilt  child."  Prophylaxis 
should  commence  in  the  education  of  the  child  and  should  be 
continued  in  the  adult  in  the  constant  endeavour  which  the  healthy 
individual  makes  to  restrain  himself.  Curative  treatment  also 


The  Mental  Aspects  of  Hysteria.         1307 

essentially  consists  in  the  endeavour  of  the  physician  to  instil  into 
the  patient's  mind  a  reasonable  interpretation  of  the  symptoms  and 
an  assurance  that  with  proper  regulation  of  the  functions  of  her 
body  they  will  disappear.  But  education  and  re-education,  as  the 
education  of  the  adult  is  sometimes  euphemistically  termed,  must 
be  patient  and  continuous.  The  example  of  those  mothers  who 
alternately  indulgently  caress  and  angrily  browbeat  their  offspring 
is  to  be  avoided,  and  an  even  temper  is  best  induced  in  those 
whom  it  is  sought  to  influence  by  the  exhibition  of  a  good  example. 
Treatment  must  throughout  be  carried  on  in  an  atmosphere  from 
which  fussy  agitation  is  rigorously  excluded,  and  by  persons 
with  sufficient  knowledge  and  experience  calmly  and  dispassionately 
to  persuade  the  patient  of  the  certainty  of  her  cure.  It  is  too  often 
supposed  in  uninformed  circles  that  there  is  an  element  of 
malingering  in  the  symptoms  of  hysteria  and  that  treatment 
should  in  consequence  be  punitive  in  character.  This  is  a  funda- 
mental error  and  will  lead  to  therapeutic  disaster.  There  are, 
of  course,  malingerers  whose  pretended  symptoms  are  akin  to  those 
of  hysteria,  but  we  here  suppose  that  such  cases  have  been 
excluded  and  that  the  diagnosis  of  hysteria  has  definitely  been 
made.  As  important  adjuvants  to  psycho-therapeutic  treatment 
isolation,  rest  and  good  feeding  stand  out  prominently.  Isolation 
implies  absence  from  home  and  relations  and  friends,  and 
the  consequent  withdrawal  of  influences  which  in  these  cases  are 
seldom  otherwise  than  harmful,  and  in  their  place  the  substitution 
of  influences  which  consist  in  properly  devised  suggestions  made 
by  properly  qualified  persons  at  the  proper  times  and  for  the  proper 
length  of  time.  In  a  few  cases  the  influence  of  a  husband  or 
relative  may  be  beneficial,  and  occasional  visits  may  be  permitted. 
Rest  and  good  feeding  are  employed  in  order  that  the  general 
health,  which  is  almost  invariably  at  a  low  level,  may  be  restored. 
Drugs  may  be  given  if  there  are  any  special  indications,  but 
strenuous  endeavours  must  be  made  that  no  drug  is  given  for  such 
a  length  of  time  that  the  patient  comes  to  depend  on  it  and 
to  regard  it  as  a  panacea  for  her  ills.  Massage,  provided  there 
is  no  tendency  to  restlessness,  and  hydro-therapeutic  measures  are 
particularly  useful  at  the  stage  when  the  patient  shows  signs  of 
improvement.  The  more  pronounced  mental  symptoms  of  hysteria 
consist  of  delirium,  in  which  hallucinations  are  a  marked  feature, 
mania,  ecstasy,  catalepsy,  lethargy,  mutism,  antero-grade  amnesia 
and  somnambulism,  and  the  diagnosis  is  in  main  founded  upon 
some  of  these  symptoms  being  either  preceded  or  accompanied  by 
other  psychic  or  somatic  manifestations  of  hysteria.  Treatment  of 


1308       The  Mental  Aspects  of  Hysteria. 

the  acute  mental  symptoms  has  been  sufficiently  indicated  under 
other  heads,  and  of  the  less  acute  must  consist  of  those  measures 
proper  to  the  treatment  of  any  of  the  other  manifestations. 
Hypnotism  has  at  times  produced  very  good  results,  but  we  prefer 
the  methods  of  re-education  and  persuasion,  for  the  results, 
although  to  procure  them  much  more  time  has  to  be  expended,  are 
built  upon  a  more  stable  and  lasting  foundation.  It  is  also  true 
that  hypnotism  is  not  unaccompanied  by  dangerous  risks,  for  the 
already  existing  hyper-suggestibility  of  the  patient  may  be  increased, 
and  though  the  peculiar  group  of  symptoms  momentarily  existing 
may  by  its  means  be  suppressed,  it  by  no  means  follows  that  it 
may  not  crop  up  in  identical  or  inverted  forms  and  that  the  last 
stage  may  not  be  worse  than  the  first.  Amputation  of  the  clitoris, 
ovariotomy  and  the  performance  of  mock  operations  are  only  here 
mentioned  to  be  utterly  condemned ;  they  are  useless  and  of 
doubtful  morality. 

MAURICE   CRAIG  and  E.  D.  MACNAMARA. 


1309 

PARANOIA. 

THE  progress  of  this  disorder  is  long  drawn  out,  and  it  is  often 
very  difficult  to  be  precise  as  to  the  date  of  the  commence- 
ment of  symptoms.  The  temperament  of  the  patient  has 
perhaps  from  the  first  been  such  that  the  development  of 
delusions  has  seemed  not  unlikely.  An  unduly  ambitious,  vain, 
jealous  or  suspicious  nature,  by  which  slights  inflicted  during 
ordinary  social  intercourse  are  exaggerated,  or  perhaps  invented, 
may  lead  the  unfortunate  individual  through  a  preliminary  stage, 
during  which  the  conduct  of  others  is  absurdly  interpreted  to 
another,  in  which  it  is  supposed  that  the  wrongs  from  which  he 
is  suffering  are  the  result  of  organised  persecution,  and  to  a  still 
further  stage,  in  which  is  evolved  the  idea  that  one  so  molested 
cannot  but  be  persecuted  because  of  his  intrinsic  importance. 
Hence  arise  delusions  of  grandeur.  The  treatment  of  these  cases 
is  not,  so  far  as  relief  of  symptoms  is  concerned,  at  all  hopeful.  It 
is  very  desirable,  where  the  temperament  early  shows  signs  of 
suspicious  morbidity,  that  education  should  be  specially  directed 
towards  its  correction,  and  the  influence  of  broad-minded  persons, 
who  are  habitually  capable  of  rising  superior  to  the  rebuffs  which 
are  the  lot  of  every  man,  is  of  considerable  value.  Change  of 
scene,  removal  from  home  surroundings  and  travel  are  often  useful 
in  the  earliest  stages  ;  while  there  is,  as  a  rule,  no  particular  indica- 
tion for  the  treatment  of  any  defect  in  nutrition.  In  later  stages, 
when  delusions  are  developed,  asylum  treatment  becomes  a 
necessity.  The  patient  is  in  this  way  placed  in  conditions  in  which 
relative  calm  is  obtainable,  though  it  is  only  too  likely  that  before 
long,  in  place  of  considering  some  person  or  body  of  persons  outside 
the  asylum  as  responsible  for  his  supposed  ills,  he  will  transfer 
the  responsibility  to  the  asylum  officials.  But  there  is  perhaps  a 
yet  more  important  reason  why  patients  suffering  from  paranoia 
should  be  interned,  and  that  is,  that  of  all  persons  of  unsound 
mind  they  are  the  most  dangerous.  When  at  length  the  patient 
has  arrived  at  a  conclusion  as  to  the  authorship  of  his  wrongs, 
the  step  is  not  far  to  the  position  in  which  he  resolves  to  avenge 
himself  by  homicide.  Those  patients  who  are  pursued  by  a  fear  of 
being  poisoned  may  refuse  to  take  food  and  have  in  consequence  to 
be  fed.  Treatment  must  in  short  be  directed  towards  the  mitiga- 
tion of  symptoms,  since,  when  once  the  condition  is  established, 
there  is  but  little  hope  of  recovery. 

MAURICE   CRAIG  and  E.  D.  MACNAMARA. 


1310 


THE   MENTAL   ASPECTS    OF   EPILEPSY. 

SOME  of  the  abnormal  mental  states  occurring  in  connection 
with  epilepsy  are  periodic  and  some  are  permanent.  Of  the 
periodic  states  some  occur  before  a  fit  and  some  after  a  fit,  while 
others  occur  quite  independently  of  the  somatic  phenomena. 
Among  the  pre-epileptic  symptoms  are  dreamy  states,  hallucinations, 
delusions,  states  of  extreme  excitement,  of  depression  and  of  general 
malaise,  accompanied  sometimes  by  tendencies  to  mistrust  of  others 
and  groundless  animosity.  Among  the  post-epileptic  symptoms  are 
automatism,  in  which  various  criminal  acts  may  be  perpetrated, 
confusion,  intense  excitement,  depression  and  delusions.  When 
the  classical  symptoms  are  wholly  replaced  by  mental  symptoms,  a 
condition  to  which  the  term  "  psychic  equivalence  "  is  applied,  there 
may  be  confusion,  automatism,  stupor,  depression,  delirium  or 
excitement,  and  it  should  be  remembered  that  there  are  epileptics 
whose  only  manifestations  are  such  as  these  and  in  whom  the  more 
common  symptoms  do  not  display  themselves. 

Among  the  permanent  mental  symptoms  are  idiocy  and  imbecility, 
occurring  where  epilepsy  has  proved  itself  antagonistic  to  the 
normal  growth  of  the  individual,  emotional  impetuosity,  extreme 
egoism,  valetudinarianism,  religiosity,  criminality  and  all  degrees  of 
mental  enfeeblement  up  to  fatuous  dementia. 

The  treatment  of  the  mental  symptoms  of  epilepsy  will  naturally 
be  essentially  the  same  as  the  treatment  of  the  somatic  symptoms, 
with  such  modifications  as  their  peculiar  characters  demand.  In 
the  event  of  certain  of  the  permanent  mental  symptoms  enumerated 
above  being  present  it  is  well  nigh  impossible  to  treat  the  patient 
except  in  an  institution.  Idiocy,  an  advanced  stage  of  dementia 
and  the  presence  of  criminal  tendencies  render  necessary  the 
protection  afforded  to  the  patient  and  to  society  in  general  by 
internment ;  while  the  other  permanent  mental  states  may  or  may 
not  necessitate  institutional  treatment  according  to  the  extent  to 
which  they  affect  the  patient's  conduct.  Egoism,  impulsiveness,  and 
valetudinarianism,  while  rendering  the  individual  exceedingly  trying 
as  a  member  of  a  household,  are  yet,  unless  carried  to  the  utmost 
extreme,  not  considered  to  justify  certification.  The  periodic  mental 
states,  though  often  characterised  by  symptoms  of  great  severity, 
are  usually  of  short  duration,  so  that  by  the  time  arrangements 


The  Mental  Aspects  of  Epilepsy.         1311 

have  been  made  for  certification  the  patient  is  well  again  or, 
if  he  has  been  received  into  an  asylum  or  hospital,  he  is  discharged 
relieved  in  a  few  days.  It  is  in  consequence  often  very  difficult  in 
such  cases  to  decide  as  to  whether  to  send  the  patient  to  an 
institution  or  not.  If  ample  provision  for  treatment  can  be  made 
in  the  patient's  own  home,  and  if  it  is  known  by  experience  of  past 
attacks  that  the  attack  is  likely  to  be  a  short  one,  there  is  then  no 
particular  reason  why  the  patient  should  be  sent  away.  On  the 
other  hand,  there  are  occasions  when  the  violence  of  the  patient  or 
the  frequency  of  his  attacks  is  such  that  it  is  quite  impossible  to 
keep  him  at  home.  In  some  of  the  psychic  equivalents  in  which 
there  is  slight  confusion,  stupor  or  depression,  it  is  merely  necessary 
to  watch  the  patient  in  order  to  prevent  him  from  doing  foolish 
things  or  accentuating  his  condition  by  restlessness,  starvation  or 
inattention  to  the  bowels.  It  must  of  course  be  recognised  that 
patients  suffering  from  the  so-called  permanent  symptoms  are  also 
certain  to  display  periodic  symptoms,  sometimes  somatic  and  some- 
times psychic ;  while,  conversely,  those  who  at  the  time  they  come 
under  observation  only  suffer  from  periodic  symptoms  are  likely 
sooner  or  later,  unless  the  disease  is  checked,  to  manifest  some 
degree  of  dementia.  It  will  therefore  be  necessary  in  advising 
treatment  to  bear  prognosis  in  mind  and,  so  far  as  is  possible,  to 
arrange  a  future  for  the  patient  in  which  the  stresses  of  life  will 
bear  but  very  lightly  upon  him. 

In  every  case  of  epilepsy  and  whatever  its  manifestations  a  minute 
examination  of  the  history  and  of  the  present  state  of  the  patient 
should  be  made.  There  are  often  present  in  epileptics  minor 
bodily  defects,  and  it  not  infrequently  happens,  especially  in  the 
young,  that  when  these  are  remedied  the  number  of  the  epileptic 
manifestations  is  reduced,  and  indeed  that  in  some  cases  no 
further  manifestation  occurs.  Morbid  conditions  of  the  accessory 
cavities  of  the  skull,  of  the  teeth,  errors  of  refraction,  circulatory, 
gastro-intestinal  and  urinary  disorders  should  therefore  be  sought 
for  and  if  found  remedied.  The  life  of  an  epileptic  should  be  passed 
in  as  peaceful  surroundings  as  can  be  obtained.  He  should  be 
moderate  in  food,  exercise  and  work,  whether  it  is  mental  or 
physical.  Excesses  of  all  sorts  are  to  be  avoided,  for  a  state  of 
exhaustion  appears  to  favour  the  occurrence  of  an  attack.  The 
dietary  must  be  nourishing,  and  milk  may  be  given  in  large 
quantities,  though  the  amount  of  meat  should  be  small  and  purin- 
free  foods  may  at  times  be  exclusively  taken  with  advantage. 
Alcohol  should  be  forbidden.  It  is  of  the  greatest  importance  that 
the  bowels  should  be  kept  well  open  and  indeed  that  every  organ 


1312       The  Mental  Aspects  of  Epilepsy. 

whereby  excretion  is  effected  should  be  stimulated  to  activity.  It 
is  unnecessary  here  to  enter  into  minute  details  as  to  the  drug 
treatment  of  epilepsy.  It  is  sufficient  to  indicate  our  belief  that  at 
any  rate  the  periodic  psychic  phenomena  can  be  mitigated  by  drugs, 
while  the  permanent  mental  states  are  probably  beyond  their 
influence  and  can  only  be  in  part  relieved  by  attention  to  the 
general  health  of  the  patient.  Of  the  drugs  the  bromides  are 
beyond  doubt  the  most  efficacious,  and  their  action  may  be  aided 
by  removing  common  salt  from  the  patient's  dietary.  The  extreme 
violence  of  some  of  the  attacks  of  excitement  may  be  abated  by 
hyoscine. 

MAURICE    CRAIG  and  E.  D.  MACNAMARA. 


1313 


OBSESSIVE  AND  IMPERATIVE  IDEAS. 

THESE  ideas  are  such  as  obtrude  themselves  with  undue  insistence 
upon  the  consciousness  of  the  individual,  interfering  with  the  proper 
course  of  the  patient's  mental  processes  and  occasionally  resulting 
in  aberrations  of  conduct.  The  varieties  of  ideas  are  innumerable 
and  are  frequently  present  to  a  slight  extent  among  normal  persons, 
though  such  persons  can  put  the  ideas  aside  and  their  conduct  is 
uninfluenced  by  them.  Obsessive  ideas  may  of  course  occur  as 
symptoms  among  persons  suffering  from  various  forms  of  mental 
disorder,  but  we  are  here  referring  to  the  mental  conditions  in  which 
they  form  the  only  symptoms,  those,  for  instance,  which  go  by  the 
names  of  folie  du  doute,  mysophobia,  agoraphobia,  nyctophobia  and 
ereutophobia.  Where  there  is  a  tendency  to  such  symptoms  it  will 
be  found  that  they  become  more  marked  when  the  patient's  general 
health  is  not  good  and  in  the  case  of  women  during  the  menstrual 
period.  It  should  therefore  be  the  aim  of  the  physician  to  enquire 
minutely  into  the  conditions  of  the  patient's  life  and  to  advise  the 
rectification  of  such  as  may  appear  to  him  to  be  faulty,  while  any 
disorder  which  he  may  discover  should  be  treated  appropriately. 
To  treat  the  symptom  it  may  be  desirable  to  place  the  patient  in 
such  circumstances  that  the  idea  is  not  suggested  to  him  ;  for 
instance,  if  the  patient  has  that  variety  of  claustrophobia  which 
prevents  him  from  entering  a  train  he  may  spend  months  in  some 
part  of  the  country  where  railway  travelling  is  quite  unnecessary,  or 
such  journeys  as  have  to  be  undertaken  may  be  made  by  motor-car. 
Such  a  method  as  this  is  sometimes  the  only  practicable  one,  for  so 
imperative  may  be  the  obsession  that  the  patient  is  unable  to  carry 
on  the  business  routine  of  his  life  as  he  cannot,  owing  to  his 
aversion  to  all  sorts  of  vehicles,  get  about  except  by  walking. 
While  the  patient  is  away  his  general  health  should  be  attended 
to  and  various  methods  of  psycho-therapeutics  employed.  In  some 
cases  which  are  less  well-marked,  or  where  avoidance  of  incitation 
of  the  idea  is  impracticable,  psycho -therapeutics  may  be  tried  with 
no  adjuvant.  Persuasion  and  suggestion,  whether  with  or  without 
hypnosis,  may  be  practised  and  undoubtedly  it  does  happen  that 
with  patience  and  tact  the  ideas  become  less  compelling  and  may 
even  vanish  altogether.  We  are  not  convinced  that  suggestion  under 
hypnosis  is  of  more  value  than  persuasion,  but  there  are  cases  in 

S.T.— VOL.  ii.  88 


1314         Obsessive  and  Imperative  Ideas. 

which  it  procures  comparatively  speedy  results,  though  on  the 
other  hand  there  are  many  cases  in  which  its  beneficial  effects  are 
wholly  absent.  Another  psycho-therapeutic  method  is  that  of 
psycho-analysis.  Sometimes  it  would  appear  that  the  symptoms 
are  due  to  the  presence  of  two  groups  of  concurrent  and  unhar- 
monious  psychic  processes  which  have  been  set  in  action  by 
emotional  disturbance.  By  the  analytic  method  it  is  sought  to 
discover  what  these  processes  are.  Often  their  source  is  unknown 
to  the  patient  himself,  or  if  known  is  not  recognised  as  being  the 
cause  of  his  symptoms,  or  if  known  and  recognised  is  studiously 
concealed.  By  hypnosis,  by  study  of  the  attentionless  associations, 
of  dreams  and  of  word-reaction  times  these  recondite  psychic 
transactions  are  laid  bare  and  can  be  dealt  with  in  the  broad  light 
of  day.  It  not  unfrequently  happens  that  with  this  exposure  and 
with  the  explanation  that  can  thereupon  be  made  the  symptoms 
disappear. 

MAURICE   CRAIG  and  E.  D.  MACNAMARA. 


1315 


PERVERSIONS. 

THOSE  impulses  which,  apparently  without  deliberation  or 
acquired  knowledge,  lead  animals  to  perform  certain  actions 
which  tend  towards  the  preservation  of  the  individual  or  of 
the  race  to  which  they  belong  and  which  we  term  instincts,  are 
sometimes  in  man  remarkable  for  their  exaggerated  character  or 
their  absence  or  perversion.  It  would  be  out  of  place  here  even  to 
catalogue  the  numerous  and  curious  examples  of  these  abnormalities 
which  from  time  to  time  are  reported,  and  it  must  suffice  that  we 
should  name,  by  way  of  example,  such  aberrant  instincts  as  the 
exaggerated  desire  to  collect,  miserliness  and  the  various  varieties 
of  sexual  perversion.  These  last  are  the  abnormalities  about  which 
advice  is  most  often  sought.  In  such  instances  the  aim  of  the 
physician  must  be  twofold,  for,  in  the  first  instance,  he  must 
endeavour  to  place  the  patient  under  such  circumstances  that  the 
peculiar  practice  to  which  he  is  addicted  is  difficult  or  impossible  of 
performance,  and  in  the  second  to  exercise  by  the  methods  of 
psycho -therapeutics  such  an  influence  that  the  evil  tendency  is 
eradicated  or  at  least  neutralised.  Neither  aim  can  be  easily  or 
rapidly  realised.  A  very  important  feature  in  treatment  is 
adequately  to  fill  out  the  patient's  time.  Among  peasant  popula- 
tions, where  the  tending  of  cattle  allows  of  very  frequent  intervals 
of  complete  idleness,  the  criminal  annals  are  full  of  accounts  of 
acts  which  have  brought  the  persons  concerned  in  these  occupations 
under  the  cognisance  of  the  law.  On  the  other  hand,  history 
teems  with  instances  of  the  effect  of  luxury  and  idleness  upon 
urban  populations,  in  which  sexual  perversion  has  appeared  to  be 
rather  the  rule  than  the  exception.  It  is  therefore  desirable  in 
any  individual  case  to  recommend  that  the  patient's  time  should 
be  filled  with  useful  occupation,  for  in  this  way  opportunities  for 
the  performance  of  the  particular  act  are  diminished  and  the 
energies  necessary  for  its  perpetration  are  otherwise  beneficially 
expended.  Psycho-therapeutics  may  consist  in  the  inculcation  of 
a  moral  standard  higher  than  that  to  which  the  patient  has  been 
used,  or  to  suggestion,  made  either  in  the  light  or  profound  stages 
of  hypnosis,  that  the  practices  to  which  the  patient  is  addicted 
should  be  abandoned. 

MAURICE    CRAIG  and  E.  D.  MACNAMARA. 

83—2 


1316 


MASTURBATION. 

MASTURBATION  is  a  frequently  occurring  symptom  among  the 
insane,  and  attacks  of  mental  disorder  are  not  uncommonly 
regarded  as  caused  by  the  practice.  There  can  be  but  little 
doubt  that  neurotic  and  imaginative  individuals  are  particularly 
addicted  to  masturbation,  and  that  it  is  also  from  the  ranks  of  such 
that  come  the  victims  of  mental  disorder ;  but  beyond  the  common 
factor  of  the  neurotic  diathesis  there  is  but  little  real  evidence  that 
the  practice  stands  to  the  disorder  in  the  relationship  of  cause  and 
effect.  In  the  case  of  the  acute  or  chronic  insanities,  whether 
occurring  in  males  or  females,  it  is  only  by  the  closest  attention  on 
the  part  of  the  nurses  that  it  can  be  sought  to  prevent  masturbation. 
Local  causes  of  irritation  ma}'  be  removed  and  sedative  drugs  may 
be  given,  but  will  effect  but  little  in  the  absence  of  supervision. 
Masturbation  is  common  among  idiots  and  imbeciles,  and  among 
these  also  careful  superintendence  is  all-important. 

Of  perhaps  more  importance  than  the  prevention  of  masturbation 
among  the  insane  is  the  problem  of  its  treatment  among  the  sane. 
Although  the  habit  does  not,  unless  in  very  exceptional  cases,  lead 
to  the  formidable  consequences  which  are  so  skilfully  portrayed  for 
the  purposes  of  terrorisation  in  the  literature  of  charlatanism,  yet 
its  effects  are  inimical  to  health.  Lassitude  of  mind  and  body, 
incapacity  for  work  or  play,  lack  of  power  of  attention,  anaemia  and 
loss  of  weight,  are  among  the  common  symptoms  and  may  lead  in 
the  predisposed  individual  to  an  increased  vulnerability  to  the 
attacks  of  the  various  agents  which  cause  nervous  and  mental 
breakdown.  In  the  case  of  the  boy  or  girl  addicted  to  the  practice 
in  whom  there  is  no  local  irritation  and  who  is  of  normal  mentality 
and  in  whose  case  the  habit  has  been  discovered,  it  is  wise  to  point 
out  the  possible  consequences  of  its  continuance  and  to  appeal  to 
that  sense  of  decency  which  is  always  present  in  the  child  who  has 
been  properly  brought  up.  Increased  supervision  may  be  necessary, 
and  the  child's  time  may  be  filled  with  the  items  of  a  programme 
in  which  there  is  a  judicious  admixture  of  mental  and  physical 
work  and  of  play.  In  the  case  of  the  child  in  whom  the  habit  has 
not  been  discovered,  but  in  whom  it  is  suspected,  it  is  perhaps  on 
the  whole  not  advisable  directly  to  tax  him  or  her  with  the  practice. 
\\ith  a  little  tact  it  will  probably  become  manifest  whether  or  no 


Masturbation. 

the  boy  or  girl  has  any  conception  of  the  subject  that  is  being 
indirectly  referred  to,  and  further  conversation  can  be  regulated 
accordingly.  "We  would  recommend  reliance  being  placed  on 
general  maxims,  on  the  inculcation  of  the  duty  of  keeping  the  body 
fit  for  its  tasks  of  work  and  trained  for  sports,  and  on  the  explana- 
tion of  the  fact  that  acts  of  impurity  diminish  its  capacities.  There 
are  some  who  advocate  the  unrestrained  elucidation  of  sexual 
matters  to  the  young,  while  there  are  others  who  would  entirely  con- 
ceal them.  For  ourselves,  we  believe  that  it  is  idle  to  lay  down  any 
universal  rule.  There  is  a  time  for  all  things,  and  there  can  be  no 
doubt  that  childhood  and  youth  are  not  the  times  for  the  considera- 
tion of  sexual  affairs  or  for  the  practice  of  sexual  acts ;  nevertheless, 
in  all  cases  to  make  a  mystery  of  such  topics  will  result  in  some 
instances  in  the  fostering  of  a  lascivious  pruriency,  while  to  teach 
all,  without  discrimination,  the  meaning  of  sexual  matters  which 
are  of  no  interest  to  the  majority  will  be  to  awaken  in  some  few  a 
curiosity  which  they  were  better  without.  We  therefore  own 
ourselves  to  be  eclectic,  and  recommend  that  treatment  of  any 
individual  case  be  founded  upon  the  indications  presented  by  that 
case.  But  whether  it  be  determined  to  enlighten  the  masturbator, 
or,  as  must  not  infrequently  happen,  the  potential  masturbator, 
upon  sexual  affairs  there  are,  at  any  rate,  modes  of  life  which  we 
may  safely  enjoin.  The  boy  or  girl  should  be  directed  to  be  an 
early  riser  ;  a  cold  bath  may  be  ordered  and  life  so  regulated  that 
the  child  has  but  little  time  for  anything  which  is  not  in  the  day's 
routine.  Such  leisure  time  as  is  not  given  to  exercise  may  well  be 
spent  in  learning  some  interesting  craft,  for  example,  carpentering, 
and  care  should  be  taken  that  the  literature  provided  is  sound  and 
lacks  any  sexual  soiiprfm.  Hypnotism,  especially  among  older 
persons,  has  been  useful  in  some  cases. 

Among  small  children,  and  even  among  infants,  masturbators 
are  occasionally  found,  and  the  practice  seems  commoner  among 
females  than  among  males.  Among  the  former  a  rubbing  move- 
ment of  the  thighs  followed  by  flushing,  pallor  and  perspiration, 
will  often  indicate  the  presence  of  the  habit.  All  local  sources  of 
irritation  must  be  looked  for,  and  if  found,  treated ;  and  for  the 
rest  some  simple  means  must  be  devised  for  rendering  manipula- 
tion by  the  hands  or  movement  of  the  thighs  impossible.  Girls,  for 
instance,  may  be  put  into  such  splints  as  cause  separation  of  the 
thighs.  If  the  habit  is  persisted  in  and  is  practised  quite  openly  it 
may  be  feared  that  there  is  present*some  degree  of  mental  defect. 

MAURICE  CRAIG  and  E.  D.  MACNAMARA. 


I3i8 


IDIOCY    AND    FEEBLE-MINDEDNESS. 

THERE  are  innumerable  gradations  in  the  scale  of  feeble-minded- 
ness.  At  the  lowest  level  of  complete  idiocy  there  is  a  condition  in 
which  there  is  an  absence  of  even  the  most  elementary  instincts. 
Further  up  the  scale  we  find  that  intelligence  is  present  though 
in  a  rudimentary  form,  and  at  the  top  of  the  scale  we  meet  with 
cases  which  with  difficulty  can  be  differentiated  from  the  normal. 
Treatment,  which  is  essentially  directed  towards  the  education  of 
the  patient,  must  manifestly  depend  upon  the  receptivity  of  the 
nervous  system.  So  soon  as  idiocy  has  been  diagnosed  educative 
efforts  should  be  commenced,  and  we  are  of  opinion  that  no  case 
should  be  at  once  dismissed  as  incapable  of  improvement.  In  the 
case  of  an  idiot  of  the  lowest  grade,  in  which  the  diagnosis  has  been 
made  at  an  early  age,  the  first  educative  efforts  are  made  in  the 
direction  of  trying  to  teach  the  patient  kinsesthetic  sensations. 
Passive  movements  and  massage  tend  to  impress  upon  such 
sensorium  as  there  may  be  a  recognition  of  the  position  of  the 
limbs.  In  the  next  stage  the  patient  may  be  taught  to  "  feel  his 
feet  "  by  being  held  in  the  upright  position  upon  them  and  later  by 
being  placed  in  a  go-cart.  From  lessons  in  standing  the  patient 
passes  to  the  acquisition  of  the  art  of  walking,  firstly  on  the  flat 
and  later  upstairs.  In  the  meanwhile  the  education  of  the  hands 
is  not  neglected,  and  in  the  first  instance  the  patient  is  taught  to 
grasp  and  handle  large  objects  of  different  sizes  and  weights  and 
gradually  to  learn  to  move  them  from  one  place  to  another.  The 
important  senses  of  heat  and  cold  may  be  developed  by  placing  the 
hands  alternately  in  hot  and  cold  water.  The  insertion  of  large 
buttons  into  large  button-holes  may  now  be  attempted  and  shortly 
followed  by  such  manoeuvres  as  the  lacing  of  boots  and  the  fixing 
of  eyes  upon  hooks,  fitting  pegs  into  holes  and  passing  marbles  of 
various  sizes  through  holes  in  a  piece  of  wood.  The  education  of 
sight,  hearing,  smell  and  taste  may  now  be  attempted,  for  instance, 
in  the  case  of  sight  by  the  insertion  of  coloured  pegs  into  holes 
around  which  is  painted  a  like  colour.  If  progress  has  so  far  been 
good  the  dressing  and  undressing  of  dolls  may  now  be  taught  and 
subsequently  the  putting  together  of  picture  puzzles.  Reading 
may  sometimes  be  taught  by  the  use  of  wooden  letters  which  are 
superimposed  upon  painted  letters  of  the  same  colour,  while  the 
patient  may  be  instructed  in  the  elements  of  writing  and  the 


Idiocy  and  Feeble-Mi ndedness.          1319 

making  of  straight  lines  and  pot-hooks.  Commencing  at  a  very 
early  age,  endeavours  are  made  to  educate  the  movements  of  the 
apparatus  of  speech  and  through  imitation  it  is  sought  to  make 
the  child  move  the  lips  and  tongue  in  special  directions,  to  articulate 
elementary  sounds,  short  syllables  and  eventually  words  and 
sentences.  When  the  power  of  articulate  expression  has  been 
acquired  an  enormous  advance  has  been  made  and  the  naming  of 
various  objects  and  the  demonstration  of  their  uses  can  be 
proceeded  with  apace.  It  is  of  very  considerable  importance 
that  the  feeble-minded  person  should  be  taught  some  handicraft. 
Basket-making,  mat-making,  gardening,  boot-making  and 
carpentering  are  all  suitable  occupations,  while  the  selection  of 
any  one  will  depend  upon  the  capacity  of  the  patient.  Games 
played  in  combination  with  others  are  of  considerable  assistance 
in  introducing  the  patient  to  the  social  amenities  and  should  by 
preference  be  carried  on  in  the  open-air. 

The  control  of  the  sphincters  is  a  matter  of  much  importance 
and  one  in  which  the  feeble-minded  are  deficient.  Much  attention 
is  necessarily  devoted  to  keeping  the  patient  clean  in  this  respect, 
and  as  soon  as  possible  a  definite  regime  should  be  adopted.  In 
some  cases,  at  any  rate  where  the  patient  is  capable  of  sitting  up, 
it  may  be  necessary  to  keep  him  on  a  nursery  commode  for  long 
periods  together,  while  in  others  he  should  be  placed  thereon  at 
regular  intervals  which,  as  time  goes  on,  may  gradually  be 
lengthened.  It  will  be  probably  found,  except  in  extreme  cases, 
that  regular  habits  will  thus  become  established. 

It  is  imperative  while  the  above  educational  efforts  are  being 
carried  on  that  the  general  health  of  the  child  should  be  carefully 
tended.  Food  should  be  of  a  simple  character  and  for  the  most 
part  farinaceous.  The  feeble-minded  must  be  taught  properly  to 
masticate  their  food,  for  they  exhibit  marked  tendencies  to  bolt  it, 
while  many  of  them  eat  voraciously  and  quite  out  of  proportion  to 
their  needs.  Cleanliness  of  person  and  neatness  of  dress  should 
be  inculcated,  and  here  also  regular  habits  must  be  early  commenced 
and  patiently  persisted  in.  Clothing  should  be  light  so  that  the 
free  movements  of  the  limbs  is  not  interfered  with,  but  it  should 
be  at  the  same  time  of  warm  material,  since  the  patients  are 
particularly  liable  to  take  chill.  The  periods  devoted  to  sleep 
should  be  long  and  regular  in  incidence  and  the  bedroom  should  be 
supplied  with  the  maximum  of  fresh  air.  Indeed,  so  far  as  is 
possible,  the  patient  should  live  in  the  open-air  and  there  receive 
his  lessons  and  take  his  meals.  Any  physical  defect  which  it  is 
possible  to  remedy  should  be  attended  to.  Errors  in  refraction  or 


1320          Idiocy  and  Feeble-Minded  ness. 

in  any  of  the  special  senses  must  be  corrected  at  the  earliest 
opportunity,  since  many  are  feeble-minded  owing  to  defect  in  the 
avenues  by  which  the  sensorium  is  reached,  and  it  will  often  be 
found  that  progress  is  far  more  rapid  when  such  defect  is  remedied. 
If  it  happens  that  such  defects  are  irremediable  educational  efforts 
must  be  directed  towards  making  still  more  use  of  the  senses  which 
are  not  affected.  For  instance,  if  the  child  is  deaf  an  endeavour 
must  be  made  to  form  in  the  patient's  mind  associations  between 
certain  ideas  and  certain  movements  of  the  teacher's  lips  or  certain 
gestures. 

The  naso-pharynx  should  be  examined  and  adenoids  or  large 
tonsils  removed.  The  teeth  should  be  attended  to.  The  prepuce, 
if  the  usual  indications  for  circumcision  are  present,  should  be 
removed.  In  certain  cases  where  there  is  an  associated  paralysis, 
orthopedic  surgery  is  useful,  and  limbs  which  have  been  quite 
useless  may  be  brought  into  such  a  condition  that  they  may 
perform  at  least  some  of  their  functions.  At  times  operations  have 
been  performed  upon  the  brain  in  the  hope  of  removing  pressure 
caused  by  meningeal  cicatrices  or  depressions  or  thickenings  of 
bone ;  experience  unfortunately  demonstrates  their  uselessness. 
In  the  case  of  cretins  much  improvement  is  produced  by  the 
administration  of  thyroid  gland,  and  in  the  case  of  epileptics  the 
bromides  are  sometimes  beneficial  and  sometimes  harmful. 

Elementary  notions  of  right  and  wrong  must  be  instilled 
wherever  practicable,  and  it  should  be  sought  to  convey  to  the 
mind  that  certain  acts  are  praiseworthy  and  others  reprehensible. 
To  effect  this  kindness  and  patience  are  essential  qualities  in  the 
teacher,  and  it  is  idle  to  make  use  of  the  punishments  which  are 
common  in  the  nursery  of  the  normal  child.  In  most  cases  a 
little  experience  will  enable  the  teacher  to  appreciate  the  likes  of 
the  patient  and  he  may  be  encouraged  in  well-doing  by  their  proper 
gratification  and  deterred  from  ill-doing  by  the  deprivation  of 
opportunities  for  satisfying  them.  It  is  surprising  of  how  great 
progress  the  feeble-minded  are  capable  when  subjected  to  such  a 
regime  as  that  outlined  above  and  how  small  is  the  residuum  in  which 
no  improvement  can  be  effected.  It  is  true  that  years  of  patient 
endeavour  must  be  passed  and  that  the  results  may  after  all  appear 
but  meagre ;  nevertheless,  for  those  endowed  with  courage  and 
patience,  there  is  ample  reward  in  the  gradual  unfolding  of  the  stunted 
intelligence  and  the  making  useful  of  lives  which  but  for  this  labour 
are  of  less  value  than  a  mere  encumbrance  upon  the  earth. 

MAURICE  CRAIG  and  E.  D.  MACNAMARA. 


AFFECTIONS  OF  MUSCLES  AND  FASCIAE. 

INJURIES  OF  MUSCLES. 

Contusions. — In  contusions  of  muscles  a  certain  amount  of 
haemorrhage  into  the  muscle  occurs,  and,  if  this  effusion  of  blood  is 
extensive,  very  serious  impairment  of  function  may  follow  from 
fibrosis  and  adhesions.  Hence  every  effort  should  be  made 
to  promote  the  absorption  of  the  effusion  as  soon  as  possible. 

In  niild  cases  in  which  there  is  but  slight  effusion  the  application 
of  hot  fomentations  for  one  or  two  days,  followed  by  the  use  of  a 
simple  liniment  night  and  morning,  is  sufficient.  If  the  pain  is  not 
marked  complete  rest  is  not  necessary,  in  fact  gentle  exercise 
assists  in  the  absorption. 

In  severe  contusions,  where  there  is  marked  effusion,  very  great 
pain  is  complained  of,  and  as  a  result  of  the  blow  there  is  often 
temporary  paralysis  of  the  part.  In  these  cases  absolute  rest  is 
indicated  both  to  ease  the  pain  and  to  assist  in  the  absorption 
of  the  effusion  ;  in  addition,  the  local  application  of  hot  Goulard  and 
opium  fomentations  is  of  great  value.  Complete  rest  should  be 
given  for  two  to  three  days,  after  which  time  local  massage  should 
be  ordered ;  the  rubbing  at  first  should  be  very  gentle  and  always  in 
an  upward  direction,  if  in  a  limb.  The  massage  should  be  persisted 
with  for  two  to  three  weeks  ;  if  the  lower  limb  is  affected  the 
patient  is  allowed  to  walk  about  in  about  ten  days  from  the  time  of 
the  accident.  By  these  means  any  liability  to  permanent  disability 
from  muscular  impairment  due  to  fibrosis  or  adhesions  is 
minimised.  In  cases  in  which  a  definite  large  haematoma  is 
formed  convalescence  may  be  hastened  by  incision  of  the  swelling 
and  evacuation  of  the  clot  under  strict  aseptic  precautions.  After 
evacuation  the  cavity  is  irrigated  with  hot  saline  solution,  the 
wound  is  then  sewn  up  without  drainage,  firm  pressure  being 
applied  by  bandaging  over  a  suitable  dressing.  As  soon  as  the 
wound  is  healed,  treatment  by  massage  as  described  above  should 
be  ordered. 

"Wounds  of  Muscle. — Small  incised  or  punctured  wounds  of 
muscle  in  the  direction  of  the  fibres  do  not  require  any  special 
treatment  other  than  that  necessary  for  the  wound  itself.  When, 
however,  the  muscle  fibres  are  divided  transversely  and  the  wound 
is  considerable,  an  endeavour  should  be  made  to  unite  the  ends  by 


1322  Injuries  of  Muscles. 

suture,  so  as  to  restore  as  far  as  possible  the  function  of  the  muscle. 
A  general  anaesthetic  having  been  given,  the  wound  is  cleansed  by 
copious  irrigation  with  a  warm  solution  of  biniodide  of  mercury 
(1  in  6,000).  The  ends  of  the  cut  muscles  are  then  isolated, 
and  the  limb  is  put  into  the  position  which  relaxes  the  muscles  to 
their  fullest  extent.  In  order  to  avoid  the  sutures  cutting  out  they 
must  be  passed  transversely  across  the  muscle  fibres,  about 
f  inch  from  the  cut  edge,  and  tied  so  as  to  include  a  bundle 
of  muscular  tissue.  Separate  sutures  are  inserted  in  this  way 
into  each  cut  end  of  the  muscle.  The  ends  of  the  sutures  are 
then  tied  firmly  together  so  as  to  approximate  the  cut  ends.  As  an 
additional  safeguard  one  or  two  mattress  sutures  may  be  inserted 
after  the  main  sutures  have  been  tied.  Chromic  catgut  is  the  best 
material  to  employ,  as  it  is  absorbed  and  no  irritating  foreign  body 
is  left  in  the  muscle.  It  is  advisable  to  insert  a  small  drainage 
tube  into  the  wound  for  forty-eight  hours. 

After  the  operation  the  muscle  is  kept  fully  relaxed  for  three  or 
four  days  ;  the  position  should  then  be  altered  slightly  each  day,  so 
that  in  about  ten  days  the  muscle  is  fully  extended.  Massage  and 
very  gentle  passive  movements  may  then  be  commenced,  so  as  to 
prevent  as  far  as  possible  the  formation  of  adhesions.  After  three 
weeks  the  patient  should  be  encouraged  to  perform  active  move- 
ments, but  no  undue  strain  should  be  allowed  to  fall  on  the  muscle 
until  at  least  five  weeks  after  the  injury,  so  as  to  avoid  any 
stretching  of  the  new  scar  tissue. 

When  very  extensive  laceration  of  muscles  has  occurred,  with 
possibly  injury  to  or  division  of  main  vessels  or  nerves,  the  question 
of  amputation  must  be  considered. 

Rupture  of  Muscles. — Subcutaneous  rupture  of  a  healthy 
muscle  is  a  rare  accident,  but  may  occur  from  a  sudden  or 
unexpected  strain  or  from  a  blow  on  the  muscle  when  it  is  firmly 
contracted.  In  these  cases,  if  the  rupture  is  complete,  there  is 
considerable  separation  between  the  parts  and  also  complete  loss  of 
power  in  the  muscle,  and  the  best  course  to  adopt  is  to  cut  down 
the  damaged  part  and  approximate  the  separate  ends  with  catgut 
sutures  as  described  under  Wounds  of  Muscle.  When  partial 
rupture  has  occurred,  the  superficial  fibres  alone  being  torn,  the 
part  should  be  immobilised  on  a  splint  about  a  week  in  such  a 
position  that  the  muscle  is  completely  relaxed  ;  after  this  time 
massage  should  be  commenced,  to  be  followed  in  a  few  days  by 
.passive  movements;  in  a  fortnight  gentle,  active  movements  may 
be  commenced,  and  full  use  of  the  part  may  be  allowed  in  three 
weeks  to  a  month. 


Injuries  of  Muscles.  1323 

In  many  cases,  especially  in  elderly  people,  a  few  deep  fibres  only 
of  a  muscle  are  ruptured  during  some  unwonted  exertion  or  from  a 
sudden  strain.  The  muscles  most  commonly  affected  are  the  calf 
muscles  and  the  erector  spinal  group.  In  either  case  there  is  a 
sudden  acute  pain  in  the  part,  often  described  by  the  patient  as 
"  like  a  blow,"  which  may  cause  him  to  fall  to  the  ground  owing  to 
the  severity  of  the  pain.  No  other  signs  are  to  be  made  out  at  the 
time  of  the  accident,  but  later  swelling  of  the  part  occurs,  with 
bruising  of  the  tissues,  which  may  take  many  days  to  appear. 

Complete  rest  in  bed  should  be  ordered  until  the  pain  and 
swelling  have  subsided.  As  soon  as  this  has  occurred  recovery 
may  be  hastened  by  local  massage  and  passive  movements.  The 
patients  are  usually  disabled  for  about  ten  days.  In  some  cases  a 
patient  is  unwilling  or  unable  to  lie  up  ;  if  this  is  the  case  relief 
from  the  pain  may  be  obtained  by  immobilising  the  part  by  the 
application  of  a  ham  splint,  if  the  lower  limb  is  affected,  or  firm 
strapping  in  the  case  of  the  back  :  treatment  by  massage  should 
be  ordered  in  these  cases  after  the  first  few  days. 

Hernia  of  Muscular  Fibres. — This  condition  occasionally 
follows  the  subcutaneous  rupture  of  the  deep  fascia  forming  the 
muscular  sheath  ;  as  a  result  a  gap  is  left  through  which  muscular 
fibres  protrude  during  the  action  of  the  muscle.  In  most  cases, 
apart  from  the  slight  deformity,  no  inconvenience  results  from  the 
accident  and  no  treatment  is  required.  In  some  few  cases  either 
pain  is  complained  of  from  nipping  of  the  muscle  in  the  opening  or, 
the  fascial  opening  being  large,  the  patient  desires  to  be  cured  of  the 
resulting  swelling.  If  this  is  so  the  best  plan  is  to  cut  down  on  the 
opening  in  the  fascia,  and,  after  refreshing  the  edges,  to  suture 
them  together  with  chromic  catgut  and  so  close  the  opening  (sec 
also  Sprains). 

C.  H.  S.  FRANKAU. 


1324 


INFLAMMATORY   AFFECTIONS   OF    MUSCLE* 

Acute  Simple  Myositis. — A  certain  degree  of  simple  inflam- 
matory reaction  almost  invariably  occurs  around  any  portion  of 
muscle  which  has  been  injured  by  contusion  ;  for  this  no  further 
treatment  is  required  other  than  that  for  the  original  contusion, 
and  no  disability  from  fibrosis  or  adhesions  should  occur  if  the 
treatment  is  adequately  carried  out. 

Acute  Suppurative  Myositis. — In  some  cases,  especially  if 
there  has  been  extensive  extravasation  of  blood,  an  infective 
myositis  may  follow  an  injury,  the  organisms  reaching  the  part 
either  through  a  skin  abrasion  or  by  the  blood  stream.  In  such 
cases  early  and  free  incisions  into  the  affected  area,  with  the  pro- 
vision of  adequate  drainage,  should  be  made  so  as  to  limit  as  far  as 
possible  the  amount  of  destruction  to  the  muscle  involved.  During 
the  later  stages  contractures  of  the  neighbouring  joints,  produced 
by  shrinking  of  the  newly  formed  scar  tissue,  are  very  likely  to 
occur.  Every  effort  should  be  made  to  avoid  this  complication  by 
the  application  of  suitable  splints  or  extension  apparatus  and  by 
the  use  of  massage  and  movements  as  soon  as  the  inflammation 
has  subsided.  In  spite  of  every  precaution  of  this  kind  it  may  be 
found  that  even  after  prolonged  treatment  some  degree  of  con- 
tracture  persists  ;  in  such  cases  the  deformity  may  be  benefited  or 
rectified  by  subcutaneous  division  of  fibrous  bands  or  even  of  the 
affected  tendons,  the  after-treatment  being  similar  to  that  described 
for  tenotomy  for  talipes,  etc.  (see  Contractures  of  Joints,  and 
Talipes). 

Rheumatic  Myositis.— In  addition  to  the  usual  treatment  by 
the  salicylates  or  aspirin,  great  relief  may  be  obtained  in  these 
cases  by  the  local  application  of  a  liniment  containing  a  compound 
of  salicylic  acid,  such  as  betulol,  i.e.,  ty.  Betulol,  gij ;  Lin.  Saponis, 
ad  jviij.  Fiat  linimentum  :  to  be  used  night  and  morning. 

Dry  heat,  either  in  the  form  of  electric  light  baths  or  the  electric 
pad,  will  also  be  found  to  give  relief,  especially  in  the  more  chronic 
cases. 

Syphilitic  Myositis. — Gummata  of  muscle  are  occasionally 
found ;  in  most  cases  they  react  readily  to  the  usual  treatment  by 
potassium  iodide  and  mercury,  but  they  may  leave  considerable 
deformity  from  a  subsequent  fibrosis.  Such  deformities  should  be 


New  Growths  of  Muscle.  1325 

treated  as  described  above  under  Acute  Suppurative  Myositis,  the 
constitutional  treatment  being  at  the  same  time  persisted  with. 

Ossifying  Myositis. — This  condition  may  be  limited  to  one 
muscle  or  group  of  muscles,  or  may  affect  the  whole  muscular 
system.  In  the  localised  form  the  commonest  site  is  the  adductor 
group,  the  adductor  longus  being  most  often  affected  and  forming 
"  riders'  bone."  If  no  very  great  disability  results  no  treatment  is 
indicated  in  these  cases.  If,  however,  the  movements  of  the  limb 
are  much  interfered  with,  the  ossified  portions  may  be  excised  with 
great  benefit  in  many  cases. 

In  the  generalised  form  the  back  muscles  are  first  affected,  the 
ossification  later  spreading  to  other  groups  of  muscles  until  death 
occurs  from  embarrassment  of  respiration  or  from  exhaustion. 
Unfortunately  no  treatment  has  at  present  been  found  which  is  of 
any  permanent  value.  The  iodides  occasionally  appear  to  check 
the  disease  in  the  early  stages  for  a  time  ;  in  the  later  stages 
radiant  heat  and  local  counter-irritants  will  be  found  to  give  relief 
in  some  cases. 

C.  H.  S.  FRANKAU. 


NEW  GROWTHS  OF  MUSCLE. 

Innocent  New  Growths. —  Lipomata  are  occasionally  met 
with  growing  between  the  fibres  of  muscles;  they  can  easily  be 
enucleated,  care  being  taken  to  avoid  division  of  muscular  fibres 
in  doing  so. 

Fibromata  are  also  found ;  they  should  be  freely  excised,  a 
wide  margin  being  allowed  around  the  tumour,  which  is  rarely 
encapsuled  and  tends  to  recur  in  situ. 

Malignant  New  Growths  (Sarcoma). — Two  varieties  may 
occur: 

(1)  The  rapidly  growing  spindle-celled  sarcoma,  which  tends  to 
rapidly   infiltrate   surrounding  muscles   and   for  which   the   only 
possible  treatment  in  the  case  of  a  limb  is  by  amputation. 

(2)  The    slowly   growing   fibro- sarcoma   or    "  recurrent    fibroid 
tumour."     These  tumours  should  be  freely  excised   in   the   first 
instance,  but  if  recurrence  occurs  rapidly,  amputation  of  the  limb 
should  be  undertaken. 

Cysts. — Hydatid  cysts  may  occur  in  muscle.  They  should  be 
treated  by  complete  excision  when  this  is  possible,  and  failing  this 

by  drainage. 

C.  H.  S.  FRANKAU. 


1326 


DISEASES   AND    AFFECTIONS    OF    TENDONS 
AND  THEIR  SHEATHS. 

INJURIES  OF  TENDONS. 

Dislocation  of  Tendons. — The  tendons  most  commonly  affected 
by  this  accident  are  the  peronei,  which  slip  forward  in  front  of  the 
external  malleolus  at  the  ankle  joint;  the  accident  is  usually 
associated  with  tearing  of  the  lateral  annular  ligament  and  the 
neighbouring  fascia  with  considerable  local  effusion  of  blood. 
In  such  cases  a  good  result  can  only  be  obtained  by  operative 
treatment;  if,  however,  operation  is  refused  or  is  contra-indicated 
for  some  reason,  the  following  method  may  be  tried. 

After  fully  everting  the  foot  the  displaced  tendon  is  manipulated 
into  its  correct  position,  the  ankle  is  then  immobilised  at  a  right 
angle,  with  the  foot  slightly  inverted,  by  means  of  a  plaster  splint. 
This  splint  is  left  on  for  ten  days  and  then  removed ;  gentle  massage 
and  movements  are  then  commenced,  care  being  taken  that  the 
tendons  do  not  redislocate ;  the  foot  is  maintained  in  an  inverted 
position  in  the  intervals  by  an  external  poroplastic  splint.  No 
attempt  at  walking  should  be  made  for  at  least  three  weeks  and  the 
patient  should  be  warned  against  forcibly  everting  the  foot  for  a 
considerable  time  afterwards. 

If  operation  is  decided  upon,  a  curved  incision  is  made  convex 
forwards,  and  a  flap  of  skin  turned  back  so  as  to  expose  the  peronaeal 
groove.  The  groove  is  then  cleared  and  deepened  if  necessary,  and 
the  tendons  having  been  replaced  in  position  the  torn  lateral 
ligament  and  deep  fascia  are  sutured  over  it  with  catgut.  The  after- 
treatment  is  similar  to  that  given  for  the  non-operative  method. 

Division  of  Tendons. — The  division  of  a  tendon  in  an  open 
wound  is  always  followed  by  loss  of  function  unless  the  cut  ends  are 
united  by  suture,  and  the  sooner  suture  is  carried  out  the  better  the 
ultimate  result.  An  anaesthetic  should  be  given  and  the  wound  area 
rendered  as  aseptic  as  possible,  since  proper  union  of  the  tendon  is 
hindered  or  prevented  if  suppuration  occurs.  The  ends  of  the 
tendon  must  next  be  identified  ;  little  difficulty  is  usually  found  in 
exposing  the  lower  end,  as  it  does  not  tend  to  retract.  The  upper 
end  may  be  difficult  to  find,  since  marked  retraction  of  the  muscle 
occurs  after  division  of  the  tendon  ;  complete  relaxation  of  the  muscle 
by  suitable  manipulation  of  the  limb  and  forcible  squeezing  down  of 


Injuries  of  Tendons.  !327 

the  muscular  belly  from  above  may  be  effectual  in  bringing  down 
the  upper  end,  but  more  often  it  is  necessary  to  extend  the 
original  wound  upwards  to  expose  the  retracted  end.  As  soon  as 
the  ends  are  found  they  should  be  temporarily  retained  by 
pressure  forceps  and  the  ends  trimmed  up  if  they  are  at  all 
ragged.  In  suturing  the  cut  ends  separate  sutures  should  be 
inserted  into  the  lateral  margins  of  the  two  cut  ends  of  the 
tendon ;  these  sutures  are  passed  through  the  whole  thickness  of 
the  tendon  and  are  tied  so  as  to  include  a  small  amount  of 
tissue ;  the  corresponding  ends  of  the  sutures  on  either  side  of  the 
division  are  then  tied  together  so  as  to  bring  the  divided  ends  into 
apposition.  In  a  small  tendon  two  such  sutures  at  either  end, 
inserted  into  the  margins  of  the  tendon,  are  usually  enough  ;  further 
sutures,  if  necessary,  may  be  inserted  in  the  central  portion,  if  the 
cut  edges  show  any  tendency  to  curl  up.  The  wound  is  then 
sutured  carefully,  a  fine  tube  or  catgut  drain  being  left  in  for  twenty- 
four  hours  at  one  angle,  well  away  from  the  site  of  the  suture,  to 
remove  any  serum  or  blood  effusion.  The  limb  is  immobilised  on 
a  splint  in  such  a  position  that  the  least  possible  strain  is  put  upon 
the  affected  tendon.  After  two  or  three  days  the  position  of  the 
limb  should  be  changed  slightly,  and  this  should  be  repeated  every 
day.  As  soon  as  the  wound  is  healed,  i.e.,  from  eight  to  ten  days, 
gentle  massage  and  passive  movements  should  be  started.  In  about 
a  fortnight  the  patient  may  be  encouraged  to  employ  active  move- 
ments. The  massage  and  passive  movements  should  be  persisted 
with  for  some  weeks  so  as  to  avoid  any  adhesions  as  far  as  possible. 
In  old  standing  cases,  in  which  the  division  of  the  tendon  has 
occurred  some  considerable  time  previously,  it  is  best  to  expose 
the  divided  tendon  by  a  curved  incision,  which  allows  a  flap  to 
be  turned  back  over  the  site  of  the  division ;  the  incision  must 
be  free,  as  in  most  cases  a  fairly  extensive  dissection  is  necessary 
to  expose  the  divided  ends  which  have  retracted  and  in  addition 
have  always  contracted  adhesions  to  the  sheaths  and  other  sur- 
rounding structures.  Having  identified  the  ends,  they  are  brought 
down  in  apposition  with  one  another  if  possible  and  sutured  by  the 
method  described  above.  If  the  ends  cannot  be  brought  into 
apposition,  some  method  of  tendon  lengthening  (see  Deformities) 
may  be  employed,  or  if  this  is  not  possible  the  interval  may  be 
bridged  by  a  network  of  chrornicised  catgut  sutures.  In  either  case 
the  after-treatment  is  similar  to  that  described  above  for  recent 
wounds,  with  the  exception  that  movements  should  be  somewhat 
delayed  so  as  to  avoid  too  great  a  strain  on  the  new  union,  which 
may  be  already  under  considerable  tension. 


1328  Injuries  of  Tendons. 

Subcutaneous  Rupture  of  Tendons. — This  is  a  somewhat  rare 
accident  ;  the  tendons  most  commonly  affected  are  the  tendo 
Achillis,  which  may  be  ruptured  in  dancing ;  the  patellar  ligament, 
which  may  be  ruptured  by  an  accident  similar  to  that  usually  pro- 
.ducing  fractures  of  the  patella ;  and  the  extensor  tendons  of  the 
fingers  whicn,  being  torn  through  at  their  attachment  to  the 
terminal  phalanx,  produce  the  condition  known  as  "  dropped 
finger." 

In  the  case  of  the  tendo  Achillis  usually  no  operative  interference 
is  necessary.  The  limb  is  kept  flexed  at  the  knee  with  the  ankle 
fully  extended  by  an  elastic  cord  running  from  a  collar  of  strapping 
fastened  round  the  middle  of  the  thigh  to  a  loop  or  hook  fastened 
to  the  sole  of  the  foot  by  a  band  of  strapping  passing  over  the  instep. 
By  these  means  the  ruptured  ends  of  the  tendon  are  maintained  in 
fair  apposition.  The  apparatus  should  be  worn  for  about  a  fort- 
night continuously,  after  which  time  it  may  be  removed  for  a  part  of 
the  day  and  gentle  movements  at  the  knee  and  ankle  should  be 
started.  In  about  three  weeks  the  apparatus  may  be  given  up,  but 
it  is  not  advisable  for  the  patient  to  put  any  weight  on  the  limb 
for  at  least  a  month  from  the  time  of  the  accident,  massage  and 
passive  and  active  movements  on  a  couch  being  alone  allowed. 
At  the  end  of  a  month  gentle  walking  exercise  may  be  allowed 
with  a  stick  and  this  may  be  gradually  increased  until  full 
ordinary  power  has  returned,  which  usually  takes  place  in  seven 
or  eight  weeks.  In  some  cases  it  will  be  easily  seen  that  it 
is  impossible  to  sufficiently  approximate  the  ends  of  the  tendon, 
either  owing  to  excessive  separation  or  owing  to  the  ends 
having  curled  up  within  the  sheath.  These  cases  are  best  treated 
by  open  operation  and  tendon  suture  as  described  above. 

In  rupture  of  the  ligamentum  patella  it  is  not  often  possible 
to  get  a  good  result  by  non-operative  measures,  since  the  torn 
ends  always  tend  to  curl  away  from  each  other  ;  tendon  suture 
by  open  operation  is  therefore  indicated.  A  curved  incision, 
convex  downwards,  should  be  made,  reaching  about  £  inch  below 
the  tuberosity  of  the  tibia;  a  flap  is  then  turned  up  and  the 
ends  of  the  tendon  having  been  identified,  are  brought  down 
into  apposition  by  fine  kangaroo  tendon  sutures  inserted  in  the 
manner  described  above.  It  is  important  to  remember  that  the 
accident  may  have  in  some  cases  involved  the  opening  of  the 
joint  by  tearing  the  lower  part  of  the  capsule.  The  after-treat- 
ment is  exactly  the  same  as  after  the  wiring  of  a  fractured 
patella,  except  that  a  leather  knee  splint  should  be  worn  for  at 
least  two  months,  so  as  to  prevent  any  strain  falling  on  the  new 


Injuries  of  Tendons.  I329 

union,  which  is  very  likely  to  stretch.  While  the  splint  is  being 
worn  massage  and  movements  to  the  limb  should  be  continued 
so  as  to  prevent  any  muscular  wasting  as  far  as  possible. 

In  cases  of  "dropped finger"  in  which  the  extensor  tendon  is 
torn  from  its  attachment  to  a  terminal  phalanx  an  attempt  may 
be  made  to  promote  union  of  the  tendon  by  immobilising  the 
finger  in  an  extended  position  on  a  straight  splint.  This  is 
successful  in  some  cases,  but  it  is  generally  more  satisfactory  to 
unite  the  ends  by  suture.  A  straight  incision  is  made  from  just 
above  the  base  of  the  nail  to  the  middle  of  the  second  phalanx ; 
the  proximal  end  of  the  tendon  is  then  sutured  to  the  distal 
end,  or  if,  as  sometimes  is  the  case,  the  tendon  has  actually 
been  torn  from  its  attachment,  to  the  periosteum  and  fibrous 
tissue  at  the  base  of  the  terminal  phalanx.  The  finger  is 
immobilised  for  a  few  days  on  a  straight  splint  in  an  extended 
position,  after  which  gentle  movements  are  commenced  (see 
Deformities). 

C.   H.   S.   FRANKAU. 


S.T. — VOL.  ii.  84 


1330 


AFFECTIONS  OF  THE  TENDON  SHEATHS. 

Acute  Simple  Tenosynovitis. — For  this  condition  in  the  early 
stages  absolute  rest  for  the  affected  part  with  the  local  application 
of  hot  fomentations  of  Goulard  and  opium  are  indicated  for  the 
relief  of  the  pain.  Later,  as  soon  as  the  pain  and  the  swelling 
have  diminished,  gentle  local  massage  and  movements  should  be 
ordered.  It  is  most  important  not  to  immobilise  the  part  for  too 
long  a  time,  since  troublesome  adhesions  may  result,  producing 
considerable  limitation  of  the  normal  tendon  movements.  The 
massage  should  be  continued  for  some  weeks,  the  patient  being 
allowed  at  the  same  time  gradually  to  return  to  the  normal  use  of 
the  limb.  Care  should  be  taken  that  the  part  is  not  overstrained 
at  too  early  a  stage,  since  by  this  means  another  acute  attack  may 
be  started,  or  the  condition  may  lapse  into  one  of  chronic  tenb- 
synovitis. 

Chronic  Simple  Tenosynovitis. — Though  occasionally  follow- 
ing an  acute  attack,  this  condition  more  frequently  is  the  result  of 
some  persistent  abnormal  strain  or  overuse  of  the  affected  tendons ; 
thus  the  extensor  tendon  sheaths  of  the  wrist  are  found  affected  in 
washerwomen,  typists,  and  occasionally  golfers ;  the  peronei  tendon 
sheaths  are  found  affected  in  chauffeurs  or  others  who  frequently 
use  a  foot-brake  or  clutch-pedal.  Consequently  the  first  essential 
of  treatment  to  adopt  is  to  avoid  the  particular  strain  which  has 
produced  the  mischief  or  to  alter  the  method  of  application  of  the 
strain  (e.g.,  the  "  grip  "  at  golf  may  be  altered,  or  the  position  of  a 
brake-pedal  may  be  altered  by  raising  the  seat,  etc.).  In  addition 
to  these  measures,  local  counter-irritation  with  rest  to  the  part  by 
means  of  Scott's  dressing  and  strapping  should  be  ordered,  to  be 
followed,  as  soon  as  the  original  symptoms  have  diminished,  by 
massage,  so  as  to  restore  the  part  to  its  normal  strength. 

Acute  Septic  Tenosynovitis. — An  acute  suppurative  infection 
of  the  tendon  sheaths  may  result  from  a  wound  or  from  the  spread 
of  infection  from  a  neighbouring  part,  e.g.,  a  theeal  whitlow.  In 
either  case  incisions  should  be  made  as  soon  as  possible  so  as  to 
provide  free  drainage,  every  endeavour  being  made  to  preserve  the 
tendons,  which  are  very  liable  to  slough  in  such  cases. 

Syphilitic  Tenosynovitis. — A  chronic  tenosynovitis  sometimes 
occurs  in  the  secondary  stages  of  syphilis ;  it  is  often  symmetrical 


Affections  of  the  Tendon  Sheaths.        1331 

and  usually  painless.  The  symptoms  speedily  disappear  under  the 
usual  constitutional  treatment,  which  may  be  assisted  by  the  local 
inunction  of  Scott's  ointment. 

In  the  tertiary  stages  a  gummatous  tenosynovitis  is  found, 
affecting  most  frequently  the  tendons  about  the  ankle  joint.  The 
condition  usually  reacts  readily  to  treatment  by  potassium  iodide, 
but  the  action  of  the  tendons  may  be  considerably  impaired  by  the 
formation  of  scar  tissue. 

Tuberculous  Tenosynovitis. — In  tuberculosis  of  the  tendon 
sheaths  a  single  sheath  may  be  affected  or  a  whole  group  of  sheaths 
may  be  involved,  as  in  compound  palmar  ganglion,  in  which  the 
whole  flexor  tendon  sheath  is  affected  above  and  below  the  annular 
ligament  at  the  wrist.  In  either  case  treatment  should  be  carried 
out  on  the  following  lines  : 

In  the  Early  Stages. — In  these  cases  palliative  treatment  may 
first  be  tried ;  the  part  should  be  absolutely  rested  with,  if 
possible,  open-air  or  sanatorium  treatment.  Tuberculin  carefully 
administered  is  also  of  value.  If  in  spite  of  this  the  condition  does 
not  improve  or  tend  to  progress,  operative  measures  should  be 
undertaken  at  once,  since  if  caseation  and  suppuration  occur  the 
prognosis  is  much  graver.  A  free  longitudinal  incision  is  made,  and 
the  diseased  sheath  or  sheaths  are  cut  away  freely.  In  the  case  of 
the  wrist  the  annular  ligament  should  be  preserved  if  possible ;  if  it 
is  found  necessary  to  divide  it,  it  may  be  possible  to  suture  the  cut 
edges  after  clearing  away  the  affected  tendon  sheaths  if  the  ligament 
itself  is  not  yet  infected.  The  wound  is  sewn  up  without  drain- 
age. The  general  treatment  should  be  continued  for  some  time 
subsequently. 

When  Caseation  lias  Occurred. — Here  the  chances  of  preserving 
a  useful  limb  are  not  good.  The  caseous  material  should  be 
evacuated,  and  as  much  of  the  tuberculous  granulation  tissue  as 
possible  should  be  curetted  away.  If  possible  drainage  should 
be  avoided,  and  great  precautions  should  be  taken  to  avoid  a 
superadded  infection.  The  general  and  constitutional  treatment 
advised  above  should  be  undertaken  as  soon  as  the  wounds  are 
healing  or  healed.  When  the  disease  is  very  extensive,  the  part 
being  riddled  with  sinuses  and  the  joints  being  affected,  the  question 
of  amputation  must  be  considered,  since  in  such  cases  at  best  a 
useless  limb  will  be  the  ultimate  result.  Amputation  is  essential  if 
from  loss  of  sleep  owing  to  pain  and  from  the  constant  discharge 
the  patient  is  going  rapidly  downhill. 

Tumours  in  connection  with  Tendon  Sheaths. — Three 
varieties  of  tumours  are  found  in  connection  with  tendon  sheaths, 


I332       Affections  of  the  Tendon  Sheaths. 

viz. :  (1)  Simple  fibroma ;  (2)  myeloid  sarcoma ;  (3)  lipoma. 
They  occur  most  commonly  on  the  palmar  aspect  of  the  fingers, 
and  in  this  situation  they  can  easily  be  removed  by  making  an 
incision  over  the  tumour  in  the  long  axis  of  the  finger  and  shelling 
it  out  from  the  loose  fibrous  tissue  connecting  it  to  the  tendon 
sheath.  It  is  uncommon  to  find  the  sheath  itself  involved  by  the 
tumour,  but  if  this  is  so  the  part  of  the  sheath  involved  may  be 
freely  excised  without  ill  results,  if  movements  of  the  affected 
tendon  are  commenced  as  soon  as  the  wound  is  commencing 
to  heal. 

Ganglion — A  simple  ganglion  is  formed  by  the  dilatation  of  the 
synovial  sheath  of  a  tendon  ;  this  dilatation  may  be  diffuse,  the 
whole  circumference  or  a  large  part  of  the  circumference  of  the 
tendon  sheath  being  involved,  or  the  dilatation  may  consist  of  a 
protrusion  of  the  synovial  membrane  through  the  fibres  of  the 
sheath ;  the  pouch  so  formed  is  connected  with  the  tendon  sheath 
proper  by  a  pedicle  of  varying  size. 

The  first  variety  occurs  mainly  in  adolescents,  and  palliative 
treatment  by  pressure  and  counter-irritation  by  means  of  Scott's 
dressing  and  strapping  is  usually  sufficient  to  produce  a  cure. 

In  the  second  variety,  and  in  the  first  variety  if  palliative  measures 
fail,  the  following  methods  of  treatment  may  be  tried  : 

(1)  Puncture. — The    surrounding    skin   having    been    carefully 
sterilised  a  small  area  over  the  centre  of  the  swelling  is  anaesthetised 
by  the  injection  of  a  few  drops  of   novocaine.     The  skin  is  then 
drawn  to  one  side  so  as  to  produce  a  valvular  opening,  and  a  sharp 
tenotome  is  inserted  into  the  centre  of  the  swelling.     The  contents 
of  the  ganglion  are  then  expressed  partly  out  of  the  opening  in  the 
skin  and  partly  into  the  surrounding  cellular  tissue.     The  injection 
of  a  counter-irritant  causes  much  pain  and  does  not  appear  to  do 
much  good.     After  expressing  the  contents  firm  pressure  is  applied 
by  means  of  bandaging  over  a  sterile  dressing.     This  treatment 
will  be  found  efficacious,  more  especially  in  the  thin -walled  variety 
of  ganglion  occurring  in  elderly  people. 

(2)  Excision. — This  on  the  whole  is  the  most  satisfactory  treat- 
ment for  the  majority  of  cases  in  which  palliative  measures  fail. 
A  curved  incision  over  the  most  prominent  part  of  the  tumour  will 
usually  be  found  to  be  the  best,  allowing  a  small  flap  to  be  turned 
back.     The  ganglion  is  freed  as  far  as  possible  by  dissection,  and  if 
a  pedicle  connects  it  to  the  tendon  sheath  this  is  tied  off  with  catgut 
and  divided.     If  the  ganglion  is  diffuse,  as  much  as  possible  of  its 
walls  is  cut  away ;  this  proceeding  often  freely  exposes  the  tendons, 
but  no  attempt  to  close  in  the  tendons  by  the  formation  of  an 


Affections  of  the  Tendon  Sheaths.        1333 

artificial  sheath  from  the  remains  of  the  walls  of  the  ganglion,  as 
sometimes  advised,  is  necessary.  The  wound  in  either  case  is 
sutured  without  drainage,  and  the  part  is  immobilised  for  a  few 
days  in  a  splint.  Movements  of  the  tendons  should  be  commenced 
at  an  early  period. 

C.  H.  S.   FRANKAU. 


1334 


DISEASES  AND  AFFECTIONS  OF  BURS^E. 

Acute  Bursitis. — Acute  bursitis  almost  invariably  ends  in 
suppuration,  but  an  endeavour  may  be  made  to  prevent  this  if  the 
case  is  seen  in  the  early  stages,  by  rest  to  the  part  with  the  local 
application  of  hot  fomentations.  If,  however,  suppuration  com- 
mences, or  has  commenced  before  the  case  is  seen,  immediate 
incision  and  drainage  are  necessary.  The  incisions  should  be 
made  at  the  most  dependent  part  of  the  bursa,  and  usually  a 
counter-opening  is  necessary  so  as  to  allow  the  cavity  to  be  irrigated 
with  saline  or  some  weak  antiseptic  solution.  In  the  case  of  the 
prepatellar  and  olecranon  burs*e  there  may  be  considerable  redness 
and  oedema  of  the  surrounding  parts ;  these  however  usually  subside 
rapidly  on  dealing  with  the  original  focus,  but  if  there  is  evidence 
of  extension  of  suppuration  around  the  bursa  further  incisions 
should  be  made. 

Chronic  Simple  Bursitis. — Chronic  inflammation  of  a  bursa 
results  from  long-continued  abnormal  pressure  on  the  part;  in 
consequence  of  this  the  bursa  is  at  first  distended  with  fluid  from 
which  lymph  is  deposited  in  the  inner  surface  of  its  walls ;  the 
walls  thus  become  thickened  and  adhesions  may  form,  producing 
loculation.  In  old-standing  cases  loose  "  melon-seed  "  bodies  may 
also  be  produced  by  the  detachment  of  fragments  of  lymph. 

It  follows  from  this  that  palliative  treatment  is  very  unlikely  to 
be  successful  and  should  only  be  adopted  if  operation  is  refused. 
The  radical  treatment  consists  in  excision  of  the  bursa. 

To  take  for  example  the  prepatellar  bursa,  which  is  the  most 
frequent  site  of  chronic  bursitis.  After  careful  sterilisation  of  the 
skin,  which  in  this  region  is  often  rough  and  ingrained  with  dirt,  a 
curved  incision  is  made  with  its  convexity  directed  upwards  and 
inwards  and  its  uppermost  limit  extending  just  above  the  upper 
border  of  a  bursa.  This  incision  is  preferable  to  a  vertical  or 
U-shaped  incision,  since  no  pressure  falls  on  the  scar  on  kneeling 
afterwards.  A  flap  is  then  turned  downwards  and  outwards  and 
the  bursa  is  dissected  out  entire.  It  is  of  no  importance  if  the 
bursa  is  opened,  in  fact  it  facilitates  removal  in  many  cases.  The 
wound  is  sutured  without  drainage,  and  after  the  application  of  a 
suitable  dressing  the  limb  is  immobilised  on  a  ham  splint.  The 


Diseases  and  Affections  of  Bursse.        1335 

splint  may  be  removed  in  two  days,  and  the  patient  can  usually 
walk  about  again  in  ten  days. 

Care  should  be  taken,  by  the  use  of.  a  kneeling  pad,  to  avoid  any 
excessive  pressure  on  the  part  afterwards,  since,  unless  this  pre- 
caution be  adopted,  an  obstinate  periostitis  of  the  unprotected 
patella  may  result. 

If  operative  measures  are  contra-indicated  or  refused,  treatment 
consists  in  prevention  of  any  further  irritation  by  avoiding  kneeling, 
or  providing  a  suitable  horseshoe-shaped  pad  which  allows  no 
pressure  to  fall  on  the  bursa.  At  the  same  time  it  may  be  possible 
to  bring  about  the  absorption  of  some  of  the  fluid  by  the  application 
of  local  counter-irritants,  such  as  iodine  or  Scott's  dressing.  The 
treatment  by  tapping  and  injection  with  iodine  or  pure  carbolic 
acid  is  as  painful  as  it  is  useless. 

Syphilitic  Bursitis. — A  gummatous  bursitis  is  occasionally  met 
with.  It  is  more  commonly  found  affecting  the  prepatellar  bursa, 
and,  if  so,  the  periosteum  of  the  patella  may  also  be  affected.  The 
cases  are  somewhat  chronic,  but  no  treatment,  apart  from  that  by 
potassium  iodide,  is  required. 

Tuberculous  Bursitis. — These  cases  should  be  treated  in  the 
early  stages  by  absolute  rest,  with  the  application  locally  of 
Scott's  dressing  and  the  usual  general  treatment.  If  these 
measures  do  not  succeed,  the  bursa  should  be  dissected  out  entire  if 
possible,  or,  if  this  cannot  be  done,  as  much  as  possible  of  it  should 
be  cut  away,  the  remainder  being  scraped,  so  as  to  remove  the 
tuberculous  pyogenic  membrane,  and  then  treated  with  pure 
carbolic  acid.  The  wound  is  sutured,  if  possible,  without  drainage. 

In  some  cases  a  large  chronic  abscess  alone  may  be  found,  the 
bursa  itself  having  been  destroyed ;  these  eases  should  be  treated 
by  evacuation  of  the  abscess  under  the  strictest  antiseptic 
precautions,  the  wound  being  sewn  up  without  drainage  after  gently 
curetting  the  abscess  cavity  and  irrigating  with  hot  dilute  antiseptic 
solution. 

Injuries  of  Bursae. — A  wound  involving  a  bursa  is  very  liable 
to  become  septic,  and  if  this  occurs  a  chronic  discharging  sinus  may 
persist  at  the  site  of  the  wound.  In  such  cases  the  best  treatment  is 
to  dissect  out  the  bursa  entire  if  possible,  or  if  this  cannot  be  done 
to  lay  it  open  freely  and,  after  scraping  away  the  lining  membrane 
as  far  as  possible,  to  allow  the  wound  to  heal  by  granulation. 

C.    H.   S.   FRANKAU. 


A  SYSTEM  OF  TREATMENT. 


INDEX. 


Abano  spa,  III.  147 

Abdomen,  bandaging  of,  in  sho'jk,  I.  97 
bullet  wounds  of,  II.  248 
contusions  of,  II.  243 
diseases  of,  II.  190,  423 
distension  of,   after  abdominal  opera- 
tions, II.  270 

evisceration  in,  IV.  4 1 7 

in  peritonitis,  II.  638 
drainage  of,  in  puerperal  sepsis,  IV.  300 
examination  of,  in  non-operative  appen- 
'  dicitis,  II.  424 

incision  of,  in  Caesarean  section,  IV.  387 
injuries  of,  II.  242-256 

complicating  thoracic  injuries,  II.  248 

convalescence  in,  II.  244 

general   considerations  and  rules  for 
treatment  of,  II.  253 

incidence  of,  II.  242 

mortality  from,  II.  243 

operation  in,  II.  254 

reaction  in,  II.  244 

table  of  cases  of,  II.  242 
operations  on.    See  Abdominal  opera- 
tions. 

pains  in,  in  food  fever,  II.  240 
pendulous,  complicating  pregnancy,  IV. 

61 

stab  wounds  of,  II.  253 
supports  for,  in  gastroptosis,  II.  319 
surgery  of,  treatment  of  vomiting  in, 

1.29 

suture  of  wall  of,  in  ovariotomy,  IV.  787 
tapping  of,  in  ascites,  It.  629 
wounds  of,   penetrating  or  not,  treat- 
ment of,  I.  565,  II.  247 
Abdominal   belt  for  umbilical  hernia,  II. 

:,-ll 

exercises  in  gymnastics,  III.  226 
muscles,  rupture  of,  II.  252 
operations,    after-treatment,     II.    262- 
276 

anaesthetic,  vomiting  after,  II.  263 

anaesthetics  in,  III.  31 

antiseptic  precautions  in,  I.  91 

belt  worn  after,  II.  268 

care  of  bladder  after,  II.  264 
bowels  after,  II.  264 
the  mouth  after,  II.  264 

S.T. 


Abdominal  operations  (contd^) — 
clothing  in,  II.  26"0 
complications  of,  II.  269 

involving  wound  after,  II.  272,  273 
distension  complicating,  II.  270 
dressings  after,  II.  266 
duration  of  confinement  to  bed  after, 

II.  267 

emergency  cases,  II.  260 
feeding  after,  II.  265 
final  directions  to  patients  after,  II.  268 
fixation  of  time  for,  II.  257 
flatulence  after,  II.  264 
insomnia  after,  II.  265 
intra-peritoneal  haemorrhage  compli- 
cating, II.  275 
massage  after,  II.  268 
nervousness  and,  II.  260 
pain  after,  II.  263 
persistent  vomiting  complicating,  II. 

269 

position  of  patient  in  bed  after,  II.  266 
post-operative  haematemesis  after,  II. 

275 
preparation  of  alimentary  canal  in, 

II.  258 

preparation  of  patients  for,  II.  257-261 
retention  of  urine  complicating,   II. 

272 

shock  complicating.  II.  269 
skin  preparation  for,  II.  259 
thirst  after,  II.  263 
thrombosis  complicating,  II.  274 
uncomplicated  cases  in,  II.  262 
visitors  to  patients  after,  II.  266 
organs,  application  of  vibration  to,  III. 

220 

pain  complicating  typhoid  fever,  I.  359 
supports  in  constipation  in  adults,   II. 

462 
wall,  incised  wounds  of,  II.  249 

sloughing  of,  complicating  abdominal 

operations,  II.  273 
wounds  of,  II.  245 

non-penetrating,  II.  246 
Abduction  splint  and  pad  for  the  shoulder, 

I.  776 

Abel  (W.),  gastro-enterostomy,  first  per- 
formed by,  II.  343 


A    SYSTEM  OF  TREATMENT. 


Abnormalities.     See  Malformations. 
Abortion,  IV.  14-22 

after-treatment  of,  IV.  22 
complicating  pregnancy,  IV.  14 
incomplete,  IV.  21 

induction  of,  by  dilatation  of  the  cervix, 
IV.  437 

by  rupturing  the  membranes,  IV.  436 

by  vaginal  Cassarean  section,  IV.  437 

in  diseases  of  pregnancy,  IV.  433 

maternal  indications  for,  IV.  433 

methods  of,  IV.  436-437 
'inevitable,  IV.  18 

later  than  first  twelve  weeks,  IV.  20 
missed,  IV.  22 

retained  placenta  in,  IV.  225 
prevention  of,  iy.  14 
threatened,  IV.  17 
Abscess,    acute,     surgical   treatment    of, 

I.  166-172 
alveolar,  III.  1174 
ano-rectal,  II.  600-606 
cavities,  irrigation  and  scraping  of,  I. 

175 
cerebral,    following    head    injuries,    I. 

885 

complicating  typhoid  fever,  I.  363 
drainage  of,  in  pelvic  cellulitis,  IV.  848 
in  appendicitis,  operation  in,  II.  419 
in  connection  with  tuberculous  disease 

of  the  spine,  1.  928-932 
in  nodule  of  the  auricle,  III.  882 
in  tuberculous  disease  of  hip-joint,  I.  757 
infective,  of  scalp,  I.  888 
infra-mammary,  II.  960 
intra-cranial,  coma  and,  II.  983 
ischio-rectal,    complicating    pulmonary 

tuberculosis,  I.  1156 
labial,  complicating  gonorrhoea,  I.  229 
mammary,  II.  958 

chronic,  II.  962 
of  areola  of  nipple,  II.  977 
of  lung,  due  to  foreign  bodies  in  the 

bronchus,  I.  1061 
cf  the  ovary,  IV.  765 
of  the  prostate,  II.  922 
peri-urethral,  II.  895-896 

complicating  gonorrhoea,  I.  226 

in  the  female,  IV.  870 
psoas,  I.  916 
pulmonary,  I.  1059 
retro-pharyngeal,  III.  789-790 

in  diseases  of  the  spine,  I.  916 
sublingual,  II.  133 
subphrenic,  II.  643-644 
supra-mammary,  II.  960 
tuberculous,  methods  of  treatment  of  I 

173-17ti 

vaccine  therapy  in,  III.  264 
Accommodation  of  the  eye,  errors  of,  III 

528-542 

spasm  in.  III.  542 
Accouchement  ford  in  podalic  version,  IV. 

466 
A.C.E.  mixture  as  anaesthetic,  III.  20 


Acetabulum,  fracture  of,  I.  607 
Acetanilide,  poisoning  by,  I.  533 
Acetone,  application  of,  to  cervix  uteri  in 

inoperable  cancer,  I.  137 
in  cancer  of  cervix,  IV.  616 
preparation  of  skin  by,  1.  73 
rubbed  into  the  skin  before  operation, 

I.  84,  88 

Acetonuria,  TI.  730 
Achondroplasia,  II.  1227 
Achylia,  atrophy  of  the  stomach,  II.  225- 

295 

gastrica,  II.  368 
Acid  baths,  III.  137 

carbolic,  antiseptic  in  typhoid  fever,  I. 

351,  354 

gangrene  due  to,  I.  219 
in  plague,  III.  406 
in  ulcer  of  the  cornea,  III.  565 
in  whooping  cough,  I.  382 
poisoning  by,  I.  527 
diacetic,  in  the  urine  in  diabetes  mellitus, 

I.  409,  417 

formation  of,  in  diabetes,  I.  423 
hydrochloric,  effect  in  gastric  function, 
II.  291 

in  gastric  neurasthenia,  II.  356 

in  typhoid  fever,  I.  355 
hydrocyanic,  poisoning  by,  1. 530 
oxalic,  poisoning  by,  I.  528 
oxybutyric  in  the  urine,  I.  417 
prussic,  poisoning  by,  I.  530 
sulphurous,  in  typhoid  fever,  I.  355 
uric,  solvents  of,  I.  436 
Acidity  in  cancer  of  the  stomach,  II.  300 
in  disordered  digestion  in  the  stomach, 

II.  370 

Acidosis,  prevention  of,  I.  410,  417 
Acids,  mineral,  poisoning  by,  I.  526 
Ackers  on  epidemic  gangrenous  proctitis, 

III.  437 

Acne  cheloid,  III.  1018 
rosacea,  III.  1135,  1136 

X-rays  in,  III.  350 
scrofulosarum,  III.  1151 
vulgaris,  III.  982-990 

after-treatment  of,  III.  987 
general  remarks  on,  III.  982 
lotions  for,  III.  984 
ointments  for,  III.  986 
operative  treatment  of,  III.  983 
parasiticide  applications  in,  III.  984 
powders  for,  III.  985 
Rontgen  rays  in,  III.  349,  987 
scarring  of  skin  in,  III.  986 
soaps  for,  III.  985 
treatment  of,  internal,  III.  987 

local,  III.  983 

vaccine  treatment  of,  III.  989 
Aconite  and  aconitine,  poisoning  by,  I.  532 
Aconitine  and  aconite,  poisoning  by,  1. 532 

in  diseases  of  the  heart,  I.  1226 
Acqui  spa,  III.  147 
Acromegaly,  II.  1226-1227 
Acromion  process,  fracture  of.  I.  586 


A    SYSTEM  OF  TREATMENT. 


Actinomycosis,  drugs  in,  I.  178 

general  treatment  of,  I.  177 

local  treatment  of,  I.  177 

of  Fallopian  tube,  IV.  800 

of  the  gall  bladder,  II.  711 

of  the  jaws,  II.  109 

of  the  lung,  surgical  treatment  of,  I. 
1175 

of  the  pharynx,  III.  765 

of  the  skull,  I.  891 

of  the  spine,  I.  919 

surgical  treatment  of,  I.  177 
Adams-Stokes'  syndrome.  I.  1237 
Adamson  (H.  G.),  the  X-rays  treatment  of 

>kin  diseases.  III.  341-359 
Addison's  disease,  II.  46-48 

complicating  pregnancy,  IV.  50 

curative  measures  in,  II.  46 

palliative  measures  in,  II.  47 

symptoms  of.  II.  48 

(pernicious)  an;emia,  II.  1-12 
Adductors,  rupturing  of  by  pressure  with 

the  thumb,  I.  945 
Adenitis  complicating  scarlet  fever,  I.  290 

tubercular,  III.  757 
Adenoids,  ana-mia  and,  II.  14 

causes  of,  I.  49 

of  the  pharyngeal  tonsil,  III.  732 

post-nasal,  and  Eustachian  obstruction, 

III.  947 
Adenoma,  fibrous,  of  the  breast,  II.  955 

of  the  prostate,  II.  940-949 
complication  of,  II.  944-946 

of  the  sweat  glands,  III.  1044 
Adenomata  in  goitre,  II.  <!3 

x'haceum,  I.  109,  III.  991 
Adenomatous   disease   of    uterus,   leucor- 

rha-a  in,  IV.  570 
Adenomyoma  of  uterus.  IV.  662 
Adhesions  in  acute  synovitis,  I.  742 

in  ovariotomy,  IV.  780 

pericardial,  I.  1189 
Adrenal  glands,  diseases  of,  II.  46-48 
Adrenalin  in  asthma,  I.  1040 

in  haemorrhage,  I.  l'2C>\ 

in  pneumonia,  I.  2U1 

in  vomiting  due  to  heart  failure,  I.  200 
Adrenalin  chloride  in  plague,  III.  4(19 
Adrenine  infusion  in  shock,  I.  98,  102 
Agar-agar  in  constipation  in  adults,  II.  451 
Agoraphobia  in  psychasthenia,  II.  1044 
Agraphia.    restoration    in    by   functional 

compensation,  II.  1050 
Ainhum,  III.  4 ('.."• 
Air  bath,  compressed,  in  emphysema,  I. 

1086 

superheated,  in  gout  and  gouty  con- 
ditions, I.  439 

cushion  in  contusions  of  coccyx,  I.  900 

complicating  labour,  IV.  161-162 

embolism,  I.  1306 

fresh,  in  pleurisy,  I.  1093 

in  pulmonary  tuberculosis,  I.  1118 

hot,  therapeutical  indications  of,  III.  324 
treatment  by,  III.  316-326 


Air  (contd.) — 

in  chlorosis,  II.  20 

vitiated,  poisoning  by,  I.  534 
Air-passages,  foreign  bodies  in,  III.   803- 
821 

upper,  catarrh  of,  climate  for,  III.  101 
Aitken  (D.  McCrae),  surgical  treatment  of 
cerebral  palsies  of  infancy,  II.  1157- 
1164 

Aix-les-Baius  spa,  III.  147 
Aix-la-Chapelle  spa,  III.  147 
Albertine  on  aortic  aneurysm,  1.  1297 
Albumen  water  in  marasmus,  1 .  465 

preparation  of,  I.  42 

in  mercurial  poisoning,  I.  530 

in  typhoid  fever,  I.  342 
Albtiminuria.  II.  733 

complicating  diphtheria,  I.  201 
pregnancy,  IV.  30-33 
pulmonary  tuberculosis,  IL  1157 

in  acute  nephritis,  II.  797 

in  pregnancy,  IV.  7 

in  scarlet  fever,  I.  292 

mineral  waters  and  baths  in,  III.  140 
Albumosuria,  II.  733 
Alcock's  apparatus  for  anaesthetics,  III. 

14 
Alcohol  as  sterilising  agent,  I.  72-73 

coma  from,  II.  984 

in  chronic  congestion  of  the  lungs,  I. 
1079 

in  diabetes  mellitus,  I.  423 

in  dietary  of  children,  I.  62 

in  fevers,  directions  for,  I.  158 

in  gout,  I.  456 

in  heart  failure,  I.  193-200 

in  infantile  weakness,  I.  66 

in  influenza,  I.  234 

in  insomnia,  II.  985 

in  marasmus,  I.  466 

in  pneumonia,  I.  260 

in  pruritus,  III.  1098 

injection  of  into  nerve  trunks,  I.  135 
in  trigeminal  neuralgia,  II.  1117 

intoxication  by,  in  epilepsy,  II.  993 

natural  resistance  to  disease  lowered  by, 
I.  5,  9 

neuritis  from,  II.  1134 

poisoning  by,  acute,  I.  495 

tolerance  of,  I.  499,  539 

use  of,  and  anaesthetics,  III.  22 
Alcoholic  gastritis,  I.  495-498,  II.  353 
Alcoholism,  I.  495-502 

acute,  I.  495 

chronic,  I.  496 
complicating  cancer  of  the  breast,  II. 

96(5 
inebriety  of,  I.  499 

delirium  tremens  in,  I.  499 

dipsomania,  I.  497 

drugs  in,  I.  495-497,  500 

gastric  complications  in,  I.  495-498,  II. 
353 

hypnotic  treatment  in.  I.  498 

nervous  disturbance  in,  I.  496  ;  II.  1134 

1—2 


A   SYSTEM  OF  TREATMENT. 


Alder  leaves  in  cancer,  I.  149 
Alexander's  operation   in   retroflexion  of 

the  uterus,  IV.  681 
Alimentary  canal,  catarrh  of,  in  children. 

1.46 

injuries  of,  250 

preparation  of  in  operations,  II.  258 
system,  cancer  of,  relief  of  obstruction 

in,  I.  139 

tract,  care  of,  in  gout,  I.  450 
diseases  of,  II.  190 

perversion   of   functions  of   in   epi- 
lepsy, II.  1018 
Alkali,  exhibition  of   in  diabetes,  I.  410, 

418 

Alkalies,  caustic,  poisoning  by,  I.  527 
in  diabetes  mellitus,  I.  423 
in  psoriasis,  III.  1114 
value  of,  in   gastric  derangements  in 

children,  I.  65 
Alkaline  waters,  III.  119 

in  chronic  gastritis,  II.  351 
Alkaloids  in  constipation   in  adults,  II. 

446 

Alkaptonuria.  II.  734 
Aloes  in  constipation  in  adults,  447 
Alopecia.  III.  992-1004 

dependent  on  morbid  conditions  of  hair 

follicles,  III.  1000 
on  the  scalp,  III.  1000 
symptomatic  of  general  diseases,  III.  999 
Alopecia  areata,  III.  992-997 
general  remarks,  III.  992 
general  treatment  of,  III.  993 
local  treatment  of,  III.  994 
physical  remedies  in.  III.  996 
Alopecia  cicatrisata,  III.  997 
congenitalis,  III.  997 
hereditaria  praematura,  III.  998 
neurotica,  III.  998 
pityrodes,  III.  1003 
seborrhoic  dermatitis,  III.  1004 
oily  type  of,  III.  1003 
or  calvities,  III.  1001 
senilis,  III.  998 

Alum,  powdered,  in  haemorrhage,  I.  1261 
Aluminium  plate  in  fractures  of  jaws,  II. 

114 

Alveolar  abscess,  III.  1174 
chronic,  III.  1175 
echinococcus  disease,  III.  523 
Amaurotic  family  idiocy,  II.  1244 
Amblyopia,  III.  543-546 
congenital,  III.  543 
toxic,  111.  543 
Amblyoscope.  Worth's,  in  strabismus,  III. 

652 

Amelies-les-Bains  spa.  III.  147 
Amenorrhcea,  IV.  725-735 
constipation  in,  IV.  726 
drugs  in,  IV.  727-728 
primary,  permanent,  IV.  730 

temporary,  IV.  725 
secondary,  IV.  731 
lactation  in,  IV.  731 


Ammonia,  acetate  of,  in  whooping  cough, 
I.  380 

poisoning  by,  I.  527 

Ammonium,     benzoate     of,    in     arterio- 
sclerosis, I.  1294 

hippurate  of,  in  arterio-sclerosis,  I.  1294 

tartrate  in  opacity  of  the  cornea,  III. 

572 

Amoebic  hepatitis.  II.  676 
Ampulla  of  Vater,  cancer  of,  II.  714 
Amputations,  I.  789-872 

at  the  elbow-joint,  I.  820-824 

at  the  knee-joint,  I.  859-861 

at  the  wrist-joint,  I.  813-816 

by  a  racket  incision,  I.  796 

by  flaps  of  skin  and  muscle,  I.  796 

by  the  circular  method,  I.  794,  795 

conditions  essential  for  good  flaps  in,  I. 
792 

control  of  haemorrhage  in,  I.  798 

dangers    and    complications    after,    I. 
803 

Faraboeuf's,  I.  855,  858 

for  gunshot  fracture,  I.  562 

for  inflammatory  condition,  including 
gangrene,  I.  790 

for  new  growths,  I.  791 

general  considerations,  I.  789 

Guyon's,  I.  850 

in  acute  suppnrative  synoviti?,  I.  744 

in  aneurysm,  I.  1303 

in '  disease  of  the  ankle  and  tarsus,  I. 
774 

in  gangrene,  I.  214-217 

instruments  for,  I.  799 

interscapulo  thoracic,  T.  830 

in  traumatic  cases,  I.  789 

in  uncontrollable  haemorrhage.  I.  559 

irregular  forms  of,  I.  797 

Lord  Lister's,  I.  852 

modified  circular,  I.  795 

neuromata,  I.  112 

of  fingers,  sites  for,  I.  804 

of  the  fingers,  I.  804-813 

of  the  foot,  I.  836-850 

of  the  knee-joint  in  tuberculous  disease, 
1.771 

of  the  toes,  I.  834-836 

osteo-periosteal  method  of,  I.  801 

periosteum  in,  I.  800 

Pirogoffs,  I.  848 

Stokes's,  I.  863 

stump,  pain  in,  I.  792 

Teale's,  I.  851 

technique  in,  I.  797 

through  the  arm,  824-827 
forearm,  I.  816-820 

through  the  leg,  I.  850-859 
the  thigh,  I.  862-866 

vitality  of  flaps  in,  I.  791 
Amyl  nitrite  in  asthma,  I.  1039    • 

in  hsemothorax,  I.  564 
Amylic   alcohol   in  inoperable  cancer, 

137 
Amyotonea  congenita,  II.  1245 


A    SYSTEM  OF  TREATMENT. 


Anaemia,  acute  rheumatism  in,  I.  15 
Addison's  (pernicious),  II.  1-12 
and  abdominal  operations,  II.  258 
and  haemorrhoids,  II.  616 

aplastic,  II.  37 
associated  with  ulceration,  I.  372 

Bright's  disease  and,  II.  17 
cancer  in,  II.  16 
caused  by  pulmonary  tuberculosis,   II. 

13 

climate  for,  III.  92 
complicating    tuberculosus    peritonitis, 

II.  646 

convalescence  from,  II.  15 
due  to  actual  loss  of  blood,  II.  18-19 
dnc  to  some  definite  malady,  II.  13-17 
heart  disease  in,  II.  15 
in  ailing  children,  II.  14 
in  pulmonary  tuberculosis,  I.  1111.* 
in  rheumatism  in  childhood,  I.  279 
intestinal  parasites  and,  II.  15 
mineral  waters  and  baths  in,  III.  143 
of  the  labyrinth,  III.  967 
of  the  larynx,  III.  822 
oxygen  inhalations  in,  II.  9 
pernicious,  anti-streptococcus  serum  in, 
II.  8 

arsenical  waters  in,  II.  5 

bone-marrow  in,  II.  9 

complications  of,  II.  10 

convalescence  in,  II.  11 

diet  in,  II.  2 

drugs  in,  II.  3 

gastro-intestinal  antiseptics  in,  II.  6 

Grawitz  method  in,  II.  9 

infusion  in,  II.  9 

intestinal  antiseptics  in,  II.  8 

iron  in,  II.  5 

oral  antiseptics  in,  II.  6 

rest  in,  II.  1 

vaccine  treatment  of,  II.  7 

with  atrophy  of  the  stomach,  II.  293 
plumbism  and,  II.  16 
septic  states  in,  II.  16 
severe,   in     post-partum     hemorrhage, 

IV.  222 

syphilis  and,  II.  17 
tropical,  II.  15 
Anaemic  obesity,  I.  468,  472 
Anaesthesia,  difficulties  anddangers  arising 

during.  III.  33 
general,   in    foreign   bodies   in   the  air 

passages,  III.  813 

infiltration,  in  treatment  of  cysts,  I.  108 
in  relation  to  shock,  I.  95 
in  sprains,  I.  740 
intravenous,  III.  35 
local,    in    foreign    bodies    in    the    air 

passages,  III.  813 

method    of,   in    malignant    disease   of 
upper  jaw,  II.  117 

in  operations  on  jaws,  II.  117 
of  the  pharynx,  III.  782 
spinal,  for  relief  of  pain,  I.  136 
treatment  of  after-effects,  III.  35 


Anaesthetic,     bichlorinated     chlorate    of 

methyl  as,  III.  13 
chloroform  as,  III.  13 
.choice  of  principles  of,  III.  21 
in  craniotomy,  IV.  405 
in  decapitation,  IV.  413 
in  operation  for  cleft  palate,  II.  149 
in  radical  operation  for  cancer  of  breast. 

II.  968 

in  version,  IV.  462 

mixtures  with  chloroform,  III.  19 

nitrous  oxide  as,  III.  2 

trichlormethane  as,  III.  13 

vomiting  after  abdominal   operations, 

II.  263 

complicating  gynaecological  surgery, 

IV.  489 
Anaesthetics,  III.  1-39 

administration  of,    antiseptic    precau- 
tions during,  I.  83 

in  certain  special  operations,  III.  26 
choice  of,  in  empyema  generalised  in 

lower  part  of  thorax,  I.  1 101 
diabetes  and,  III.  24 
for  the  reduction  of  dislocations,  III.  33 
general,  III.  1 

in  common     use     and    methods    by 

which  administered,  III.  2 
in  abdominal  operations,  III.  31 
in  evisceration,  IV.  416 
in  excision  of  the  eye,  III.  30 
in  exophthalmic  goitre,  II.  59 
in  hypertrophy  of  the  pharyngeal  tonsil, 

III.  734 

in  labour,  IV.  376-381 

conclusions  on,  IV.  380 
in  operations  for  cancer  of  the  breast, 

III.  31 

for  empyema,  III.  30 

for  intestinal  obstruction,  III.  32 

for  mature  cataract,  III.  622 

upon     the    genito-urinary    passages, 

III.  32 

upon  the  rectum,  III.  32 
in  perforation  of  the  intestine,  II.  551 
local,  teeth  extraction  under,  III.  1190 
in  pregnancy,  III.  24  ;  IV.  58,  375-376, 

489 

teeth  extraction  under,  III.  1190 
Anaesthetist,  methods  of,  at  operations,  I. 

83 
Analgesia,  local,  III.  38 

spinal,  III.  36 
Anderson  (Edith  McC.),  management  of 

the  sick  room,  I.  26-43 
Andrews  (H.  Russell),  abscess  of  the  ovary, 

IV.  765 

affections  of  the  breasts  during  preg- 
nancy and  the  puerperium,  IV.  330- 
336 

chronic  ovarian  pain,  IV.  766 

hernia  of  the  ovary,  IV.  767 

intra-ligamentary  tumours,  IV.  768- 
770 

malignant  ovarian  tumours,  IV.  770 


A    SYSTEM  OF   TREATMENT. 


Andrews  (H.  Russell)  (contd.*) — 

ovarian     tumours     discovered     during 
labour,  IV.  773-7  74 

discovered    during    pregnancy,    IV. 
771-772 

discovered  during  puerperiutn,  IV.  774 
ovariotomy,  IV.  775-795 
prolapse  of  the  ovary,  IV.  796 
suppurating  ovarian  cysts,  IV.  797-798 
Anencephalus  of  newborn  child,  IV.  357 
Aneurysm,  amputation  in,  I.  1303 

aortic,  chloroform  inhalations  in,  1. 1299 

haemorrhage  in,  I.  1300 

iodide  of  potassium  in,  I.  1298 

measures  which  aim  at  producing  a 
cure  in,  I.  1297 

measures  which  aim  at  the  relief  of 
symptoms,  I.  1299 

medical  treatment  of,  I.  1297 

pain  in,  I.  1299 

rest  in,  I.  1299 

subcutaneous  injection  of  gelatine  in, 
I.  1298 

tracheotomy  in,  I.  1299 

Tufnell's  treatment  of,  I.  1297 

venesection  in,  I.  1299 
arteriorrhaphy  in,  I.  1303 
arterio-venous,  I.  1305 

of  the  orbit,  III.  662 

of  the  scalp,  I.  893 
cirsoid,  of  the  scalp,  I.  893 
compression  in,  I.  1302 
diffuse,  I.  1304 
excision  in,  1.  1301 
femoral,  I.  1304 
general  treatment  of,  I.  1301 
glnteal,  I.  1304 
intra-cranial,  I.  1304 
intra-orbital,  I.  1304 
introduction  of  foreign  bodies  to  procure 

coagulation  in,  I.  1302 
ligature  for,  I.  1302 
of  hepatic  artery,  II.  667 
of  renal  artery,  II.  752 
popliteal,  I.  1304 
sciatic,  I.  1304 
simple  of  the  scalp,  I.  893 
subclavian,  I.  1304 
summary  of,  I.  1303 
surgical  treatment  of,  I.  1301-1305 
traumatic  in  gunshot  wounds,  I.  560 
Angina,  acute  membranous,  III.  771 
pectoris,  I.  124fi 

attacks  of,  I.  1251 

in  gout  and  gouty  conditions,  I.  443 

neurosis  of,  I.  1252 

palpitation  and,  I.  1252 
streptococcus,  III.  771 
Vincent's,  III.  771 
Angiokeratoma.  III.  1151 
Angioma  of  the  auricle,  III.  879 
of  lingual  tonsil,  III.  762 
of  the  umbilicus  in  newborn  child,  IV. 

37o 
Angiomata  of  the  scalp,  I.  893 


Angioneurotic  oedema.  II.  1228-1229 
Angiotripsy  in  haemorrhage,  I.  1257 
Aniline  eczema,  I.  117 

poisoning  by,  I.  533 
Animal  food,  II.  192 

in  gout,  I.  451. 

foodstuffs  (Bunge),  II.  74:> 
Anisometropia,  III.  528-529 

eyes  used  alternately  in,  III.  528 

one  eye  permanently   excluded    from 
vision  in,  III.  529 

simultaneous  binocular  vision   in,  III. 

529 
Ankle,  dislocations  of,  I.  731 

tuberculous  disease  of,  1.  772-77.1 
Ankle-joint,  suction  glass  for,  in  hyper- 
aernic  treatment.  III.  59 

Syme's  disarticulation  at,  I.  845 
Ankylosis  in  gunshot  injuries  of  joints,  I. 
562 

in  tuberculous  disease  of  the  hip-joint, 
I.  761-763 

of  hip-joint,  osteotomy  in,  I.  764 

of  the  jaw,  II.  105,  106 
Ankylostomiasis.  III.  487 

beta-naphtbol  in,  III.  492 

eucalyptus  in,  III.  491 

prophylaxis  of,  III.  487 

routes  of  entry  in,  III.  489 

thymol  treatment  of,  III.  490 
Ankylostomum  duodeuale,  expulsion  of,  I. 

522 

Annulus  migraus,  II.  126-129 
Anodyne  fomentations  in  acute  rheuma- 
tism, I.  269 

Anodynes  for  relief  of  pain,  I.  134 
Ano-rectal  area,  diseases  of,  II.  593-612 
Anorexia  and  cancer  of  the  stomach,  II. 
298 

nervosa  neurasthenia,  II.  1C42 
Anthelmintic   treatment  of  taeniasis   in- 
testinal, III.  518 
Anthracene  purgatives  in  constipation  in 

adults.  II.  447 

Anthrarobin  in  psoriasis.  III.  1119 
Anthrax  complicating  pregnancy,  IV.  49 

cutaneous,  I.  179 

malignant  pustule,  I.  179 

intestinal,  I.  179 

methods  of  examination  in,  I.  180 

respiratory,  I.  179 

sclavo  serum  in,  I.  179 

treatment  of,  I.  179 
Antibodies  in  serum  therapy,  III.  259 
Anti-coli  serum  in  bacillus  coli  injections, 

III.  271 

Antidotes  and  poisons,  I.  526-535 
Antifebrin  in  diseases  of  the  heart,  I.  1225 
Antimony,  acute  poisoning  by,  I.  529 
Antimonyl    tartrate   in    trypanosomiasis, 

111.421 

Anti-pneumococcus  serum,  III.  285 
Antipyretic  treatment   of   typhoid  fever, 

I.  348.  351 
Antipyretics,  use  of  in  pyrexia,  I.  159 


A    SYSTEM  OF  TREATMENT. 


Antipyrin.  dosage  of,  in  children's  diseases, 

I.  67 

in  influenza,  I.  234 
poisoning  by,  I.  533 
Antirabic   serum   injection   in   rabies,    I. 

265 

Antiscorbutics  in  scurvy,  I.  476 
Antisepsis  in  surgical  technique,  1. 84-92 
Antiseptic    solutions    in     gynaecological 

operations,  IV.  484 
treatment  of  typhoid  fever,  I.  352 
Antiseptics,  composition  and  strength  of, 

I.  76,  81 

definition  of,  I.  161 
in  chronic  dilatation  of  the  stomach,  II. 

312 

in  pernicious  anaemia.  II.  6 
intestinal,  I.  387 
in  chlorosis,  II.  28 
in  pernicious  anaemia,  II.  8 
Anti-streptococcus  serum,  III.  290 
in  cellulitis,  I.  183 
in  infective  endocarditis,  I.  205 
in  pelvic  cellulitis,  IV.  849 
in  pernicious  anasmia,  II.  8 
in  scarlet  fever,  I.  288 
in  septic  arthritis,  I.  291 
Antitoxic  serum  in  tetanus,  I.  329 

therapy, III.  259 
Antitoxin,  intravenous  injection  of,  dosage 

of,  I.  191 

method  of  administration,  I.  191 
prophylactic  use  of,  I.  192 
treatment  of  diphtheria,  I.  189-192 

sequelas  of,  I.  193 
Antitoxins  in  chronic  rhinitis,  III.  709 

in  serum  therapy,  III.  259 
Antrum,  suppuration  of,  in  acute  inflam- 
mation of  middle  ear,  III.  897 
Anuria,  calculous,  II.  755 

complicating  diphtheria,  1.  201 
Anus,  abrasion  of,  in  constipation  in  chil- 
dren, II.  436 
abscess  of,  II.  600 
artificial,  in  fistulas  of  the  intestines,  II. 

488 

diseases  of,  II.  593-625 
fissure  of,  II.  597 

in  constipation  in  children,  II.  436 
operative  treatment  for,  II.  598 
fistula  of,  II.  606-610 
complications  of,  II.  608 
due  to  tuberculosis,  II.  609 
imperforate,  in  newborn  child,  IV.  362 
infective  ulcerative  proctitis,  II.  610 
ischio-rectal  abscess  of,  II.  601 

after-treatment,  II.  603 
malformations  of,  II.  613 
pelvi-rectal  abscess  of,  II.  604 
pruritus  of,  II.  593  ;  III.  1102-1105 
retro-rectal  abscess  of,  II.  604 
subcutaneous  abscess  of,  II.  600 
sub-mucous  abscess  of,  II.  604 
Aorta,      abdominal,      ligature      of,      for 
anenrysm,  I.  1304 


Aorta  (fontd.) — 
aneurysm  of,  medical  treatment  of,  I. 

1297 
.thoracic,   surgery  of   in   aneurysm,    I. 

1303 
Aperient  waters,  in  constipation  in  adults, 

II.  466 
Aperients  in  constipation  in  children,  II. 

437 

in  prevention  of  lead  poisoning,  I.  514 
Aperiosteal  method  of  amputation,  I.  801 
Aphakia,  III.  530 

Aphasia  and  other  speech  defects  of  cere- 
bral origin,  II.  1143-1149 
hysterical,  II.  1147 
of  cerebral  origin,  II.  1143-1149 
speech    restoration    in,    by  functional 

compensation,  II.  1147 
syphilitic,  II.  1144 
temporary,  II.  1145 
Aphonia,  application  of  vibration  in,  III. 

219 

hysterical,  III.  842 
Aplastic  anasmia,  II.  37 
Apomorphine  in  dipsomania,  I.  497 
Aponeuroses,    chronic  rheumatism   of,  I. 

484 

of  external  oblique,  division  of  in  in- 
guinal hernia,  II.  501 
Apoplexy,  cerebral,  II.  1070 
Apparatus,  surgical,  sterilisation  of,  I.  80- 

83 
Appendicectomy,     after-care  of  patients 

from,  II.  268 
incision  through  sheath  of  rectus  muscle, 

II.  413 

muscle-splitting  incision,  II.  412 
Appendicitis,  II.  401-425 
abscess  in,  II.  404 

operation  in,  II.  419 
acute  cases  of,  II.  402 
in  children.  II.  405 
and  enteric  fever,  II.  411 
and  pregnancy,  II.  406  ;  IV.  54 
cases  of  diffuse  and  general  peritonitis 

and,  II.  423 
chronic,  II.  409 

closure  of  the  wound  in,  II.  416 
desperate  cases  of,  II.  405 
fulminating,  II.  405 
in  children,  statistics  of  at  St.  George's 

Hospital,  II.  406 
in  elderly  patients,  II.  406 
indications  for  operation  in,  II.  401 
intussusception  of  the  appendix  in,  II. 

422 

non-operative,  II.  422-425 
acute  cases  of,  II.  423 
prophylactic  treatment  of,  II.  424 
subacute  cases  of,  II.  423 
operations  for,  II.  411 
in  acute  cases,  II.  418 
special  difficulties  in,  II.  417 
perforative,  and  Bier's  treatment,  III. 
44 


A    SYSTEM  OF  TREATMENT. 


Appendicitis  (contd.~) — 

quiescent  appendix  in,  II.  407 
statistics  of  in  St.  George's  Hospital,  II. 

402 

subacute  cases  of,  II.  407 
with  symptoms  of  general   peritonitis, 

II.  405 
Appendicostomy  for  chronic  constipation, 

II.  470 

for  chronic  mucous  colitis,  II.  571 
in  constipation  in  adults,  II.  468 
in  ulcerative  colitis,  II.  576 
Appendix  and  tuberculous  peritonitis,  II. 

411 

dyspepsia,  II.  409 
in  a  hernial  sac,  II.  410 
intussusception  of,  in  appendicitis.  II. 

422 

isolation  of,  II.  413 
malignant  disease  of,  II.  411 
quiescent,  in  appendicitis,  II.  407 
removal  of,  II.  414 
during  laparotomy,  II.  410 
in  quiescent  stage,  II.  411 
when  abscess  is  present  in  appendi- 
citis, II.  421 
Apraxia,  II.  1150-1152 
Arc  light,  concentrated,  III.  199 

use  of,  III.  186  ;  190 
Areola,  abscess  of,  II.  977 
Argeles-Gazost  spa,  III.  147 
Argyrol,  installations  of,  in  pyelitis,  II.  804 
Arm,  amputation  through,  I.  824-830 
brawny,  of  breast  cancer,  lymph-angio- 

plasty  in,  I.  144 
fractures  of,  I.  586,  596 
modified  circular  amputation  through, 

I.  825 

Armour  (Donald),  abscess  in  connection 
with  tuberculous  disease  of  the  spine, 
I.  928-932 

diseases  of  the  spine,  I.  912-921 
infective  lesions  of  bones  of  the  skull, 

1.  889—891 
surgical    diseases    of    the    scalp    and 

cranium,  I.  888 
surgical  treatment  of   tumours  of  the 

brain,  II.  1204-1207 
tumours  of  the  scalp,  I.  892-896 

spinal  cord,  II.  1221-1225 
Arrowroot,  preparation  of,  I.  42 
Arsacetin  in  syphilis,  I.  321 

iu  trypanosomiasis,  III.  421 
Arsanilates  in  trypanosomiasis.  III.  419 
Arsenic,  dosage  of,  in  children's  diseases, 

I.  68 

in  cerebro-spinal  syphilis,  II.  1067 
in  chlorosis,  II.  27 
in  chorea,  II.  1258 
in  diabetes  mellitus,  I.  424 
in  Hodgkin's  disease,  I.  1343 
in  intermittent  hydrarthrosis,  I.  749 
in  leukaemia,  II.  39 
in  pellagra,  I.  523 
in  pernicious  anaemia,  II.  3 


Arsenic  (contd.} — 
in  psoriasis.  III.  1111 
in  syphilis,  I.  321 
tolerance  of,  I.  503 
tiisulphide  of,  in  ^rvpanosomiasis,  III 

421 

Arsenical  dermatitis,  I.  117 
neuritis,  II.  1138 
poisoning,  acute,  I.  543,  529 

chronic,  I.  504 
waters,  III.  122 

in  pernicious  antenna,  II.  5 
Arsenious  acid  in  trypanosomiasis,    111. 

421 
Arseniuretted  hydrogen,  poisoning  by,  I. 

535 
Arsenophenylglycin    in    trypanosomiasis, 

III.  418 
Arterial  tension,  high,  I.  1281 

headache  from,  II.  1034 
Arteries,  compression  of  in  hasmorrhage, 

I.  799 
diseases  and  affections  of,  1. 1255-1308 

in  gouty  subjects,  I.  436 
effect  of  shock  on  blood  pressure  in,  1. 93 
gangrene  due  to  gradual  obliteration  of, 

1.215 

to  sudden  obliteration  of,  I.  215 
gluteal,  injuries  to,  I.  1276 
haemorrhage  from.  I.  1255-1277 
injuries  of,  I.  1255-1277 
intercostal,  wounds  of,  I.  1026 
lacerated  wounds  of,  I.  1280 
ligation  of  in  gunshot  wounds.  I.  559 

in  inoperable  cancer,  I.  136 
mesenteric.  embolism  by,  I.  1307 
palmar,  wounds  of.  I.  1276 
primary  haemorrhage  of,  I.  1270 
sciatic,  injuries  to,  I.  1276 
senile  changes  of,  cerebral  thrombosis 

due  to,  II.  1178 

subcutaneous  injuries  of,  I.  1278 
suture  of,  in  injuries  to,  I.  1279 
wounds  of,  1. 1278-1280 
See  also  under  Artery. 
Arterio-capillary  fibrosis,  I.  1288 
Arteriorrhaphy  in  aneurysm,  I.  1303 
Arterio-sclerosis,  I.  1287-1295 
causes  of  hypertension  in,  I.  1289 
diet  in,  I.  1290 
exercise  in,  I.  1291 
general  treatment  of}  I.  1290-1292 
hygiene  of  the  skin  in,  I.  1291 
medicinal  treatment  of,  I.  1292 
oedema  and  hydrothorax  in,  I.  1294 
spa  treatment  of,  I.  1291 
surgical  aspects  of,  I.  1296 
Arterio-venous  aneurysm,  I.  1305 

communications  in  gunshot  wounds,  I. 

560 

Arterio-visceral-sclerosis.  I.  1287 
Artery,  axillary,  excision  of.  in  aneurism, 

I.  1304 

brachial,  hemorrhage  from,  1.  1275 
femoral,  injuries  of,  I.  1276 


8 


A    SYSTEM  OF  TREATMENT. 


Artery  (contd.) — 

fneual,  rupture  of,  II.  S7ti 

gangrene  due  to  mechanical  obstruction 

of,  I.  215 

hepatic,  aneuiysm  of,  II.  667 
iliac,  ligature  of,  for  aneurysm,  I.  1304 
innominate,  ligature  of  for  aneurysm, 

I.  1303 

internal  mammary,  wounds  of,  I.  1025 
middle   meningeal,   haemorrhage   from, 

I.  1275 

palatine,  haemorrhage  from,  I.  1275 
renal,  aneurysm  of,  II.  752 
subclavian,  haemorrhage  from,  I.  1275 

See  also  under  Arteries. 
Arthralgia,  I.  781-784 
Arthrectomy  in  disease  of  the  ankle  and 

tarsus,  I.  773 
Arthritis,  acute  suppurative,  I.  742-745 

general  treatment  of,  I.  744 

local  treatment  of,  I.  742 
adhesions  of,  in  hemiplegia,  II.  1187 
arthrotomy  in,  I.  745 
bursae  and  cysts  in  association  with,  I. 

749-750 

chronic,  I.  745-748 
complicating  scarlet  fever,  I.  290 

typhoid  fever,  I.  363 
deformans,  I.  391-399 

climate  for,  I.  392 

diet  in,  I.  393 

electrical  treatment,  I.  398 

local  treatment  of,  I.  396 

localised  foci  in,  I.  391 

medicinal  treatment  of,  I.  395 

surgical  measures  in,  I.  397 

treatment  by  natural  thermal  baths, 

I.  397 

electro-therapeutics  in,  I.  746 
enteric,  I.  784 
fibrolysin  in,  I.  748 
gonorrhceal,  I.  781-783 

vaccine  therapy  of,  III.  281 
hydro-therapeutics  in,  I.  745 
in  haemophilia,  I.  786 
in  syringomyelia,  I.  786 
infective,  I.  741 
local  applications  in,  I.  748 
mineral  waters  and  baths  in,  III.  142 
neuropathic,  I.  785 
pneumococcal,  I.  783-784 
rheumatoid,   chronic  rheumatism   and, 
1.483 

complicating  pregnancy,  IV.  57 

massage  in,  III.  208 

treatment  of  by  counter  irritation  of 

the  spine,  I.  405-407 
Arthrotomy    in    chronic     synovitis    and 

arthritis,  I.  745 
Ascariasis,  III.  493 

prophylaxis  of,  III.  493 
santonin  in,  III.  494 
Ascites,  II.  626-631 
cardiac,  II.  630 
complicating  pregnancy,  IV.  55 


Ascites  (contd.) — 

diaphoresis  in,  II.  628 

diet  in,  II.  626 

diuretics  in,  II.  627 

general  treatment  of,  II.  626 

operative  measures  in,  II.  631 

pain  in,  II.  627 

paracentesis  in,  II.  628 

purgatives  in,  II.  627 

removal  of,  II.  627 

special  forms  of,  II.  630 

tapping  abdomen  in,  II.  629 
Ascitic    fluid   in   tuberculous  peritonitis, 

removal  of,  II.  647 
Asepsis  in  operative  treatment  of  fractures, 

1.636 

Aspergillosis,  pulmonary,  1.  1116 
Asphyxia  in  cut  throat,  II.  164 

local,  II.,  1238-1241 

of  the  newborn  child,  IV*.  350-355,  473 
Schultze's    artificial    respiration   in, 

IV.  352 

treatment  of,  IV.  351 
Aspiration  in  hasraatoma,  I.  545 

in  joint  affections,  I.  755 

in  pleural  effusion,  I.  1095 

of  tuberculous  abscess,  I.  174 
Aspirin  in  acute  rheumatism,  I.  271,  278 

in  chronic  rheumatism,  I.  490 

in  influenza,  I.  233 

Association  method  in  hysteria,  II.  1011 
Asthma,  I.  1035-1042 

application  of  vibration  in,  III.  216 

cardiac,  I.  1253 

climate  for,  I.  1037 

diet  in,  I.  1036 

in  children,  I.  1041 

physical  exercises  in,  III.  251 

pneumatic  treatment  of,  I.  1042 

spasmodic,  III.  691 

treatment     in    the     intervals    of     the 

paroxysms,  I.  1041 
of  the  aetiological  factors  of,  I.  1035 
of  the  paroxysms  of,  1038-1041 
Astigmatism,  III.  530 

irregular,  III.  533 
Astragalus,  dislocation  of,  I.  733 

excision  of,  1.  775 

fracture  of.  I.  633 
Atazia  of  the  vocal  cords,  III.  841 

in  hemiplegia,  II.  1188 
Ataxy,  locomotor,  II.  1085-1092 

physical  exercises  in,  III.  256 
Atelectasis  and  collapse  of  the  lung,  1. 
1063-1065 

in  newborn  child,  IV.  361 
Atmospheric  influences,  1.  534,  1118 

children  susceptible  to,  I.  63 
Atomiser  for  spraying  nasal  cavities,  III. 

696 
Atoxyl  in  cancer,  I.  149 

in  pellagra,  I.  522 

in  syphilis,  I.  321 

in  trypanosomiasis,  III.  420 

in  undefined  tropical  fevers,  III.  411 


9 


A    SYSTEM   OF   TREATMENT. 


Atresia,  congenital,  of  the  pylorus,  II.  344 

superficial,  of  the  vulva,  IV.  513 
Atrophy,    muscular,    in    hemiplegia,    II. 
1187 

myotonic,  II.  1252 

of' the  nails,  III.  1082 

progressive  muscular,  II.  1081-1082 
Atr opine,  hypodermic  injection  of,  before 
operation,  I.  84 

in  acute  iritis,  III.  584 

in  alcoholism,  I.  501 

in  asthma,  I.  1038 

in  constipation  in  adults,  II.  446 

in  diabetes  insipidus,  I.  429 

in  diphtheritic  paralysis,  I.  200-201 

in  diseases  of  the  heart,  I.  1226 

in  hypermetropia,  III.  536 

in  hyperopia,  III.  536 

in  nocturnal  enuresis,  II.  75 

in  pneumonia,  I.  262 

poisoning  by,  I.  532 
Atticotomy  in  acute  inflammation  of  the 

middle  ear,  III.  917 
Attie  punch  forceps,  III.  916 
Atwater  and  Bryant,  food  analyses  of,  II. 

192 
Aural  probe,  III.  908 

snare,  III.  909 

vertigo,  operation  on,   indication   for, 

III.  974 
Auricle,  abscess  in  lobule  of,  III.  882 

angeioma  of,  III.  879 

blackheads  of,  III.  881 

cervical,  III.  876 

comedones  of,  III.  881 

cysts  of,  III.  879 

dermatitis  of,  phlegmonous,  III.  881 

dermoid  cysts  of,  III.  879 

diseases  of,  III.  880 
local,  III.  880-882 

eczema  of,  III.  880 

erysipelas  of,  III.  880 

fibromata  of,  III.  879 

foreign  bodies  in,  III.  888 

herpes  of,  III.  880 

keloids  of,  III.  879 

lupus  of,  III.  881 

new  growths  of,  III.  878 

noma  of,  III.  882 

perichondritis  of,  III.  881 

Raynaud's  disease  of,  III.  880 

rodent  ulcer  of,  III.  879 

tophi  of,  III.  880 
Auricles,  accessory,  III.  876 
Auricular  fibrillation  of  the  heart,  I.  1231 
Auscultation  in  normal  labour,  IV.  130 
Auto-inoculation,  guides  to   the   control 
of,  I.  1162 

in  vaccine  therapy,  III.  264 

regulation  of  in  pulmonary  tuberculosis, 

I.  1121 
Auto-intoxication,  I.  386-390 

in  epilepsy,  II.  993 
Auto-massage  in  constipation  in  adults, 

II.  463 


Automatism  in  epilepsy,  II.  1005 
Auvard's     three-bladed    cephalotribe     in 

craniotomy,  IV.  410 

Axilla,  in  small-pox,  immunity  of,  I.  303 
Axillary  artery,  excision  of,  in  aneurysm, 
I.  1304 

cellulitis,  I.  183 
Azoo'spermia,  sterility  in,  IV.  848 


Babes  and  Vasilin  on  atoxyl  in  pellagra,  I. 
522 

Bachman  on  strophanthus,  I.  1223 

Bacillary  plugs,  embolism  by,  I.  1306 

Bacilluria,  II.  751 

complicating  typhoid  fever,  I.  361 
in  typhoid  fever,  I.  346 

Bacillus   serogenes   capsulatus,   gangrene 

due  to,   I.  582 
coli  infections,  acute  and  chronic,  III. 

272 

anti-coli  serum  in,  III.  271 
serum  therapy  in,  III.  271-272 
vaccine  therapy  in,  III.  271-272 

Bacon  fat  in  dietary  of  children,  I.  59 

Back  (Ivor),  circumcision,  II.  880-881 
diseases  of  bone,  I.  695-712 
diseases  of  the  scrotum,  II.  900 
diseases  of  the  testicle,  II.  901-910 
extravasation  of  urine,  II.  893-894 
fistulas  of  the  urethra,  II.  894 
injuries  of  the  urethra,  II.  882-885 
peri-urethral  abscess,  II.  895-896 
stricture  of  the  urethra,  II.  886-892 

Back,  contusions  of,  I.  898 
hot-air  apparatus  for,  III.  323 
suction  apparatus  for,   in    hyperaeniic 

treatment,  III.  60 
wound  of,  I.  901 

Bacterial  decomposition  and  gout,  I.  450 
food  poisoning,  I.  507-510 

Bactericidal  serum  therapy,  III.  259 

Bacterio-therapeuties  of  diphtheria,  III. 
273-279 

Bacteriology  of  puerperal  infection,  IV. 
284 

Bacteriolysins    in    serum    therapy,    III. 
259 

Baden-Baden  spa,  III.  147 

Baden- Weiler  spa,  III.  147 

Bagneres  de  Bigorre  spa,  III.  148 

Bagnoles  de  1'Orne  spa.  III.  148 

Bagnoli  spa,  III.  154 

Bagshawe  (A.  G.)   trypanosomiasis,   III. 
417-422 

Bailey,  (H.  C.),  on  strophanthus,  I.  1222 

Bainbridge  (S.),  on  trypsin  in  cancer,  I. 
151 

Bains-les-Bains  spa,  III.  148 

Balance  movements  for  scoliosis.  III.  244 

Balanitis.  II.  874 

Ball  (Sir  Charles),  method  of  operation  for 
pruritus  ani,  II.  597 

Ballance's  operation   in   diseases  of  the 
mastoid  process,  III.  928,  929 


10 


A    SYSTEM  OF  TREATMENT. 


Ballantyne    (J.    W.),     management     of 
puberty  and  the  menopause,  IV.  498- 
503 
the  general  management  of  pregnancy, 

IV.  1-13 
Balneotherapy  in  arthritis  deformans,  I. 

397,  439 

See  also  Baths  un<1  Mineral  Waters. 
Balsams,  urinary,  I.  225 
Bandages,  after  abdominal  operations,  II. 

2(17 

for  control  of  haemorrhage,  I.  798,  1259 
for  fractures  of  lower  jaw,  I.   87;    II. 

101 
Bandaging  in  treatment  of  ulcers,  I.  371 

value  of  in  shock,  I.  97 
Banting's  treatment  of  obesity,  I.  468,  471 
Barbados  tar  in  water  itch,  III.  486 
Bardswell,  on  diet  in  tuberculosis,  II.  203 
Bareges  spa,  III.  149 
Barium,  salts  of,  poisoning  by,  I.  529 
Barker's  flushing  spoon,  use  of,  I.  175 
Barker's  solution,  injection  of,  for  spinal 

analgesia,  III.  37 
Barley  water  in  infant  feeding,  IV.  347 

preparation  of,  I.  42 
Barr's  antipyretic  treatment  in  typhoid 

IVver,  I.  350 
Barwell  (Harold),  diseases  of  the  crico- 

arytenoid  joint,  III.  823 
injuries  of  the  larynx,  III.  825-826 
injuries  and  malformations  of  the  nose, 

III.  671-677 
leprosy    of    the    nose,    pharynx,    and 

larynx,  III.  780 

lupus  of  the  larynx,  III.  838-839 
of  the  pharynx,  III.  781 
and  tuberculosis  of   the  nares,   III. 

687-688 

of  the  naso-pharynx,  III.  742 
new   growths  of  the  larynx  (benign), 

III.  846-852 
paroxysmal  or   vasomotor  rhinorrhrea, 

III.  689-691 

perichondritis  of  the  larynx,  III.  861-862 
stenosis  (cicatricial)  of  the  larynx,  III. 

863-867 
tuberculosis  of  the  larynx,  III.  870-875 

of  the  pharynx,  III.  793-794 
Barwell-Lake  epiglottis  punch,  III.  875 
Basedow's  disease,  climate  for,  III.  99 
Bashford  (E.  F.),  on  cancer  in  mice,  1. 132 
Basilar  meningitis,  chronic,  I.  253-255 
Bath,  cabinet  light,  III.  187 
combined  double-light,  III.  320 
douche,  III.  127 
electric,  III.  101 
large,  for  recumbent  position  in  radiant 

heat  therapy,  III.  318 
for  sitting   position  in  radiant  heat 

therapy,  III.  317 
light,  III.  187 
local  light,  III.  195 

portable  limb,  for  radiant  heat  therapy, 
III.  316 


Bath  (contd.) — 

portable  trunk  in  radiant  heat  therapy, 
III.  319 

radiant  heat,  duration  of,  III.  325 

reflector,  in  radiant  heat  therapy,  III. 
321 

spa,  III.  148 
Baths,  acid,  III.  137 

cold,  in  eclampsia,  IV.  37 
in  impotence,  I.  231 
reaction  to,  III.  113 
use  of,  I.  36 

continuous,  I.  38 

creosote,  in  bronchiectasis,  I.  1044 
vapour,  in  pulmonary  tuberculosis,  I. 
1149 

effervescent,  III.  131 

electrical,    in    chronic    synovitis    and 
arthritis,  I.  747 

for  chlorosis,  II.  26 

for  infants  and  children,  I.  47 

for  osteo-arthritis,  I.  402 

general  action  of,  III.  112 

hot  air,  I.  37,  III.  128 

in  atony  of  the  stomach,  II.  289 

in  gouty  joints,  I.  397,  439 

in  obesity,  I.  470 

kinds  of,  and  their  uses,  III.  124 

local  hot  air,  III.  128 

local  light,  III.  194 

marine,  III.  129,  130 

mineral,   in   diseases  of   the   heart,   I. 
1210 

mud,  III.  136 

peat,  III.  135 

sand, III.  136 

special  in  chorea,  II.  1263 

sub-thermal,  III.  113 

sulphur,  III.  133 

superheated   air,    in    gout   and   gouty 
conditions,  I.  439 

temperature  of,  I.  36,  38,  47 

thermal,  III.  124 
in  arthritis  deformans,  I.  397 

Turkish,    in    acute   gout,    contra-indi- 
cated, I.  441 

value  of  in  children's  diseases,  I.  69 

vapour,  III.  129 

warm,  effect  on  nervous  system,  I.  70 
Battaglia  spa,  III.  148 
Battle's  fbcision  in  appendicitis,  II.  412 
Bavarian  splint,  I.  574 
Bayly  (H.  Wansey),  the  clinical   patho- 
logy of  syphilis  in  relation   to    treat- 
ment, I.  325-228 
Bazin's  disease,  III.  1151 
Beard,  ringworm  of,  III.  1130 
Beatson    (Sir    O.)    on    oophorectomy  in 

mammary  cancer,  I.  150 
Beaunis'     method     of     hypnotism,    III. 

164 

Beckmann's  post-nasal  curette,  III.  734 
Bed,    confinement    to,    after    abdominal 
operations,  II.  267 

in  acute  bronchitis,  I.  1050 


11 


A    SYSTEM  OF  TREATMENT. 


Bed  (contd.') — 

petition  of  patient  in,  after  abdominal 
operations,  II.  266 

preparation  of  for  operation,  I.  30 
Bedclothes,  heavy,  to  be  avoided,  I.  45 
Bedding,  disinfection  of,  I.  162 
Bedmaking,  instructions  as  to,  I.  30 
Bedrooms,    disinfection     of    during    and 

after  contagious  complaints,  I.  164 
Bedsores,  avoidance  of,  I.  157 

in  myelitis,  II.  1218 

in  paraplegia,  II.  1199 

prevention  of,  I.  365 
and  treatment  of,  I.  31 
in  injuries  of  the  spine,  I.  910 
Bed-wetting,  II.  75-77 
Beds,  double  and  single,  choice  of,  I.  26 
Beef,  chemical  composition  of,  II.  192 

essence,  preparation  of,  I.  43 

inspection  of,  in  the  tropics,  III.  385 

raw,  essence,  preparation  of,  I.  42 
Beef-tea  custard,  preparation  of,  I.  43 

peptonised,  preparation  of,  I.  42 

salted,  as  a  stimulant,  I.  158 
Beer  in  gouty  conditions,  I.  456 
Bell  (W.  Blair),  fistulae  of  the  uterus,  IV. 
664-668 

hermaphroditism     and    pseudo-herma- 
phroditism,  IV.  865-867 

injuries  of  the  uterus,  IV.  707-710 

malformations  of  the  uterus,  IV.  711- 
717 

sub-involution  of  the  uterus,  IV.  720-724 
Belladonna,  applications  in  spinal  sprain, 
I.  900 

dosage  of  in  children's  diseases,  I.  68 

in  constipation  in  adults,  II.  446 

in  epilepsy,  II.  998 

in  exophthalmic  goitre,  II.  55 

in  nocturnal  enuresis,  II.  75 

in  small-pox,  I.  305 

in  vomiting  due  to  heart  failure,  I.  200 

in  whooping  cough,  I.  381 

poisoning  by,  I.  532 
Bell's  nerve,  injuries  of.  II.  1112 

treatment  of  spina  bifida,  I.  912 
Bellingham  on  aortic  aneurysm,  I.  1297 
Belt  for  gastroptosis,  II.  320 

for  movable  kidney,  II.  788 

use  of,  after  abdominal  operations,  II. 

268 
Bennett  (Norman  C.),  dental  surgery,  III 

1164-1194 

Bennett  (Sir  William  H.),  varicocele    I 
1323-1327 

varicose  veins,  I.  1309-1322 
Benzene  compounds,  poisoning  by  treat- 
ment of,  I.  533 

Beraneck's  tuberculin,  III.  293 
Berger's  amputation,  I.  146 

operation,  re-section  of  clavicle,  followed 
by  division  of  main  vessels  and  nerves 
I.  831-834 
Bergmann's     post  -  aural     operation     in 

diseases  of  mastoid  process,  III.  922-923 


Beri-beri,  III.  414-416 

neuritis  in.  II.  1139 

Berkeley  (Comyns),  craniotomy,  IV.  403- 
412 

decapitation,  IV.  413-415 

evisceration,  IV.  416 

fibroids,  IV.  634-663 

forceps,  IV.  417-432 

induction   of    abortion   and  premature 
labour,  IV.  433-445 

infusion  set  for  haemorrhage,  I.  1264 

obstetric  operations,  IV.  373-374 

on    connection     between    leucoplakia 
and  cancer,  I.  119. 

spondylotomy,  IV.  451 

version  or  turning,  IV.  461-473 
Berkeley's  infusion  apparatus,  IV.  478 

self-containing  retractor,  IV.  477 

table,  IV.  480 

vaginal  clamp,  IV.  481 
Bernheim's  method  of  hypnotism,  III.  164 
Berries,  chemical  composition  of,  II.  196 
Berry  (James),  affections  of  the  lips,  II. 
96-98 

cleft  palate,  II.  147-156 

harelip,  II.  85-95 
Besridka,  on   serum   therapy  of   scarlet 

fever,  I.  287 

Beta-naphthol  in  ankylostomiasis,  III.  492 
Bex  spa,  III.  148 

Beyea's  operation  for  gastroptosis,  II.  324 
Bezold's  rnastoid  abscess,  III.  932 
Bicarbonate  of  Soda.     See  Soda. 
Bier's  hyperagmic  treatment  by  means  of 
cupping  glasses,  III.  56 

by  partial  vacuum,  III.  56 

by  suction  apparatus,  III.  56 

"  heated  air,"  III.  61 

in  acute  abscess,  I.  168-182 

in  whitlow,  I.  169 

induced  hyperasmia,  III.  40-68 

in  infective  lesions  of  scalp,  I.  888 

in  tuberculous  joints,  I.  751 

methods  and  rules  of,  III.  43,  45 

passive,  induced  by  elastic  constriction, 

III.  46 

Big  heel,  III.  465 

Bigelow's  method  in  dislocations,  I.  724 
Bile  on  constipation  in  adults,  II.  454 

stagnation    of,  and    cholelithiasis,   II. 

682 

Bile  ducts,  cancer  of,  obstruction  due  to, 
I.  143 

catarrh  of,  infective,  II.  704 

congenital  obliteration  of,  II.  673 

croupous  inflammation  of,  II.  702 

diseases  of,  II.  680 

fistulas  of,  II.  699 

inflammation  of,  II.  699-709 

injuries  of,  II.  680 

perforation  of,  II.  707 

primary  malignant  disease  of,  II.  713 

stricture  of,  II.  706 

tumours  of,  II.  713-715 
cystic,  II.  713 


12 


A    SYSTEM  OF  TREATMENT. 


Bile  (contd.)— 

typhoid  infection  of,  I.  353 

passages,  injection    of,    and   choleli- 
thiasis, II.  683 
wounds  of,  II.  680 
Bilharzia  disease,  III.  498-500 
general  treatment  in,  III.  499 
medicinal  treatment  of,  III.  499 
preceding  carcinoma,  I.  119 
prophylaxis  of,  III.  498 
Biliousness,  effect  of  chalky  water  in,  II. 

345 

Binder  in  third  stage  of  labour,  IV.  125 
Biniodide   solution  for  actinomycosis,  I. 

177 

Birth,  injuries  of  newborn  child,  IV.  3(53 
marks,  III.  1077-1081 
paralysis,  brachial,  II.  1110 
Bismuth,  carbonate  of,  in  acute  gastritis, 

II.  352 

dressing,  ineffective,  I.  78 
emulsion    of,    injection    into     abscess 

cavities,  I.  176 
in  achylia,  II.  294 
in  chronic  dilatation  of  the  stomach,  II. 

314 

in  typhoid  fever,  I.  354 
injection    of,    in     fistulous    tracks    in 

empyema,  I.  1110 
mixture  in  vomiting,  I.  507,  509 
Blacker  (G.),  menorrhagia   and    metror- 

rhagia,  IV.  751-7tU 
Blackheads  of  the  auricle,  III.  881 
Blackwater  fever,  III.  386-389 
local  applications  in,  III.  389 
stimulants  in,  III.  389 
use  of  morphia  in,  III.  388 
Bladder,     acquired     sacculation     of,    in 

vesical  calculus,  II.  854,  864 
calculus  of,  II.  852-857 
cancer  of,  II.  871 
fistula  due  to,  I.  142 
palliative  operations  for,  II.  873 
care  of,  after  abdominal  operations,  II. 

264 

complications,    in   gynaecological    sur- 
gery, IV.  487,  496 
control  of,  in  children,  I.  53 

in  typhoid  fever,  I.  362 
diseases  of,  II.  852 
diverticula  of,  II.  864 
ectopia,  II.  866 

extrophy  of,  in  newborn  child,  IV.  360 
female,  calculi  in,  IV.  733 

in  supra-pubic  cystotomy,  IV.  734 
diseases  of,  IV.  868,  875 
displacements  of,  IV.  875 
fissure  of  neck  of,  IV.  883 
foreign  bodies  in,  IV.  875 
fistulae  of,  at  the  umbilicus  in  adults,  II. 

279 

in  infants,  II.  278 
gun  shot  wounds  of,  I.  566 
hydronephrosis  due  to  obstruction  in, 
II.  772 


Bladder  (contil.~)  — 

in  abdominal  operations,  II.  259 

in  gynaecological  surgery,  IV.  487,  496 

inflammation  of,  complicating  typhoid 

•    fever,  I.  361 

injuries  to,  II.  252 

intestine  and,  fistulas  between,  II.  491 

papilloma  of,  single,  II.  870 

papillomata  of,  multiple,  II.  871 

plastic  closure  of,  in  ectopia  vesicae,  II. 

866 
rupture  of,  II.  868 

after  treatment,  II.  869 
sacculi  of,  II.  854,  864 
separation  of,  in  Wertheim's  operation, 

IV.  (506 
sphincter    of,     troublesome    in     tabes 

dorsalis,  II.  1090 
weakness   in  disseminated    sclerosis, 

II.  1075 

tuberculosis  of,  II.  820,  824 
tumours  of,  I.  119,  120  ;  II.  870-873 
washing  out  of,  I.  910 
wounds  of,  II.  868-869 
Blake's  tympanic  syringe,  III.  912 
Bland-Button  (J.),  actinomycosis  of  Fallo- 
pian tube,  IV.  800 

cancer  of  Fallopian  tube,  IV.  801-803 
chorion-epithelioma  of  F'allopian  tube, 

IV.  804 
diseases  and  affections  of  the  Fallopian 

tubes,  IV.  799-823 

hernia  of  the  Fallopian  tube,  IV.  804 
hydatids  of  the  broad  ligaments,  IV. 

820-821 
inflammation    of    the    Fallopian    tube 

(salpiugitis),  IV.  805-815 
papilloma  of  the  Fallopian  tube,  IV.  816 
preventive  treatment  of  salpingitis,  IV. 

815 
thrombosis  of  the  veins  of  the  broad 

ligaments,  IV.  822-823 
tubal  pregnancy,  IV.  78-88 
tuberculous  diseases  of  the  Fallopian 
tubes  (tuberculous  salpingitis),   IV. 
817-819 

tumours  of  the  broad  ligaments,  IV.  823 
Blankets,  disinfection  of,  I.  162 
Blastomycetic  dermatitis,  III.  1005 
Blepharitis  of  the  eyelids,  iii.  577 
Blepharospasra,  clonic,  II.  1047 
Blindness,  snow,  of  the  conjunctiva,  III. 

560 

Blistering  in  chorea,  II.  1262 
Blisters,  application  of,  I.  36 

in    counter-irritation     in     rheumatoid 

arthritis,  I.  405 
in  iritis,  III.  586 
in  joint  affections,  I.  748 
value  of  in  children's  diseases,  I.  69 
Blondel  (Raoul)  on  lacto  serum,  I.  1295 
Blood,  action  of  arc  light  bath  on,  III.  191 
anaemia  due  to  actual  loss  of,  II.  18-19 
circulation  of,  effect  of  massage  on,  III. 
204 


13 


A    SYSTEM  OF  TREATMENT. 


Blood  circulation  (coittd.') — 
effect  of  shock  on,  I.  94 
in  Bier's  hyperaemic  treatment.  III. 

42 
coagulability  of,  effect  of  animal  serum 

on,  I.  129 
coagulation   of,   encouragement  of,   in 

haemophilia,  II.  32 
co«nt,  differential,  in  pelvic  cellulitis, 

IV.  826 

deficiency  of  lime  salts  in,  IV.  721 
direct  transfusion  of,  in  haemorrhage,  I. 

1269 

diseases  of,  II.  1-45 
effusion  of  in  fractures,  I.  570 
elimination  of  noxious  materials  from, 

I.  7 

in  normal  puerperium,  IV.  258 
massage  in,  III.  207 
transfusion  of  in  pellagra,  I.  523 

See  also  Transfusion. 
Blood  cysts  of  neck,  II.  167 
Blood-forming    organs,    diseases    of,    II. 

1-45 
Blood  mole  complicating  pregnancy,  IV. 

59 

Blood-pressure,  I.  1281-1286 
effect  of  infusion  in,  I.  98,  102 
high,  I.  1281 

relief  for,  I.  10 

in  cerebral  compression,  I.  880 
in  gouty  subjects,  I.  436 
influence  of  shock  on,  I.  93 
low,  I.  1284 
Blood  stasis,  torsion-clamp  method  of  in 

elephantiasis  scroti,  III.  509 
Blood  states,   abnormal,  cerebral   throm- 
bosis due  to,  II.  1179 
Blood-vessels,    division    of    in    Berger's 

operation,  I.  831 
injuries  to  large,  I.  1030 
ligature  of,  I.  1254 

in  amputations,  I.  801 
special,  wounds  of,  I.  1274 
Blue  light,  use  of,  III.  187 

bath,  III.  193 
pill  in  gout,  I.  432,  436 

in  gouty  complications,  I.  443-446 
Blumfield  (J.),  anaesthetics,  III.  1-39 
Body,  causes  of  loss  of  natural  resistance 

to  disease  in,  I.  5 
Boeck,  multiple  benign   sarcoid  of,   III. 

1152 

Boiling,  disinfection  by  means  of,  I.  161 
sterilisation  by,  I.  72 
of  instruments,  directions  for,  I.  27,  30 
Boils,  ceridine  in,  III.  1008 

complicating  diabetes  mellitus,  I.  425 
general  treatment  of,  III.  1007 
ionic  medication  of.  III.  184 
local  treatment  of,  III.  1009 
nuclein  in,  III.  1008 
sulphur  in,  III.  1007 
vaccine  treatment  of,  III.  1008 
yeast  in,  III.  1006 


v.  Bokay  on  intubation,  III.  804 
Bone-grafting  in|  sarcoma  of    jaws,   II. 

115 

Bone-marrow  in  pernicious  anaemia,  II.  9 
Bones,  cancer  of,  spontaneous   fractures 

in,  I.  146 
deformities  of  in  children,  I.  56 

in  rickets,  I.  481 
direct   union    of,    in    fracture    of    the 

jaws,  II.  102 

diseases  of,  I.  695-712,  756,  772 
complicating  typhoid  fever,  I.  363 
fracture  of,  in  extraction  of  teeth,  III. 

1188 

infective  lesions  of,  I.  889 
injuries  of,  I.  568-633 
necrosis  of  following  abscess,  I.  167,  171 

in  burns,  I.  541 
vaccine  therapy  in,  III.  264 
sarcoma  of,  Coley's  fluid  in.  I.  153 
section  of,  I.  800 
spread  of,  I.  124,  711 
tuberculosis  of,  I.  704 
tumours  of,  I.  708 

Bonney  (Victor),  after-treatment  and  post- 
operative complications  of  gynaeco- 
logical surgery,  IV.  487-497 
carcinoma  of  body  of  uterus,  IV.  575- 

581 

the  cervix,  IV.  582-617 
chorio-carcinoma  (chorion  epithelioma, 

deciduous  malignum),  IV.  618-619 
connection  between  cancer  and  leuco- 

plakia,  I.  117 

general  points  in  the  technique  of 
gynaecological  operations,  IV.  474- 
486 

puerperal  infection,  IV.  282-323 
sarcoma  of  the  uterus,  IV.  718-719 
Bonney's  dissecting  forceps,  IV.  476,  477 
needles,  IV.  477 
vaginal  clamp,  IV.  481 
Boracic  dressings  in  burns  and  scalds,  I. 

541 

fomentations  in  cellulitis,  I.  181 
Borax  in  thrush,  II.  123 
Boric  gauze  and  wool,  I.  78 
Bormio  spa,  III.  148 
Bossi's  dilator  in  accidental  haemorrhage 

during  pregnancy,  IV.  26 
metallic  dilator  in  eclampsia,  IV.  39 
Bottle-feeding  of  infants,  II.  221 
Botulism,  I.  510 

Bouchard,   on  auto-intoxication,  I.  386 
Bougie,    black    elastic    oesophageal,    II. 

172 
conical-ended  black  elastic  oesophageal, 

II.  172 
Eustachian,  in  patency  of  Eustachian 

tube.  III.  949 
gum-elastic,  in  inducing  of  premature 

labour,  IV.  437 

Schrotter's  hollow  vulcanite,  III.  865 
silk  web  oesophageal,  II.  172,  173 
sterilisation  of,  I.  92 


14 


A    SYSTEM   OF   TREATMENT. 


Bourbon-lAchambauld  spa,  III.  148 
Bourbon-Lancy  spa.  III.  148 
Bourbonne-les-Bains  spa,  III.  148 
la  Bourboule  spa,  III.  152 
Bowels.    Sre.  Intestines. 
Bow-leg  and  genu  varum,  I.  1*62 
Bowls  and  dishes,  preparation  of,  I.  72 
Bowman's  spoon  for  cataract,  III.  628 
Boxwood  screw  wedges  in  fibrous  anky- 

losis  of  the  jaws,  II.  106 
wedge  for  fibrous  ankylosis  of  the  jaw, 

II.  106 
Brachial    artery,   hemorrhage    from,    I. 

1376 
birth    paralysis,   II.    1012,    1110;    IV. 

365 

neuralgia,  II.  1121 
plexus,  injuries  of,  II.  1012,  1110 
Bi aid's  method  of  hypnotism,  III.  160,  163 
Brain,  abscess  of,  complicating  diseases 

of  the  ear,  III.  939-941 
following  head  injuries,  I.  885 
anaemia  of,  due  to  shock,  I.  94 
apoplexy  of,  II.  1070 
compression  of,  I.  878,  880 
concussion  of,  I.  878 
contusion  of,  I.  878 
direct  drainage  from,  in  meningitis,  I. 

252 
diseases  of,  II.  1143 

aphasia  in.  II.  1143-1149 
electro-therapeutics  in,  III.  109 
paraplegia  in,  II.  1195 
speech  defects  in,  II.  1143 
embolism  of,  II.  1167 
exhaustion  of  the  vasomotor  centres  in, 

I.  IK; 

gouty  conditions  of,  I.  447 
iiunshot  injuries  of,  I.  562 
hsemorrhage  of,  II.  1168-1176 
hernia  of,  II.  1190 
injuries  of,  I.  878-884 
oedema  of,  in  injuries  of  the  head,  I. 

884 
palsies  of,  in  infancy,  II.    1055-1058, 

1153-il5C, 
surgical     treatment,    II.    1059-1066, 

1157-1164 

syphilis  of,  headache  from,  II.  1034 
thrombosis  of ,  II.  1177-1180 

syphilitic.-.  II.  1068 
tumours  of, 
fits  in,  II.  1202 
in  children,  II.  1068,  1166 
intra-cranial,  localised,  II.  1202.  1203 
medical  treatment,  II.  1200-1203 
optic  neuritis  in,  II.  1201 
palliative  operations  in,  II.  1204 
radical  operations  in,  II.  1205 
surgical  treatment  of.  II.  1204-1207 
Bramwell's  method  of  hypnotism.  1 1 1 .  1 65 
Branchial  cysts  of  neck,  II.  167 
dermoids,  I.  110 
fistulas  of  neck.  II.  lilt', 
Brand  cancers  of  cattle,  I.  117 


Brandy  in  collapse  and  diarrhoea,  I.  28.  37. 

508 

Brawny  arm  of  cancer  of  breast,  treat- 
ment of,  I.  144 

Bread,  chemical  composition  of,  II.  195 
cleansing  of  walls  by,  I.  163 
food  in  diabetes,  I.  413 
\n  diet  for  gout,  I.  454 
in  dietary  of  children,  I.  59 
rye,  gangrene  from  use  of,  I.  219 
Breakfast,  abuse  of,  in  dietary  of  children, 

I.  62 
Breast,  abscess  of,  II.  958 

affections  of,  in  pregnancy,  IV.  330-336 

in  the  puerperium,  IV.  330-336 
atrophic  scirrhus  of,  II.  964 
cancer  of,    after-treatment   in   radical 
operations  for,  II.  972 

age  of  patient  and,  II.  965 

anaesthetics  in  operations  for,  III.  31 

axillary  dissection  in  radical  operation 
for,  II.  970 

both,  II.  965 

chronic  alcoholism  and,  II.  966 

chronic  bronchitis  and,  II.  966 

cirrhosis  and,  II.  966 

complications  of,  I.  145,  146 

diabetes  and,  II.  966 

drainage  after  radical  operation  for, 
II.  971 

dressings  after  radical  operations  for, 
II.  972 

exploration  of  tumour  in,  II.  968 

incision  in  radical  operafion  for,  II. 
969 

oophorectomy  in,  I.  150 

operations  for,  II.  967 

palliative  operations  for,  IF.  973 

position  of  patient  in  radical  opera- 
tion for,  II.  968 

pregnancy  and.  II.  965 

preparation   of    patient    for    radical 
operation  for,  II.  967 

radical  operation  for,  II.  967 

radium  therapy  in,  III.  313 

recurrent,  II.  974 

spread  of,  I.  126 

suture  of  wound  after  radical  opera- 
tion for,  II.  971 
care   of,  in     normal    puerperium,  IV. 

266 

chronic  abscess  of,  II.  962 
cysts  of,  II.  952-954 

multiple,  II.,  !>.v_> 

operation  for,  1 1.  953 

simple,  II.  952 

with  intra-cystic  growths,  II.  954 
diseases  and  affections  of,  II.  952-981 
duct  papilloma  of,  II.  954 
fever  in  puerperal  sepsis,  IV.  315 
fibro-adenomata  of,  II.  '.'55 

operation  for,  II.  955 
galactocele  of,  II.  953 
hydatid  cysts  of.  II.  '.'54 
hypertrophy  of  II.  957 


15 


A    SYSTEM  OF  TREATMENT. 


Breast  ( 

iii  normal  puerperium,  IV.  258 
inflammation  of,  II.  958-962 
infra-mammary  abscess  of,  II.  960 
malignant  disease  of,  II.  963-975 

enlargement      of     supra  -  clavicular 

glands  in,  II.  964 

indications  for  operation,  II.  963  „ 
results  of  operative  treatment,  II.  963 
management  of,  in  pregnancy,  IV.  330 
massage   of,  for  painful  engorgement, 

IV.  332 
mastitis  of,  chronic  interstitial,  II.  961 

chronic  lobar,  II.  961 
neuralgia  of,  II.  976 
operations  upon,  preparations  for,  I.  89 
painful  engorgement  of,  in  the  puer- 
perium, IV.  331 
persistent  sinuses  of,  II.  960 
removal  of,  in  malignant  disease  of,  II. 

971 

sarcoma  of,  II.  975 
suction  apparatus  for,   in   hyperasmic 

treatment,  III.  60 

supra-mammary  abscess  of,  II.  960 
treatment  'of.  when  patient  is  not  going 

to  suckle  the  infant,  IV.  330 
tuberculosis  of,  II.  981 
tumours  of,  operative  diagnosis  of,  II. 

979-980 

doubtful,  II.  979 
Breast-feeding,  contra-indications  to,   in 

normal  puerperium,  I V.  269 
in  normal  puerperium,  IV.  266 
of  infants,  II.  215 
of  the  new-born  child,  IV.  340 
Breath,  chronic  foetor  of,  II.  127 
Breathing,  children  to  be  instructed  as  to, 

1.49 
exercises,  III.  227 

in  pulmonary  diseases,  III.  249 
Brehmer  on  pulmonary    tuberculosis,   I. 

1121 

Brewis,  (N.  T.),  endometritis,  IV.  620-631 
erosion  or  adenomatous  disease  of  the 

cervix,  IV.  632-633 

hypertrophy  of  the  cervix,  IV.  700-706 
Brides  les-Bains  spa,  III.  149 
Brides-Salins  spas,  III.  149 
Bridge  of  Allan  spa,  III.  149 
Bright's  disease,  acute,  II.  796-797 
acerbations  in,  II.  798 
chronic,  II.  798 

decapsulation  in,  II.  799 
epistaxis  in,  I.  15 
in  anasmia,  II.  17 
Brine  baths,  III.  130 
Briscoe    (J.   C.),    Broncho-pneumonia,   I. 

1066-1073 

Broad  ligaments,  diseases  of,  IV.  836-839 
ribroids  of ,  I V .  653 
false,  IV.  652 
hydatids  of,  IV.  836-837 
tumours  of,  IV.  839 
veins  of,  thrombosis  of,  IV.  838-839 


Bromide  acne,  II.  997 

Bromides,   combinations  of,  in   epilepsy, 

II.  996 
dosage  of,  in  children's  diseases,  I.  67 

in  epilepsy,  II.  995 
in  diseases  of  the  heart,  I.  1225 
in  epilepsy,  II.  993 
in  small-pox,  I.  305 
Bromine,  new  preparations  of,  II.  997 
Bromism  in  epilepsy,  II.  994 
Bromoform  in  whooping  cough,  I.  382 
Bronchi,  diseases  of,  I.  1035-1075 
empyema  ruptured  into,  I.  1106 
foreign   bodies   in,   abscess  due  to,   I. 

1061 
Bronchial  catarrh,  complicating  influenza, 

I.  239 

Bronchiectasis,  I.  1043-1048 
methods  of  treatment  of,  I.  1047 
surgical  treatment  of,  I.  1048 
Bronchiectatic   cavities  of    the   lung,   I. 

1061 
Bronchitis,  I.  1049-1058 

acute,  general  measures,  I.  1050 
chronic,  1.  1054-1058 
climatic  treatment  of,  I.  1055 
complicating  cancer  of  the  breast,  II. 

966 

general  measures  in,  I.  1054 
medicinal  treatment  of,  I.  1056 
physical  exercises  in,  III.  251 
vaccine  treatment  of,  I.  1056 
complicating    gynecological    surgery, 

IV.  494 

whooping  cough.  I.  378,  384 
in  injuries  of  the  spine,  I.  909 
in  measles,  I.  245 
in  myelitis,  II.  1216 
medicinal  measures  in,  I.  1051 
peculiar  forms  of,  I.  1058 
plastic,  I.  1058 
putrid,  I.  1058 
sicca,  I.  1058 
sub-acute,  I.  1053 
Broncho-pneumonia,  I.  1066-1073 
complicating    gynaecological    surgery, 

IV.  494 

small-pox,  I.  308 
diet  in,  I.  1068 
drugs  in,  I.  1068 
general  management  in,  I.  1066 
special  symptoms  in  early  stages  of,  I. 

1069 
treatment   in    the    later   stages  of,  I. 

1070 

Bronchorrhoea  serosa,  I.  1058 
Bronchoscope,  Briinings,  III.  810 

introduction  of,  in  foreign  bodies  in  the 

air  passages,  III.  816 
Bronchoscopy,  description  of,  III.  803-821 
Brophy's   operation   in    cleft   palate,   II. 

149 

Broths  for  young  children,  I.  58 
Brow  presentation,  forceps  in,  IV.  422 
in  labour,  IV.  137-139 


16 


A    SYSTEM  OF  TREATMENT. 


Brown    (W.    Carnegie),     ankylostomasis 
(uncinariasis,  hookworm  disease),  III. 
487-482 
ascariasis.  oxyuriasis  and  trichocephalis, 

III.  493-497 
dracontiasis  (infection  by  guinea-worm, 

filaria  medinensis),  III.  501-502 
leprosy,  III.  447-453 
oriental  sore,  III.  454-456 
sprue.  III.  442-446 
hvniusis,  intestinal,  III.  517-520 
trichiniasis  (trichinosis,  trichiuelliasis), 

III.  524-527 
uln-rating  granuloma  of  the  pudenda, 

III.  457-458 

yaws  (fnmibcKsia  tropica),  III.  4<U 
Brace   (J.  Mitchell),  principles  of  treat- 
ment. 1.  1-25 

Bruce  (W.  Ironside),  X-ray  treatment  of 
diseases  other  than  skin  diseases, 
111.  360-368 

Briinings  bronchoscope,  III.  806 
dilatable  bronchoscope,  description  of, 

III.  810 

direct  laryngoscope,  III.  849 
forceps,  description  of,  III.  808 
hand  lamp,  description  of,  III.  810 
cesophagoscope  for  foreign  bodies  in  the 

oesophagus,  II.  187 
Brunton  (Sir  T.  L.),  on  arterio-sclerosis, 

I.  12114 

Bryant's  splint,  I.  617 
suspension  apparatus  for  fractures  of 

femur,  I.  616 
Bubo,  climatic,  III.  467 
parotid,  II.  131 
plague,  III.  405 
suppurating,   complicating  chancre,  I. 

3i:> 
Buckley      (Charles      W.),      rheumatism 

(chronic),  I.  483-491 
(muscular),  I.  492-494 
Budd  on  incidence  of  gout,  1.  448 
Bulbar  palsy,  II.  1061 
acute,  II.,  1061 
progressive,  II.  1061 
Buller's  shield  for  gonorrhoeal  ophthalmia 

in  the  adult,  III.  555 
Bullet  wounds.     See  Wounds,  gunshot. 
Burns,  continuous  baths  for,  I.  38 
scars  of,  the  seat  of  carcinoma,  I.  117 
and  injuries  by  electricity,  I.  547-549 
and  scalds,  I.  540-544 
general  treatment  of,  I.  543 
immediate  treatment  of,  I.  540 
local  treatment  of  the  burnt  areas  in, 

1.  540 

and  treatment  of  contractions,  I.  543 
of  the  conjunctiva,  III.  547 
of  the  external  ear,  III.  888 
of  the  oesophagus,  II.  188 
Burrows'  solution  in  erysipelas,  I.  210 
Bursse    and    cysts     in     association    with 

arthritis,  I.  749-750 
chronic  rheumatism  of,  I.  484 


Bursae  (fontd.~) — 

diseases  of,  IL  1334-1335 

prepatellar,  chronic  bursitisof,  II.  1334 

.wounds  of,  II.  1335 
Bursal  cyst  of  neck,  II.  168 
Bursitis."  acute,  II.  1334 

chronic  simple,  II.  1334 

syphilitic,  II.  1335 

tuberculous,  II.  1335 

Bury  (Jndson   S.),   acute  anterior  polio- 
myelitis, II.  1055-1058 

facial  paralysis,  II.  1093-1095 
Butlin  (Sir  H.    T.)    on  mortality   from 
operations  on  jaws,  II.  117 

on  operations  on  the  tongue,  II.   140, 

143 

Butyl  chloral  in  infantile  diseases,  I.  67 
Buxton  spa,  III.  149 

Buzzard   (E.  Farquhar),  caisson   disease, 
II.  1208-1209 

cerebro-spinal  syphilis,  II.  1063-1069 

general  paralysis  of  the  insane,  II.  1077^ 
1080 

haematomyelia,  II.  1210-1211 

hemiplegia,  II.  1181-1190 

myelitis,  II.  1212-1218 


Cachexia,  relief  of  in  inoperable  cancer,  I. 

132 

saturnine,  in  lead  poisoning,  I.  514 
strumipriva  complicating  operation  for 

goitre,  II.  70 
Caecal  region,  growths  in,  excision  of,  II. 

580 
Caecostomy  for  cancer  of  the  colon,  II. 

584 

in  chronic  mucous  colitis,  II.  571 
valvular,  in  chronic  mucous  colitis,  II. 

571,  573 
Caecum,  cancer  of,  relief  of  obstruction  in, 

I.  141 

Caesarean  hysterectomy,  IV.  398-402 
mortality  from,  IV.  401 
operation  of,  IV.  399 
operation  for  contracted  pelvis,  table  of 

mortality  of,  IV.  402 
section.  IV.  382-398 

abdominal,  in  eclampsia,  IV.  40 

incision  in,  IV.  387 
after-treatment  of,  IV.  396 
ethical  standpoint  of,  IV.  394 
extraction  of  child  in,  IV.  390 
extra-peritoneal,  IV.  397 
in     accidental     haemorrhage   during 

pregnancy,  IV.  25 
in  contracted  pelvis,  IV.  383 

complicating  labour,  IV.  170,  171 
in  eclampsia,  IV.  384 
in  libro-myomata  of  the  uterus,  IV. 

384 

in  ovarian  tumours,  IV.  384 
in  placenta  praevia,  IV.  385 
mortality  from,  IV.  401 


17 


A    SYSTEM  OF  TREATMENT. 


Caesarean  section  (contd) — 

preparation  of  patient  in,  IV.  385 
removal  of  placenta  in,  IV.  391 
repeated,  danger  of,  IV.  395 
sterilisation  in,  IV.  394,  396 
stitching  the  uterus  in,  IV.  391 
time  of  operating  in,  IV.  386 
uterine  incision  in,  IV.  388 
vaginal,  for   inducing  abortion,  IV. 

437 
in   forcible   methods  of    delivery, 

IV.  444 

Caffeine  citrate  for  relief  of  pain,  I.  134 
in  diseases  of  the  heart,  1.  1227 
in  influenza,  I.  233 

Caigrer  (F.  Foord)  and  H.  E.  Cuff,  diph- 
theria, I.  187-202 
general  treatment  of  infectious  diseases, 

I.  157-160 

scarlet  fever,  I.  281-294 
typhus  fever,  I.  365-367 
^Caisson  disease,  1.  1306  ;  II.  1208-1209 
preventive  measures,  II.  1208 
remedial  measures,  II.  1208 
Calabar  bean,  poisoning  by,  I.  533 
Calcareous     deposits    of    the    tympanic 

membrane,  III.  892 
waters,  III.  120 

Calcium  chloride  in  haemorrhage,  I.  1261 
lactate  in  acute  alcoholism,  I.  495 
in  haemophilia,  II.  34 
in  haemorrhage,  I.  1261 
permanganate  of  in  lead  colic,  I.  513 
Calculous  disease,  diet  in,  II.  207 
Calculus,  II.  753-766 
anuria  in,  II.  755 

operations  for,  II.  757 
bilateral  renal,  II.  765 
in  a  solitary  kidney,  II.  766 
nephrectomy  for,  II.  765,  779 
pancreatic,  II.  724-725 
prophylactic  treatment,  II.  753 
prostatic,  II.  918 

complicating  prostatic  adenoma,  II. 

945 
renal,  cases  unsuitable  for  operation,  II. 

758 

colic  and,  II.  755 
haematuria  and,  II.  755 
hydronephrosis  with,  II.  773 
nephrolithotomy  for,  II.  759,  764 
operative  treatment  of,  II.  758 
pyelolithotomy  for,  II.  763,  764 
salivary  impacted,  causing  simple  paro- 
titis, II.  157 
and  inflammation  of  parotid  gland, 

II.  159 

ureteral,  II.  846-851 
vesical,  II.  852-857 
in  female  bladder,  IV.  876 
litholapaxy  in,  II.  854,  855 
median  perineal  lithotomy  for,   II. 

856 

mineral  waters  and  baths  in,  III.  140 
operations  for,  II.  854 


18 


Calculus  vesical  (contd.~) — 

preventive  treatment  of,  II.  853 
removal  of  through  urethra,  IV.  876 
supra-pubic  lithotomy  for,  II.  856 
Callard  diabetic  food,  I.  414,  418,  421 

flour,  I.  421 
Callus,   formation    of,   massage    and,    I. 

579 
Calomel  in  acute  gastritis,  II.  347 

in  acute  gout,  I.  432 

in  acute  rheumatism,  I.  270 

in  amoebic  dysentery,  III.  432 

in  syphilis.  I.  318 

in  typhoid  fever,  I.  353 
Caloric  value  of  foods,  II.  198 

table  of  values,  II.  198 
Calvities    or    alopecia    seborrhoica,    III. 

1001 
Cameron  (Samuel   J.),   amenorrhcea   and 

scanty  menstruation,  IV.  725-735 
Camphor,  compound  tincture  of,   use  of, 
I.  245 

in  chronic  congestion  of  the  lungs,  I. 
1079 

liniment  in  bronchitis,  I.  245 
Cancer  a  deux,  I.  120 

aetiology  of,  I.  116-119 

alder  leaves  in,  I.  149 

and  anaemia,  II.  16 

atoxyl  in,  I.  149 

cataphoresis  in,  I.  153 

chronic  irritation  as  a  cause,  I.  118 

Coley's  fluid  in,  I.  152 

diagnosis  of,  I.  121 

drug  treatment  of,  I.  148 

electrical  methods  in,  I.  153 

exploratory  incision  in,  I.  121 

ferments  in  treatment  of,  I.  151 

fulguration  in,  I.  154 

gastric,  II.  296-301 

general   principles  of  treatment  of,  I. 
116-156 

haemorrhage  from  stomach  in,  II.  329 

infection  of,  I.  120 

inoperable,  treatment  of,  by  control  of 
discharge,  haemorrhage  and  ulcera  • 
tion,  I.  136 

by  empirical  remedies,  I.  147 
by  palliative  removal  of  growth,  I. 

131 

by  relief  of  cachexia,  I.  132 
by  relief  of  obstructions,  I.  138 
by  relief  of  pain,  I.  133 
by  relief  of  special  symptoms,  I.  144 
by  vaccines,  I.  133 

irradiation  in,  I.  155 

Keith  methods  in,  I.  149 

local  infection  in   same  individual,   I. 
120 

lymphatic  permeation  of,  I.  125 

mammary,  spread  of,  I.  126 

metastatic  growths  of,  I.  124 

of  alimentary  system,  I.  139-142 

of  ampulla  of  Vater,  II.  714 

of  biliary  passages,  I.  143 


A    SYSTEM   OF  TREATMENT. 


Cancer  (contd.) — 

of  bladder,  II.  871 

of  bones  of  the  skull,  I.  895 

of  both  breasts,  II.  9G5 

of  cervix  uteri,  IV.  567,  582  617 

of  colon,  II.  578-584 

of  corpus  uteri,  leucorrhcea  in,  IV.  570 

of  female  urethra,  IV.  872 

of  Fallopian  tube,  IV.  801-803 

of  glands,  I.  1350 

of  jaws,  II.  112 
mortality  of,  II.  117 

of  pancreas,  II.  729 

of  prostate,  II.  933 

of  respiratory  organs,  I.  142 

of  tongue,  operative  treatment,  II.  141- 
144 

of  urinary  organs,  I.  142 

of  uterus,  IV.  570,  575-581 

oophorectomy  in,  I.  150 

operability  of,  I.  122 

operations  on,  complications  of,  I.  128 

organo-therapy  in,  I.  149 

pain  in,  relief  of,  I.  133 

pathological  anatomy  of,  I.  123 

placental  extract  in,  I.  150 

post-operative  treatment  of,  I.  129 

pre-cancerous  conditions,  I.  116-119 

preventive  treatment  of,  I.  116-121 

primary,  of  the  vagina.  IV.  553 

radical  treatment  of  operable,  I.  123 

radium  in,  I.  155 

recurrence  of,  I.  123 

secondary  of  the  umbilicus,  II.  281 

serum  treatment  of.  I.  152 

soamin  in,  I.  149 

sijuamous  cell,  eczema  preceding,  I.  117 
ovarian  dermoids  the  seat  of,  I.  110 

synthetic  preparations  in,  I.  149 

thymus  extract  in,  1. 150 

thyroid  extract  in,  I.  150 

vaccine  therapy  of,  1.  152 

vegetable  preparations  for,  I.  148 

violet  leaves  in,  I.  149 

X-ray  treatment  in  inoperable,  I.  155 
Cancer-cell  injection  of  operation  area  in 

vaginal  hysterectomy,  IV.  600 
Cancer-cells,  growth  of,  inhibition  of,  I. 

129 

Cancer-houses,  I.  120 
Cancroin,  valueless,  I.  152 
Cancrum  oris,  II.  124-125 

complicating  measles,  I.  247 
typhoid  fever,  I.  357 

and  noma,  gangrenous,  I.  219 
Canines,  lower,  extraction  of,  III.  1183 

upper,  extraction  of,  1181 
Cannula  for  venous  infusion,  subcutaneous, 

IV.  222 

Cantharides  plasters  in  counter-irritation 
for  rheumatoid  arthritis,  I.  405 

poisoning  by,  treatment  of,  I.  532 
Cantlie    (James),   abscess    of    the    liver, 

surgical  aspects  of,  II.  648-656 
Capsule  forceps  for  cataract,  III.  626 


Caraate  or  piiita,  III.  477 
Carbohydrates,  digestion  of,  II.  191 
effect  in  rickets,  1.  479,  481 
food-tables,  showing  percentages  of,  I. 

411,  419 
foods  arranged  in  order  of  value  in,  1 1. 

197 

in  diabetes  mellitus,  I.  422 
in  dietetics,  II.  201 
in  typhoid  fever,  I.  342 
Carbolic  acid  antiseptic  in  typhoid  fever, 

I.  S51,  354 

in  pruritis,  III.  1098 
in  ulcer  of  the  cornea,  III.  565 
in  whooping  cough,  I.  382 
poisoning  by,  I.  527 
sterilisation  with,  I.  72 
fomentations,    gangrene    following,    I. 

168,  170 

gauze  and  wool,  I.  78 
Carbon  dioxide  in  port-wine  stains,  III. 

1078 

poisoning,  I.  534 
solid,   in  lupus    erythematosus,   III. 

1071 

rodent  ulcer  treated  by,  I.  115 
in  warts,  III.  1157 
snow  in  small  capillary   naevi,  III. 

1078 

monoxide  poisoning,  I.  534 
Carbonic  acid  poisoning,  I.  534 
Carbuncles,  I.  888  ;  III.  1012-1014 
complicating  diabetes  mellitus,  I.  425 
general  treatment  of,  III.  406,  1012 
in  plague,  III.  406 
ionic  medication  of,  III.  184 
local  treatment  of,  III.  1013 
vaccine  treatment  of,  III.  1013 
Carcinoma.     See  Cancer. 
Garden's  operation,  I.  862 
Cardio-vascular  disease  in  insomnia,  II. 

1019 

Cardiolysis  in  pericarditis,  I.  1189 
Cardiospasm  of  the  stomach,  II.  357 
Carlsbad  water  in  acute  gastritis,  II.  347, 

352 
Carneous  mole  complicating  pregnancy, 

IV.  59 

Carpets,  disinfection  of,  I.  162 
in  sick  room,  cleansing  of,  I.  26 
use  of  in  nursery,  I.  44 
Capillary  haemorrhage,  I.  1272 
Carotid   artery,  common,  excision  of,  in 
aneurysm,  1.  1303 

wounds  of,  I.  1274 
external,  excision  of,  in  aneurysm,  I. 

1303 

wounds  of,  I.  1274 
internal,  excision  of,  in   aneurysm,  I. 

1303 

wounds  of,  I.  1274 
Carpus,  fractures  of,  I.  604 
Carr  (J.  Walter),  whooping  cough,  I.  376- 

385 
'•  Carriers  "  of  disease,  I.  336 

19  2—2 


A    SYSTEM  OF  TREATMENT. 


"  Carrion's  fever,"  III.  459 
Carr's  splint,  I.  603 
Carton's  catheter,  IV.  115 
Caruncle  of  the  female  urethra,  IV.  872 
vascular,  of  the  meatus  urinarius,  IV. 

512 
Cascara  sagrada  in  constipation  in  adults, 

II.  448 
Caseation  in  tuberculous  disease   of  the 

knee-joint,  I.  768 
Castellammare  spa,  III.  149 
Castor  oil  enema,  I.  32 

in  constipation  in  adults,  II.  448 
Cataphoresis  in  arthritis  and  synovitis,  I. 

746 

in  cancer,  1.  153 

in  gout  and  gouty  conditions,  I.  441 
Cataract,  III.  607-641 
after-,  III.  634 

complicated  capsular   opacities,   III. 

637 

simple  capsular  opacities,  III.  634 
complete  milky,  III.  608 
complicated,  III.  641 
complications      by      presentation      of 

vitreous  humour,  III.  628 
extracting,  bandages  for  eyes  after,  III. 

631 
immature,  Smith's  operation  for,  III. 

621 

juvenile,  III.  607 
lamellar,  III.  608 

curette  evacuation  of  lens  in,  III.  613 
discission  of  the  lens  in,  III.  611 
linear  extraction  of  lens  in,  III.  613 
operative  treatment  of  lens  in,  III.  611 
mature,  delivery  of  the  lens  in,  III.  626 
general  treatment,  III.  633 
iridectomy  for,  III.  624 
operations  for,  III.  622 

anfesthetic  in,  III.  622 
position  of  patient  and  surgeon   in, 

III.  623 

post -operative  treatment  of,  III.  630 
preparation  of   patient  in   operation 

for,  III.  622 

solutions  for  use  in,  III.  623 
preliminary  iridectomy  in,  III.  619 
refraction  and,  III.  618 
secondary,  III.  641 
senile,  III.  615 

ante-operative  treatment,  III.  616 
artificial  maturation  of,  III.  620 
immature,  operations  to  extract,  III. 

620 

monocular,  III.  615 

shrunken  malformed  lenses  in,  III    607 
toilet  after.  III.  627 
traumatic,  III.  638 
Catarrh,   avoidance    of    in    infants    and 

children,  I.  46,  52 
chronic  endo-cervical  in  nulliparse,  IV. 

566 

conjunctival,  III.  551 
gastric,  alkalies  in,  I.  64 


Catarrh,  gastric  (contd.) — 
diet  in,  II.  209 

or  acute  indigestion,  I.  506-507 
mineral  waters  and  baths  in,  III.  143 
nasal,  in  young  children,  I.  49 
naso-pharyngeal,  III.  739-741 
of  upper  air  passages,  climate  for,  III. 

101 

pituitous,  I.  1058 

spring,  of  the  conjunctiva,  III.  560 
Catgut  ligatures,  sterilisation  of,  I.  72 
suture,    continuous,    in    operation    for 

inguinal  hernia,  II.  506 
Cathcart   (George   C.),   stammering,    III. 

327-330 

voice  production,  III.  331-340 
Catheter,  Carton's,  IV.  115 

Eustachian,  for  patency  of  Eustachian 

tube,  III.  948 
for  nasal  feeding,  I.  33 
for  rectal  feeding,  I.  29 
Jacques's,  in  cancer  of  the  stomach,  II. 

306 
passing  of,  I.  40 

in  females,  I.  40 
sterilisation  of,  I.  92,  909 
ureteral,  drainage  by  in  pyonephrosis. 

II.  815 
Caton,  on  cardiac  lesions  in  rheumatism, 

I.  278 

Cattle,  cancer  in,  I.  117 
Caustic  alkalies,  poisoning  by,  I.  527 

fluids,  injuries  to  stomach  by,  II.  284 
Caustics  in  cancer,  I.  148 

of  cervix,  IV.  616 
Cauterets  spa,  III.  149 
Cauterisation  in  cancer  of  cervix,  IV.  615 
in  lupus,  III.  1149 
of  granulations  in  chronic  inflammation 

of  the  middle  ear,  III.  908 
Cautery,  galvano,  in  haemorrhage,  I.  1258, 

1260 

in  haemorrhoids,  II.  619 
Cautley  (Edmund),  hypertrophic  stenosis 

of  the  pylorus,  II.  337-341 
laryngeal  spasm  in  children,  III.  827- 

830 

night  terrors,  II.  1036-1037 
rickets,  I.  478-482 
tetany  in  children,  II.  1272-1273 
Cavernositis,  II.  874 
Cellulitis,  axillary,  I.  183 
causes  of,  L  181 
cervical,   complicating  scarlet  fever,  I. 

290 

chronic  atrophic  form  of,  IV.  851 
complicating  gynecological  surgery,  IV. 

493 

constitutional  treatment  of,  I.  182 
Lud wig's  angina,  I.  183 
of  the  orbit,  III.  661 
pelvic,  IV.  322-838 

abscess  cavities  in,  drainage  of,  IV.  832 
anti-streptococcus  serum  in,  IV.  833 
diseases  of  pelvic  bones  in,  IV.  836 


20 


A    SYSTEM  OF  TREATMENT. 


Cellulitis,  pelvic  (contd.')— 

inflammation  virulent  in,  IV.  847 
moderate     acute    infection    in,    IV. 

827 
parametritis,  chronic  in,  IV.  834 

remote  in,  IV.  833 
summary  of  treatment,  IV.  837 
suppuration  in,  IV.  828 
vaccine  treatment  of,  IV.  837 
Centanni's  method  in  rabies,  I.  265 
Cephalhsematoma  of  newborn  child,  IV. 

363 
Cephalhsematomata  on  head,   injuries  in 

the  infar.t,  I.  S8C> 
Cephalotribe,    Auvard's   three-bladed    in 

craniotomy,  IV.  408,  411 
difficulties  of,  IV.  409 
in  craniotomy,  IV.  408,  409 
merits  of,  IV.  410 
Cerebellum,   diseases  of,  in  children,  II. 

1168-1166 

disorders  of,  II.  1246 
Cerebro  spinal   fluid,   escape  of,  in  spina 

bifida,  I.  913 
meningitis,  I.  250 
paraplegia,  II.  1196 
Ceresole-Reale  spa,  III.  149 
Ceridine  in  boils,  III.  1008 
Cerumen,  hypersecretion  of,  in  the  meatus, 

III.  884 

Cervical  auricle,  III.  876 
forceps  for  post-partum   haemorrhage, 

IV.  221 
Cervix     uteri,     acetone     applied    after 

curetting,  I.  137 

adenomatous  disease  of,  IV.  632-633 
amputation   of,  in  prolapse  of  uterus, 

IV.  1!)4,  199.  695 
atresia  of.  IV.  158,  712 

complicating  labour,  IV.  158 
cancer  of,  IV.  582-617 
acetone  in,  IV.  616 
appearance  of  early,  IV.  585 
caustics  for,  IV.  616 
cauterisation  in,  IV.  615 
complicating  labour,  IV.  160 
curative  treatment,  IV.  584 
differential  diagnosis  in,  IV.  589 
early  diagnosis  in,  IV.  584 
fibroids  of,  IV.  159 
fulguration  in,  IV.  617 
leucorrhoea  in,  IV.  567 
ligature  of  arteries  in,  1.  13(5 
operative  cure  of,  IV.  591 
palliative  treatment,  IV.  til") 
preventive  treatment,  IV.  582 
radical  abdominal  operation  in,  IV. 

601 
radical   hystero-vaginectomy  in,  IV. 

till 

radium  in,  IV.  615 
relief  of  symptoms  in,  IV.  617 
retardation  of  growth  in,  IV.  615 
signs  established  in,  IV.  587 
symptoms  of.  IV.  .">s.~> 


Cervix,  cancer  of  (contd.~) — 

total  abdominal  hysterectomy  in,  IV. 

600 

vaginal  hysterectomy  in,  IV.  593 
after-treatment,  IV.  596 
technique  of  operation,  IV.  593 
Wertheim's  operation  in,  IV.  601 
congenital  hypertrophy  of,  IV.  716 
conical,  IV.  713-716 
dilatation  of,  in  dysmenorrhoea,  IV.  762 
in  forcible  methods  of  delivery,  IV. 

442 
in   induction   of    premature    labour, 

IV.  439 

in  sterility,  IV.  854 
endometritis  of,  IV.  627 
erosion  of,  IV.  632-633 
fibroid  of,  anterior,   hysterectomy   in, 

IV.  651 

central,  hysterectomy  for,  IV.  648 
polypus  of,  IV.  658 
posterior,  hysterectomy  for,  IV.  652 
gonorrhoea  of,  leucorrhoea  in,  IV.  566 
hypertrophy  of,  IV.  700-706 
incision  of,  in  eclampsia,  IV.  40 
incomplete    removal    of,     in     vaginal 

hysterectomy.  IV.  600 
inflammation  of,  acute,  leucorrhoea  in, 

IV.  566 

chronic,  leucorrhoea  in,  IV.  566 
injuries  of.  IV.  707 
laceration  of,  severe,  IV.  189 

sterility  in,  IV.  857 
leucorrhrea  from,  IV.  566 
mucous  polypi  of,  IV.  567,  662 
podalic  version  in,  IV.  468 
rigidity  of,  IV.  159 
stenosis  of,  IV.  715 
supra-vaginal  portion,  hypertrophy  of, 

IV.  703,  705 

vaginal  portion,  amputation  of  in  endo- 
metritis, IV.  630  ;  hypertrophy  of, 
IV.  700,  701 

Chalazia  of  the  eyelids,  III.  578 
Chalybeate  waters,  III.  122 

in  chlorosis,  II.  26 
Championniere   (Lucas),   on    massage    in 

fractures,  I.  578 
on  fractures  of  clavicle,  I.  .~>S  t 
Chancre,  syphilitic,  I.  316 
of  the  tongue,  II.  134 
soft,  I.  315 

Chantemesse'sserum  in  typhoid  fever,  1. 347 
Chapman  on  diet  in  tuberculosis,  II.  203 
Chappa,  III.  466 

Charcot's  disease  of  joints,  I.  785 
Charles  (Sir  R.  H.),  elephantiasis  scroti, 

III.  504-516 
sunstroke,  I.  53ii-.r>3'.i 
Charwomen's  dermatitis,  III.  1030 
Chatel  Guyon  spa,  III.  1411 
Chaulmoogra  oil  in  leprosy.  III.  44!i 
Cheatle   (G.  L.),  on  extension  of  rodent 

ulcers,  I.  123 
surgical  technique,  I.  71-92 


21 


A    SYSTEM   OF  TREATMENT. 


Cheese,  chemical  composition  of,  II.  194 
Cheiropompholyx,  III.  1015-1016 
Cheloid  or  acne  cheloid,  III.  1018 
Cheloids,  causes  and  treatment  of,  I.  113 

of  the  scalp,  I.  893 
"  Chelsea  Pensioner,"  in  rheumatism,  I. 

490 

Cheltenham  spa,  III.  149 
Chemotherapy,  general  principles  of,  III. 

417 
Chest, 

-clapping  exercise  in  pulmonary  diseases, 

III.  252 

contusions  of,  I.  1025 
deformities  of,  due  to  incorrect  breath- 
ing, I.  50 

empyema  following  injury  to,  I.  1027 
generalised  in  the  lower  part  of,  I. 

1101 

expansion   exercises  for   spinal  curva- 
tures, III.  237 
foreign  bodies  in,  I.  1027 
injuries  of  the  contents  of,  I.  1028-1031 
new  growths  of,  I.  1034 
penetrating  gunshot  wounds  of,  I.  564 
stab  wounds  of,  II.  253 
voice  production  and,  III.  333 
wounds  of,  I.  1025-1028 
Cheyne's  (Sir  Watson),  operation  for  mal- 
formation of  the  nose,  III.  674 
Chian  turpentine  in  cancer,  I.  148 
Chianciano  spa,  III.  149 
Chicken-pox,  malignant  form  of,  I.  185 
prophylaxis  of,  I.  186 
treatment  of,  I.  186 
Chilblains,  III.  1019-1020 
Child,  newborn.     See  Infants. 
Children,  acute  appendicitis  in,  II.  405 
bronchitis  in,  I.  1052 
rheumatism  in,  I.  268,  271 
ailing,  anaemia  in,  II.  14 
antiflexion  of  uterus  in,  IV.  670 
asthma  in,  I.  1041 
baths  for,  directions  as  to,  I.  47 
brain  tumours  in,  II.  1166 
care  of,  I.  44-70 

the  digestion  in,  I.  45 
the  feet  in,  I.  57 

cerebellar  conditions  in,  II.  1165-1166 
clothing  of,  directions  as  to,  I.  50  ;  IV. 

339 

colic  in,  II.  428-431 
constipation  in,  II.  432-438 
centra-indications    to    excisions   in,   I. 

770 
control  of  the  bladder  and  bowels  in, 

I.  53 

cookery  for,  directions  for,  I.  59 
deafness  in,  causes  of,  III.  979 
educational  treatment  of,  III.  981 
surgical  treatment  of,  III.  980 
diarrhceal  diseases  of,  II.  471-478 
dietary  suitable  for,  I.  58-81  ;  II.  202 
digestive  system  of,  derangements  of, 
causes  of,  I.  64 


Children  (contd.~) — 

diseases  of,  external  applications  in,  I. 

69 

dosage  of  medicines  for,  I.  66 
^exercises  for,  I.  51,  57 
fat,  not  always  healthy,  I.  59 
fatigue  in,  to  be  avoided,  I.  56 
foreign  bodies  in  the  ear  of,  III.  889 
gonorrhoeal  salpingitis  in,  IV.  807 
"  hardening  "  of,  danger  of,  I.  46,  50 
hip  joint,  disease  in,  I.  754 
hygiene  of,  I.  44-70 
laryngeal  spasm  in,  III.  827-830 
management    of,    during    anaesthetics, 

III.  25 

multiple  papillomata  in,  III.  851 
muscular  atrophy  in,  family  form  of, 

II.  1247 

ponos  in,  III.  440 
postures  of,  I.  56 

premature,  treatment  of,  IV.  372 
pyelitis  in,  II.  805 
rest  for,  I.  56 
rheumatism  in,  I.  276-279 
sleep  of,  amount  required,  I.  54 
tetany  in,  II.  1272-1273 
tumours  of  the  kidney  in,  II.  836 
vulvitis  in,  IV.  560 
vulvo-vaginitis  in,  IV.  528,  560 

See  also  Infants. 
Chill,  avoidance  of,  after  baths  and  packs, 

I.  38 
in  infants  and  children,  I.  46,  50,  52, 

53 

and  food  fever,  II.  236 
Chinosol  in  syphilitic  ulcers,  II.  136 
Chittenden  on  food  values,  I.  450 

on  over-nutrition,  I.  451 
Chittenden's  diet  tables,  II.  200 
Chloasma,  III.  1017 
Chloral    in     diseases    of    the    heart,    I. 

1225 

hydrate  in  asthma,  I.  1040 
in  epilepsy,  II.  996 
in  restlessness  of  fever,  I.  244 
poisoning,  treatment  of,  I.  530 
use  of,  in  diseases  of  children,  I.  67 
in  morphinism,  I.  518 
Chloralamide  in  insomnia,  I.  366 

of  scarlet  fever,  I.  286 
in  simple  insomnia,  I.  159 
Chloretone  in  children's  diseases,  I.  67 
Chloride  in  opacity  of  the   cornea,   III. 

572 

of  sodium,  ionisation  with,  I.  488 
Chlorine  in  typhoid  fever,  1.  354 
ions,  III.  184 

solution,  mouth  wash  of,  I.  285 
Chloroform,    anaesthetic    mixtures    with, 

III.  19 

as  anaesthetic,  III.  13 
in  convulsions,  I.  292 
in  eclampsia,  IV.  36 
inhalation  of,   in   aortic   aneurysm,   I. 
1299 


22 


A    SYSTEM  OF  TREATMENT. 


Chloroform  (contd.) — 

Junker's  inhaler  for  administration  of, 
III.  16 

poisoning,  delayed,  in  fatty  liver,  II. 

669 

treatment  of,  I.  531 

Chloroma  of  the  bones  of  the  skull,  I.  895 
Chlorosis,  II.  20-31 

arsenic  in.  II.  27 

baths  for,  II.  26 

chalybeate  waters  in,  II.  26 

constipation  in,  II.  30 

diet  in,  II.  29 

digitalis  in,  II.  27 

emetics  in,  II.  28 

general  principles  in,  II.  20,  30 

intestinal  antiseptics  in,  II.  28 

iron  preparations  in,  II.  21 

manganese  in.  II.  27 

marriage  and,  II.  31 

mineral  waters  and  baths  in,  III.  143 

organic  iron  compounds  in,  II.  24 

quinine  in,  II.  27 

rest  in,  II.  20 

salt  in,  restricted,  II.  28 

scale  preparations  in,  II.  24 

spas  for,  II.  26 

sulphur  in,  II.  27 

sunshine  in,  II.  20 

theocin-sodium  acetate  in,  II.  27 

wines  in,  II.  25 

Cholangiostomy,  intrahepatic,  I.  144 
Chlorotic  thrombosis,  I.  1331 
Cholangitis.  II.  701 

infective,  II.  704 

suppurative,  II.  705 

Cholecyst-enterostomy  in   biliary  cancer, 
I.  143 

in  cholelithiasis,  II.  694,  695 
Cholecystitis,  catarrhal,  II.  700 

obliterative,  II.  701 

phlegmonons,  acute,  II.  704 
Cholecystostomy  in  biliary  cancer,  I.  143 

for  cholelithiasis,  II.  686,  693 
.Cholelithiasis,  II.  682-685 

after  treatment,  II.  695 

biliary  colic  in,  II.  684 

cholecystenterostomy  in,  II.  694,  695 

cholecystotomy  for,  II.  686,  693 

cholelithotrity  and,  II.  695 

diet  in,  II.  683 

enlargement  of  the   pancreas   and,  II. 
694 

general  treatment,  II.  682 

intermittent  hepatic  fever  in,  II.  684 

intervisceral  fistula  and,  II.  695 

malignant  disease  and,  II.  695 

prophylaxis  of,  II.  682 

spa  treatment  of,  II.  683 

surgical  treatment  of,  II.  686-697 
Cholelithotrity  and  cholelithiasis,  II.  695 
Cholera,  III.  423-427 

anti-choleraic  vaccination  of,  III.  423 

convalescence  in,  III.  427 

diseases  of  the  intesiines  in,  III.  I.'." 


Cholera  (contd.}— 

personal  hygiene  in,  III.  424 
prophylactic  measures  in,  III.  423 
stage  of  collapse  in,  III.  426 
invasion  in,  III.  425 
reaction  in,  III.  427 
treatment  of  an  attack  of,  III.  425 
diarrhoea  in,  III.  425 
discharges  in,  III.  427 
vaccine  therapy  in,  III.  273 
Cholesteatoma,  III.  934 
Chondrodystrophia  fatalis,  II.  1227 
Chondroma  of  the  scalp,  I.  893 
Chopart's    disarticulation    at    the    mid- 

tarsal  joint,  I.  840 
operation,  comments  on,  I.  842 
disarticulation  in,  I.  842 
flaps  in,  I.  842 
incision  in,  I.  842 
indications  for,  I.  840 
superficial  landmarks  in,  I.  841 
Chordee    and    painful    erections   of    the 

penis  complicating  gonorrhosa,  1.  226 
Chorea,  II.  1257-1263 
blistering  in,  II.  1262 
care  of  the  bowels  in,  II.  1261 
convalescence  of,  II.  1262 
diet  in,  II.  1261 
Huntingdon's,  II.  1249 
hypnotism  in  case  of,  III.  174 
in  children,  ergot  in,  I.  68 
massage  in,  II.  1263 
medicinal  measures  in,  II.  1257 
nursing  in,  II.  1262 
rest  in,  II.  1260 
spa  treatment  in,  II.  1263 
special  baths  in,  II.  1263 
Chorea   gravidarum.    complicating  preg- 
nancy, IV.  51 
Chorio-carcinoma  of  the  uterus,  IV.  618- 

619 
Chorion-epithelioma  of  Fallopian  tube,  IV. 

804 

of  the  uterus,  IV.  618-619 
Choroid,  diseases  of,  III.  597 
rupture  of,  III.  597 
tumours  of,  III.  597 
Choroiditis,  III.  597 
Chromidrosis,  or  coloured  sweating,  III. 

1021 
Chrysarobin  in  alopecia  areata,  III.  995 

in  psoriasis,  III.  1117 
Chyluria  in  tilariasis.  III.  503 

(non-parasitic),  II.  752 
Cicatricial  oedema  of  larynx,  III.  863-876 
Cicatrix.  formation,  after  amputation,  I. 

793,  795 

Cider  in  gout,  I.  467 
Ciliary  body,  diseases   of,  III.   583,  592- 

596 
inflammation  of,  III.  592 

vitreous  opacities  in,  III.  593 
paracentesis  of  anterior  chamber,   III. 

593 
tumours  of,  III.  596 


23 


A    SYSTEM  OF  TREATMENT. 


Cinchona  in  alcoholism,  I.  501 
Circulation,  disorders  of,  Zander  treatment 

in,  III.  371 
enfeebled,  cerebral  thrombosis  due  to, 

II.  1178 
in tra- cranial  venous,  vascular  tumours 

in  communication  with,  I.  894 
Circulatory  system,    diseases  of,   climate 

for,  III.  97 

electro-therapeutics  in,  III.  109 
massage  and  the,  III.  209 
Circumcision,  II.  880-881 
Circumflex  nerve,  injuries  of,  II.  1111 
Cirrhosis  hepatic,  II.  631 
Citrated  milk,  II.  225 
Citrates  in  influenza,  I,  223 
Clamp  for  haemorrhoids,  II.  619 
Clarke  (Ernest),  errors  of  refraction  and 

accommodation,  III.  528-542 
Claudication,  intermittent,  II.  1234-1236 

serum  treatment  of,  II.  1235 
Claustrophobia  in  psychasthenia,  II.  1044 
Clavicle,  dislocation  of,  I.  714 
fractures  of,  I.  583,  680 

in  newborn  child,  IV.  354,  366 
resection  of    in  Berger's  operation,  I. 

831 
Cleaves  (Margaret),  on   "light  energy," 

III.  191 

Cleft  palate,  II.  147-156 
Cleidotomy  in  contracted  pelvis  compli- 
cating labour,  IV.  171 
in  craniotomy,  IV.  412 
Climate,     conditions     unfavourable    for 

abdominal  operations,  II.  257 
diseases  induced  by,  I.  5 
effect  of,  in  dietetics,  II.  200 
for  anaemia,  III.  92 
for  arthritis  deformans,  I.  392 
for  asthma,  I.  1037 
for  Basedow's  disease,  III.  99 
for  catarrh  of  upper  air  passages,  III. 

101 

for  diabetes,  III.  96 
for  diseases  of  the  circulatory  system, 

III.  97 
of    digestive   system,    II.   351  ;    III. 

98 

of  the  heart,  III.  97 
of  the  kidney,  III.  101 
for  exophthalmic  goitre,  III.  99 
for  gout,  III.  93 
for  Graves's  disease,  III.  99 
for  nervous  ailments,  III.  99 
for  obesity,  III.  92 
for  rheumatism,  III.  94 
for  rheumatoid  conditions,  III.  94 
for  rickets,  III.  96 
for  tuberculosis,  III.  100 
in  atony  of  the  stomach,  II.  289 
in  chronic  bronchitis,  I.  1055 
in  exophthalmic  goitre,  II.  56 
in  gastric  disorders,  II.  351,  354,  360 
in  gout  and  gouty  conditions,  I.  460 
in  liypertrophic  emphysema,  I.  1083 


Climate  (contd.) — 

of  tropics,  adaptation  of  habits  to,  III. 
376 

pulmonary  tuberculosis  and,  I.  1118 
Climates,  classification  of,  III.  85 

tropical,  varieties  of,  III.  375 

warm,  diseases  of,  III.  375-516 

where  heat  demand  is  large,  III.  88 
is  medium,  III.  87 
is  small,  III.  86 

See  also  Tropical  diseases,  and  Tropics. 
Climatic  bubo,  III.  467 

demand,  law  of,  in  climatology,  III.  71 
Climatology,  III.  69-102 

climatic   requirements   in  disease   and, 
III.  91 

law  of  climatic  demand  in,  III.  71 

individual  response  in,  III.  78 
local  requirement  in,  III.  83 
Clinical  phenomena  of  disease,  I.  15 
Clitoris,  hypertrophy  of,  IV.  514 
Clothing,  disinfection  of,  I.  161 

during  pregnancy,  IV.  8 

faulty,  in  spinal  curvatures,  III.  236 

for  infants  ano!  children,  I.  50  ;  JV.  339 

in  abdominal  operations,  II.  260 

in  arthritis  deformans,  I.  393 

in  chronic  bronchitis,  I.  1055 
rheumatism,  I.  485 

in  rickets,  I.  478- 

in  the  tropics,  III.  377 
Clover's  crutch  for  retained  placenta,  IV. 
232 

in  lacerations  of  the  genital  tract,  IV.  188 

inhaler,  Hewitt's  modification  of,  III.  7 
Club-foot,  bar  on  outside  edge  of  sole  and 
inside  brace  for,  I.  954 

case  of  neglected,  I.  956 

congenital,  I.  951 

shoe,  I.  953 
Coagulation,   locally,  encouragement   of, 

in  haemophilia,  II.  32 
Coal-tar  derivatives  in  typhoid  fever,  I.  352 
Cocaine  in  whooping  cough,  I.  311 

poisoning  by,  I.  532  , 

Cocainisation,  for  foreign   bodies  in  air 

passages,  III.  816 
Cocainism,  I.  505,  532 
Coccydynia  or  coccygovynia,  I.  900,  921 
Coccyx,  contusions  of,  I.  900 

fracture  of,  I.  608 
Cochlea,   removal  of,   operation   for,  III 

973-974 
Cocoa,  chemical  composition  of,  II.  197 

in  typhoid  fever,  I.  343 
Codeine  in  constipation  in  adults,  II.  446 

in  diabetes  insipidus,  I.  429 

mellitus,  I.  424 
Cod-liver  oil,  dosage  of,  for  children,  I.  66 

in  rickets,  I.  479 

inunction  of,  I.  70 
Cceliac  disease,  II.  426-427 
Coffee  as  antidote  in  poisoning,   I.   530, 
532,  534 

in  typhoid  fever,  I.  343 


A    SYSTEM  OF  TREATMENT. 


Coin  catchers,  II.  185 

Colchiciiie  pills  in  gout,  I.  433,  4:'..", 

poisoning  by,  treatment  of,  I.  533 
Colchicum  in  gout,  I.  433,  435 

poisoning  by,  I.  533 
Cold,  exposure  to,  cause  of  rheumatism,  I. 

277,  279,  484 
in  haemorrhage,  I.  1260 
in  sprains,  I.  737 
protection    from,   necessary   to   young 

children,  I.  50 
Cold  baths  for  children,  directions  as  to, 

I.  47 

in  eclampsia,  IV.  37 
in  typhoid  fever,  I.  348 
use  of,  I.  36 
pack  in  cutaneous  inelasticity,  I.  69 

use  of,  I.  37 

sponging  in  fever,  I.  244 
in  hyperpyrexia,  I.  160 
Colds.     See  Catarrh. 

Colectomy  in  constipation  in  adults,  II.  468 
Coley's  fluid,  dosage  of,  III.  298 
in  cancer  and  sarcoma,  I.  152 
in  epithelioma  of  tongue,  II.  144 
in  inoperable  sarcoma,  I.  920 
in  malignant  tumours,  III.  298 
in  sarcoma  of  jaw,  II.  1 18 
prophylactic  use  of,  I.  130 
Coli-bacilluria  in  anaemia,  II.  14 
Colic,  biliary,  and  cholelithiasis,  II.  684 
from  foods  containing  curds,  II.  231 
in  children,  II.  428-431 
in  lead  poisoning,  I.  512 
renal  and  calculus,  II.  755 
Colitis,  II.  562-569 

chronic  mucous,  II.  570 

mucous,  appendicostomy  for,  II.  571 
caecostomy  in,  II.  571 
valvular  caecostomy  in,  II.  571-573 
complicating  gastroptosis,  II.  321 
haamorrhagic,  11.  574 
membranous,  II.  563 
surgical  treatment  of,  II.  570 
ulcerative,  II.  568,  576 
diet  in,  II.  211 

in  mercurial  poisoning,  t.  530 
Collapse  and  anaesthetics,  III.  24 
cause  of,  I.  94 
following  sudden  suppression  of  drugs, 

1.516 

in  abdominal  injuries,  II.  244 
in  emergency  cases  of  abdominal  opera- 
tions, II.  260 
in  food  poisoning,  I.  509 
in  marasmus,  I.  467 
intravenous  infusion  in,  I.  104 
mustard  bath  for,  I.  3S 
saline  injections  in.  I.  33 
treatment  of,  I.  94,  1U4 
Colles's  fracture,  I.  602 

of  radius,  I.  578 

Collier  (James),  aphasia  and  other  speech 
defects  of  cerebral  origin,  I.  1143- 
1149 


Collier  (James)  (cunfd.) — 
apraxia,  If.  1150-1J52 
migraine  aQd  other  forms  of   periodic 
•    headache,  II.  1027-1035 
treatment   to  facilitate   restoration   of 
speech  faculties  by  functional  com- 
pensation, II.  1049-1051 
Collodion,  dressing  with,  method  of,  I.  89 
flexile,  use  of,  in  bedsores,  I.  911 
in  small-pox,  I.  305 
in  wounds,  I.  552 

Colon,    abnormalities  of,  chronic   consti- 
pation due  to,  II.  470 
adhesions  of,  II.  559 

non-operative  treatment  in,  II.  559 
operative  treatment,  II.  560 
bacillus  peritonitis,  II.  641 
cancer  of,  II.  578-584 
caecostomy  for,  II.  584 
colotomy  for,  II.  581 
excision  of  growths  in  csecal  region, 

II.  580 

immediate  anastomosis  in,  II.  579 
left,  inguinal  colotomy  for,  II.  581 
lumbar  colotomy  in,  II.  583 
palliative  operations  for,  II.  580 
Paul's  operation  for,  II.  580,  584 
relief  of  obstruction  in,  I.  141 
resection  of  the  growth,  II.  579 
short-circuiting  operation  for,  II.  580 
congenital  abnormalities  of,  II.  585 
dilatation  of,  II.  585 

acute  obstruction  in,  II.  585 
colotomy  for,  II.  586 
non-operative  treatment,  II.  585 
operative  treatment,  II.  586 
resection  in,  II.  586 
hypertrophy  of,  II.  585 
diseases  of,  II.  559-592 

chronic  constipation  due  to,  II.  470 
mineral  waters  and  baths  in,  III.  139 
exclusion  of,  in  constipation  in  adults, 

II.  468 

hyperplastic  tuberculosis  of,  II.  590 
in  enteroptosis,  surgery  of,  I.  431 
multiple  polypi  of,  II.  588 
perforation  of,  II.  558 
in  pericolitis,  II.  576 
tuberculosis  of,  II.  590 

ulcer  of,  with  perforation,  II.  589 
volvulus  of,  II.  591 
operation  for  shortening    mesocolon 

in,  II.  592 

Colostomy  in  cancer  of  intestines,  I.  141 
Colotomy  in  cancer  of  the  colon,  II.  581 
in  congenital  dilation  of  the  colon,  II. 

586 
left  inguinal,  for  cancer  of  the  colon, 

11.581 
lumbar,   in   cancer  of    the    colon,   II. 

583 

Colpo-perineorruaphy,    posterior,   in   pro- 
lapse of  uterus,  IV.  694 
Colporrhaphy,  anterior,  IV.  549 
in  prolapse  of  uterus,  IV.  694 


A    SYSTEM  OF  TREATMENT. 


Colpotomy  in  tubal  pregnancy,  IV.  87 
Coma,  II.  982-985      . 
alcoholic,  II.  984 
associated    with    intra-cranial   abscess 

and  tumour,  II.  983 
cerebral  haemorrhage  and,  II.  984 
diabetic,  1.  424  ;  II.  983 
epileptic,  II.  983 

following  morphia  poisoning,  II.  984 
in  heat  stroke,  II.  985 
malarial,  II.  985 
urasrnic,  II.  982 
Combretum  sundiacum  in  opium  smoking, 

1.518 

Comedones,  III.  1022-1023 
local  procedure  for,  III.  1022 
of  the  auricle,  III.  881 
Rontgen  rays  in,  III.  1023 
Complications  and  sequelae  of  disease,  I. 

22 

Compresses,  changing  of,  I.  36 
Conception,  retention  of  products  of,  sub- 
involution  of  uterus  by,  IV.  721 
Concretions  of  the  stomach,  II.  359 

See  also  Calculi. 
Concussion  of  brain  in  cranial  fractures, 

1.877 

Condiments  in  obesity,  I.  472 
Condurango  in  anorexia  of  gastric  cancer, 

II.  298 
Condylomata,  acuminate,  of  the  vulva,  IV. 

511 
Congenital  abnormalities  of  the  colon,  II. 

585-587 
absence  of    the  tympanic  membrane, 

III.  891 

affections  of  the  heart,  I.  1254' 
alopecia,  III.  997 
amblyopia,  III.  543 
amyotonia,  II.  1245 
anteflexion  of  the  uterus,  IV.  670 
atresia  of  the  meatus,  III.  882 
pylorus,  II.  344 

cystic  disease  of  kidney  in  foetus  com- 
plicating labour,  IV.  180 
goitre  complicating  labour,  IV. 

180 
defects  of  the  newborn  child,  IV.  355- 

363 

dilatation  of  the  colon,  II.  585 
elevation  of  the  shoulder,  I.  985 
hydronephrosis,  II.  772 
hypertrophy  of  cervix,  IV.  716 

of  the  colon,  II.  585 
malformations   of    the   penis,  II.   875- 

87« 

of  the  umbilicus,  II.  277 
of  the  ureter,  II.  774 
of  the  vagina,  IV.  541 
myotonia,  II.  1252 
obliteration    of      the     bile-ducts,     II. 

673 
perforations  of  the  tympanic  membrane, 

III.  891 
ptosis,  III.  650 


Congenital  abnormalities  (contd.~) — 
syphilis  in  newborn  child,  IV.  369 

and  jaundice,  II.  672 
varix,  I.  1310 

webs  of  the  meatus,  III.  882 
Congestion,    passive.      See    Bier's    treat- 
ment. 

Conjunctiva,  burns  of,  III.  547 
diseases  of,  III.  547-562 

general  rules  in,  III.  548 

prescriptions  in,  III.  548 
pterygiurn  of,  III.  561 
snow  blindness  of,  III.  560 
spring  catarrh  of,  III.  560 
symblepharon  of,  III.  548 
tuberculosis  of,  III.  560 
tumours  of,  III.  561 
wounds  of,  III.  547 
xerosis  of,  III.  561 
Conjunctivitis,  catarrhal,  III.  551 
complicating  influenza,  I.  239 

small-pox,  I.  309 
diphtheritic,  III.  557 
electric,  III.  560 
in  measles,  1.  246 
phlyctenular,  III.  552 
Connell   (Arthur),   diseases  of   the   lym- 
phatic glands,  I.  1339-1340 
injuries  of  the  spleen,  II.  79-80 
lymphatic  vessels,  I.  1351-1352 
new  growths  of  glands,  I.  1350 
surgical  treatment  of  spleen,  II.  81 

of  tuberculous  glands,  I.  134S 
Connell  (K.),  on   acid  urine  in  typhoid 

fever,  I.  346 
Constipation  after  abdominal  operations, 

II.  264 

and  insomnia,  II.  986 
and   modifications    of    diet  in    simple 

digestive  disorders,  II.  231 
auto-intoxication  and,  I.  387 
chronic,  appendicostomy  for,  II.  470 

due  to  abnormalities  of  the  colon,  II. 
470 

due  to  disease  of  colon,  II.  470 

ileo-sigmoidostomy  for,  II.  470 

massage  in,  III.  21 1 

complicating      diabetes      mellitus,     I. 
426 

typhoid  fever,  I.  358 

ulcer  of  the  stomach,  II.  381 
constitutional,  II.  445 
cumulative,  II.  445 
diet  in,  II.  212 
in  adults,  II.  439-469 

abdominal  supports  in,  J  I.  462 

alkaloids  in,  II.  446 

amount   of  fluid  for  enemata  in,  II. 
454 

castor  oil  in,  II.  448 

choice   and  dosage  of  purgatives  in, 
II.  445 

dietetic  treatment  of,  II.  441 

electrical  treatment,  II.  464 

enemata  in,  II.  452,  457 


26 


A   SYSTEM  OF  TREATMENT. 


Constipation  in  adults  (i-nntd.)— 
exercise  in,  II.  459 
general    indications   for   the    use    of 

eiiemata  in,  II.  457 
glycerine  suppositories  in,  II.  453 
hydrotlierapy  in.  II.  459 
hygiene  of  the  bowels  in,  II.  439 
indications  for  purgatives  in,  II.  444 
intestinal  lavage  in,  II.  467 
massage  in,  11.  462 
medicinal  treatment  of,  II.  444 
mercurial  purgatives  in,  II.  450 
natural  aperient  waters  in,  II.  466 
operative  treatment  of,  II.  467 
psychotherapy  in.  11.411 
removal  of  impacted  faeces  in,  II.  l"»i' 
saline  purgatives  in,  II.  449 
short-circuiting    operations    for,    II. 

467 

spa  treatment  of,  II.  465 
substaiices  which  increase  the  bulk  of 

the  faeces  in,  II.  45(1 
suppositories  in,  II.  452 
Swedish  gymnastics  in,  II.  459,  460 
^ynthfsised  purgatives  in,  II.  449 
varieties  of  enemata  in,  II.  l.">4 
vegetable  purgatives  in,  II.  447 
in  amenorrhoaa,  IV.  726 
in  atony  of  the  stomach,  II.  287 
in  cancer  of  the  stomach,  II.  300 
in  children,  II.  432-438 
anal  fissure  in,  II.  436 
atonic  dilatation  of  the  bowel  in,  H. 

435 

local  causes  of,  II.  434 
overloaded  condition  of  sigmoid  in, 

II.  435 

prevention  of,  II.  432 
spasmodic  contraction  of    sphincter 

ani  in,  II.  436 
in  chlorosis,  II.  30 
in  general  paralysis  of  the  insane,  II. 

1079 

in  insomnia,  II.  1018 
in  newborn  child,  IV.  368 
in  secretory  disorders  of  the  stomach, 

II.  363 
intestinal,  electricity  in,  II.  464 

eneuiata  in,  II.  457 
intractable,  II.  445 
mineral  waters  and  baths  in.  III.  139 
neurasthenic,  electricity  in,  II.  465 
senile,  II.  4  15 
symptomatic,  II.  444 
Constitution,   bodily,  causes  of  weakness 

of,  I.  r> 

Consumption,  pulmonary,  I.  1117-1126 
Contacts,  plague.  III.  402 
Contagious  diseases,  disinfection   of   bed- 
rooms during  and  after.  I.  l<>4 
Contractions  following  burns  and  scalds, 
l.  :>4:< 

wounds,  1.  555 
Contrexeville  spa,  III.  149 
Contusions  and  hcematoma,  I.  545-546 


Convalescence,  cautions  as  to,  I.  22 

from  acute  rheumatism,  I.  273 

from  anaemia,  II.  15 

from  influenza,  I.  '-'85 

from  typhoid  fever.  I.  364 

from      whooping      cough,     treatment 
during,  I.  384 

in  acute  bronchitis,  I.  1053 

in  chorea,  II.  1262 

in  pernicious  anaemia,  II.  11 

management  of.  I .  L'L' 
in  children,  I.  lit 

protracted,    mineral  waters  and  baths 
in,  III.  146 

quinine  during,  I.  65 
Convulsions,  chloroform  in,  I.  292 

in  measles,  I.  246 

in  newborn  child,  IV.  371 

infantile,  II.  986-989 
rapidly  repeated,  II.  988 

warm  baths  in,  I.  70 
Cookery  for  children,  directions  for,  I.  59 

for  the  sick  room,  I.  42 
Cooking,  effect  on  food,  II.  198 
Coolie  itch,  III.  486 
Cooper's       modification      of      Lisfranc's 

amputation,  I.  840 

Copper,  salts  of,  acute  poisoning  by,  I.  529 
Coracoid  process,  fracture  of,  I.  586 
Corn  preparations,  chemical  compositions 

of,  II.  195 
Cornea,  conical,  III.  563 

dermoid  of,  III.  563 

diseases  of.  III.  563-573 

herpes  frontalis  and,  III.  571 

interstitial  keratitis  of,  III.  568 

Mooren's  ulcer  of,  III.  566 

opacities  of,  III.  571 

phlyctenular  ulceration  of,  III.  567 

rodent  ulcer  of,  III.  566 

sclerosing  keratitis  of,  III.  570 

tuberculous  keratitis  of,  III.  569 

ulcer  of,  III.  563 

complicating  small-pox,  I.  309 

vascular,  keratitis  of,  III.  570 
Corner  (Edred  M.),  abdominal   injuries, 
II.  242-256 

peritonitis,  II.  632-642 

subphrenic  abscess,  II.  643-644 
Cornflour,  preparation  of,  I.  42 
Corns,  III.  1024-1025 
Coronoid  process,  fracture  of,  I.  598 
Corpus     cavernosum,    thrombosis    of,    I. 

1331 

Corrosive  poisoning,  I.  526 
Corrosives,     atrophy    of    stomach    from 

ingestion  of.  II.  294 

Corsets,  avoidance  of,  in  gastroptosis,  II. 
319 

for  movable  kidney,  II.  789 
Costo-transversectomy  in  abscess  in  con- 
nection with  tuberculous  disease  of  the 

spine,  I.  931 

Cotton  good*,  disinfection  of,  I.  161 
wool  jackets  in  bronchitis,  I.  245 


27 


A    SYSTEM  OF  TREATMENT. 


Cough  and  abdominal  operations,  II.  258 
extra-pulmonary  in  pulmonary  tuber- 
culosis, I.  1144 
in  emphysema,  I.  1087 
in  measles,  relief  of,  I.  245 
in  pulmonary  tuberculosis,  I.  1144 
intermediate   cause  of,   in   pulmonary 

tuberculosis,  I.  1146 
intra-pulmonary,  I.  1147 
nervous  laryngeal,  III.  841 
relief  of,  in  pleurisy,  I.  1094 
Counter-irritation   in   joint   affections,   I. 

748 
of  the  spine  in  treatment  of  rheumatoid 

arthritis,  I.  405-407 
use  of,  in  children's  diseases,  I.  69 
Cow-pox,  Jennerian,  I.  311 
Cow's  milk  in  infant  feeding,  II.  219 
Coxa  valga,  I.  959 
Coxa  vara,  I,  958 
Cradling  described,  I.  37 
Craft  palsies,  II.  1267 
Craig  (M.).  cocainism,  I.  505 
dementia  praecox,  II.  1305 
exhaustion  psychoses,  II.  1299-1300 
idiocy  and  feeble-mindedness,  II.  1318- 

1320 

insomnia,  II.  1014-1024 
mania,  II.  1284-1289 
masturbation,  II.  1316-1317 
melancholia,  II.  1290-1298 
mental   aspects  of  epilepsy,  II.   1310- 

1312 
mental  aspects  of  hysteria,   II.  1306- 

1308 

mental  diseases,  II.  1274-1283 
morphinism,  I.  516-520 
obsessive  and  imperative  ideas,  II.  1313- 

1314 

paranoia,  II.  1309 
perversions,  II.  1315 
psychoses  associated   with   changes  in 

thyroid  gland,  II.  1301-1302 
toxic  psychoses,  II.  1303-1304 
Cramp,  hammerman's,  II.  1267 
telegraphist's,  II.  1266 
writer's,  II.  1264 

hypnotism    in    case    of,     III.     174, 

175 
Cranial  bones,  indentations  of,  in  infants, 

I.  886 

meningocele,  II.  1194 
puncture  in  hydrocephalus,  II.  1191 
Cranioclasm  operation  of,  cranioclast  in. 

IV.  407 

Cranioclast,  dangers  of,  IV.  409 
in  craniotomy,  IV.  406 
merits  of,  IV.  410 
Craniotomy,  IV.  403-412 
anaesthetic  in,  IV.  405 
Auvard's  three-bladed  cephalotribe  in, 

IV.  410 
cephalotribe  in,  IV.  408,  409 

merits  of,  IV.  410 
cleidotomy  in.  IV.  412 


Craniotomy  (tvntd.) — 

cranioclast  in.  IV.  406 

crotchet  in,  IV.  411 

crushing  in,  IV.  4(M> 

extraction  in,  IV.  406 

of  after-coming  head,  IV.  412 
of  the  body  in,  IV.  411 

forceps  in,  IV.  411 

in  breech  presentation,  IV.  406 

in  brow  presentation,  IV.  405 

in  face  presentation,  IV.  405 

in  vertex  presentation,  IV.  405 

indications  for,  IV.  403 

instrumental  crushing,  IV.  406 

perforation  in,  405 
dangers  of,  IV.  405 

version  in,  IV.  411 

vertebral  hook  in,  IV.  411 
Cranium.     See  Skull. 
Craw-craw,  III.  468 
Cream  in  infant  feeding,  II.  227 
Creams  in  pruritus,  III.  1099 
Creasy  (Eliot)  on  static  wave  currents  in 

arthritis,  I.  746 
Crede's   method  of   expression    in    post- 

partum  haemorrhage,  IV.  218 
Cremation  of  infected  material,  I.  161, 164 
Creosote  as  anti-pyretic,  I.  352 

baths  in  bronchiectasis,  I.  1044 

vapour  bath  in  pulmonary  tuberculosis, 

I. 1149 
Cresolene  vapour  in  whooping  cough,  I. 

379 

Cretinism  and  myxoedema,  1 1.  72 
Crico-arytenoid  joint,  III.  823 
Crile's  apparatus  for  use  of  ether  adminis- 
tration, III.  27 
Croft's  splint,  I.  629 

for  fractures,  I.  565 
Crotchet  in  craniotomy,  IV.  411 
Croup  in  measles,  I.  245 
Croupons  inflammation  of  the  bile  ducts 
II.  702 

of  the  gall  bladder,  II.  702 
Crashing  clamp  for  removal  of  the  ap- 
pendix. II.  414 
Crypto-menorrhcea,  IV.  732 
Crystalline  lens,  delivery  of,  III.  626 

discission  of  in  cataract,  III.  611 

linear  extraction  of,  III.  613 

operative  treatment  of,  III.  611 

shrunken  malformed,  III.  607 

spoon  delivery  of,  III.  628 
Cubitus  valgus  at  the  elbow-joint,  I.  938 
Cudowa  spa,  III.  149 

Cuff  (H.  E.)  and  F.  Foord  Caiger.  diph- 
theria, I.  187-202 

general    treatment    of   infectious    dis- 
eases, I.  157-160 

scarlet  fever,  I.  281-294 

typhus  fever,  I.  365-367 
Cunningham    (H.   H.   B.),    diseases    and 
affections   of   the  external  ear,  III. 
876-889 

tympanic  membrane,  III.  891-893 


28 


A    SYSTEM  OF  TREATMENT. 


Cupping,  method  of,  I.  35 
glasses  for  hyperaamic  treatment,  III. 

56 
Curettage,      after  -  treatment      of,      IV. 

626 

application  of  acetone  after,  I.  137 
danger  of,  IV.  626 
in  acute  endometritis,  IV.  621 
in  chronic  endometritis,  IV.  622 
in  menorrhagia,  IV.  758 
in  metrorrhagia,  IV.  758 
leucorrhosa  after,  IV.  627 
Curette   evacuation    of  lens    in  lamellar 

cataract,  I1L  613 
flushing,  IV.  621 
Roulte's  pattern  for  retained  placenta, 

IV. 227 

for  cataract,  III.  625 
loup,  IV.  624 
narrow  loup,  IV.  625 
Roux's,  IV.  624 
Currents,   high   frequency  and   static  in 

arthritis,  I.  746 

Curtains,  disinfection  of,  I.  162 
Gushing' s  method  in  cranial  fracture,  I. 

882 

Cushny  on  auricular  fibrillation,  I.  1232 
on  drugs  for  diseases  of  the  heart,  I. 

1212 

Custards,  preparation  of,  I.  42.  Ill 
Cut  throat,  II.  164  ;  III.  825 
Cyanide  gauze  and  wool,  double,  I.  75 

powder  and  paste,  I.  74 
Cyanides,  poisoning  by,  I.  530 
Cyanogen,     percentage    of,     in    cyanide 

gauze,  I.  76 
Cyclitis,  III.  592 

traumatic,  III.  595 

Cyclophoria  of  ocular  muscles,  III.  648 
Cycloplegia,  III.  534 
Cyllin  in  gastric  dilatation,  II.  315 
Cysticercosis,  III.  522 
Cystinuria,  II.  734 
Cystitis,  II.  858-860 
acute,  II.  858 
chronic,  II.  859 
complicating  adenoma  of  the  prostate, 

II.  944 

gonorrhoea,  I.  228 
gynaecological  surgery,  IV.  496 
the  puerperium,  IV.  272 
in  bilharzia  disease,  III.  500 
in  female,  IV.  881-883 
in  injuries  of  the  spine,  I.  909 
in  myelitis,  II.  1217 
in  pregnancy,  IV.  272 
in  the  puerperium,  IV.  273 
mineral    waters    and     baths     in,    III. 

140 
tuberculous,  II.  861-863 

complicating  pulmonary  tuberculosis, 

I.  1156 
primary  source  of    infection  in,   II. 

861 
vaccine  therapy  in,  II.  860 


Cystocele  of  the  vagina  complicated  by 

ulceration,  IV.  547 
operative  treatment,  IV.  549 

.    palliative  treatment  of,  IV.  547 

of  uterus,  surgical  treatment  of,  IV.  693 
Cystostomy  in  carcinoma  of  the  bladder, 
II.  873 

in  vesical  cancer,  I.  143 
Cystotome  for  cataract,  III.  625 
Cystotomy,    suprapubic  for    calculus    in 

female  bladder,  IV.  877 
Cysts    and    bursse     in    association    with 
arthritis,  I.  749-750 

dental,  of  the  gums,  III.  1193 

dentigerous,  of  maxillary  alveolus,  III. 
719 

of  the  auricle,  III.  879 

of  the  breast,  II.  952-954 

of  lingual  tonsils,  III.  762 

of  muscle,  II.  1325 

of  the  neck,  II.  167 

of  the  scalp,  1.  892 

of  the  vagina,  IV.  531-532 

of  the  vulva,  IV.  511 

sebaceous,  III.  1140 

surgical  treatment  of,  I.  108-111 


Daily  notes  in  sanatorium  treatment  of 

pulmonary  tuberculosis,  I.  1132-1142 
Dakin  (W.  E.),   accidental   haemorrhage 
during  pregnancy,  IV.  23-29 

placenta  praevia  in  pregnancy,  IV.  65-69 
Damp,  cause  of  chronic  rheumatism.  I.  484 
Daniels  (C.  W.),  beri-beri,  III.  414-416 

blackwater  fever,  III.  386-389 

chronic  dysentery,  III.  433-436 

dengue  fever,  III.  390 

epidemic  dropsy,  III.  416 

Japanese  river  fever,  III.  390 

kala  azar,  III.  391 

malaria.  III.  392-398 

Malta  fever,  III.  399-400 

phlebotomus  fever  (•'  sand  fly  "  fever), 
III.  400 

relapsing  fevers,  I.  266-267 

undefined  tropical  fevers,  III.  410-411 

yellow  fever,  III.  412-413 
Darier's  disease,  III.  1026 
Davos,  climate  of,  III.  84 
Dax  spa,  III.  149 
Dead,  disposal  of,  I.  164 
Deaf-mutism,  III.  979-981 

diagnosis  of,  III.  980 

pathology  of,  III.  979 

prognosis  of,  III.  980 
Deafness,  due  to  disturbance  of  cochlea 
division  of  eighth  nerve,  III.  977 

hysterical,  and  the  labyrinth,  III.  968 

in  adults,  educational  treatment  of,  III. 
981 

in  children,  causes  of,  III.  979 
educational  treatment  of,  III.  981 
surgical  treatment  of,  III.  980 

in  otosclerosis,  III.  956 


29 


A    SYSTEM  OF   TREATMENT. 


Decapitation,  foetal  difficulties  of,  IV.  415 

in  contracted  pelvis,  IV.  415 

operation  of,  steps  of,  IV.  413 

sepsis  in,  IV.  415 
Deciduoma  malignum  of  the  uterus,  IV. 

618-619 

Decortication  of  lung  in  empyema,  I.  1108 
Deformities,  acquired,  of  the  lips,  II.  96 
of  the  lower  limb,  I.  958-970 

after  amputation    in    disease    of    the 
ankle  and  tarsus,  I.  774 

after  excision  of  the  knee-joint,  I.  771 

due  to  spinal  and  nerve  paralysis,  I. 
988-990 

in  tuberculous  disease  of  the  hip-joint, 

I.  759-761 
of  the  knee-joint,  I.  767,  769 

of  the  upper  limb,  I.  935-943 

rachitic,  1.  970-972 

recuperative  factors  in,  I.  11 
Degeneration,  amyloid,  I.  462 
Deglutition  in  diphtheritic   paralysis,   I. 

201 
Delirium  in  typhoid  fever,  I.  362 

tremens  in  chronic  alcoholism,  I.  499 
Delstanche's  malleus  extractor,  III.  915 

otomasseur,  III.  952 
Dementia  praecox,  II.  1305 
Dengue  fever,  III.  390 
Dent  (C.  T.),  obstruction  of  the  intestine, 

II.  528  540 
Dental  cysts  of  the  gums,  III.  1193 

forceps,  III.  1180-1187 

neuralgia,  II.  1114 

surgery,  III.  1164-1194 
Deny's  bouillon  nitre"  tuberculin,  III.  293 
Deodorants,  definition  of,  I.  161 
Depilatories  in  hypertrichosis,  III.  1047 
Dermatitis  artefacta,  III.  1027 

blastomycetic,  III.  1005 

following  external  applications,  I.  486 

herpetiformis,  III.  1028 

occupation,  III.  1029 

phlegmonous,  of  the  auricle,  III.  881 

seborrhoeic,  III.  1004,  1143 

X-ray,  III.  1161 

preceding  cancer,  I.  117 
Dermatophiliasis,  III.  481 
Dermatosis,  chronic,  preceding  cancer,  I. 

116 
Dermoid  cysts,  I.  109 

of  the  auricle,  III.  879 

of  the  cornea,  III.  563 

of  floor  of  mouth,  II.  145 

of  neck,  II.  168 

of  the  scalp,  I.  892 

of  the  tongue,  II.  145 
Desmoid  fibroma,  I.  113 
Desquamation,  infectivity  of,  I.  288 
De  Wecher's  forceps  scissors  for  traumatic 

cataract,  III.  639 

Dextrocardia  in  newborn  child,  IV.  361 
Dhobie's  itch,  III.  478 
Diabetes  and  anaesthetics,  III.  24 

cancer  complicating,  I.  128 


Diabetes  (contd.~) — 
climate  for,  III.  96 
coma  in,  II.  983 

complicating  cancer  of  the  breast,  II. 
966 

pulmonary  tuberculosis,  I.  1158 
drugs  in,  I.  423 
gangrene  in,  I.  217 
in  gout  and  gouty  conditions,  I.  446 
insipidus,  I.  428-429 

complicating  pregnancy,  IV.  55 

drugs  in,  I.  428-429 

general  treatment  of,  I.  428 

polyuria  of,  I.  428 

prophylaxis  of,  I.  428 
mellitus,  I.  408-427 

alcohol  in,  I.  423 

alkalies  in,  I.  423 

coma  of,  I.  424 

complicating  pregnancy,  IV.  54 

complications  of,  I.  425-427 

constipation  in,  I.  426 

dietetic  and  hygienic  treatment  of,  I, 
409 

exercise  in,  I.  422 

gangrene  complicating,  I.  426 

nephritis  complicating,  I.  426 

oatmeal  treatment  of,  I.  421 

opium  in,  I.  424 

pregnancy  in,  I.  425 

prophylaxis  of,  I.  408 
neuritis  in,  II.  1131 
ulcers  complicating,  I.  373 
xanthoma  in,  III.  1160 
Diabetic  foods,  I.  414,  419 

mastoiditis,  III.  932 
Diacetic  acid  in  urine  in  diabetes,  I.  409, 

417 

Diaphoresis  in  ascites,  II.  628 
Diaphragm,  absence  of  half  of,  in  new- 
born child,  IV.  361 
rupture  of,  I.  1028 
wounds  of,  II.  253 
Diaphragmatic  hernia,  I.  1028 
Diarrhoea,  acute  in  adults,  II.  479 

caused    by    mushroom    poisoning,    II. 

480 

chronic  in  adults,  II.  480 
complicating  diabetes  mellitus,  I.  426 

sprue,  III.  445 

tuberculous  peritonitis,  II.  645 

typhoid  fever,  I.  358 
in  children,  II.  471-478 

lienteric  form  of,  II.  477 
in  cholera,  III.  425 
in  food  poisoning,  I.  509 
in  measles,  I.  246 
in  pellagra,  I.  522 
in  pernicious  anasmia,  II.  4 
infantile,  acute  summer,  II.  473 

preventive  treatment  of,  II.  472 
of  the  hills,  III.  438 
septic,  in  children,  baths  in,  I.  69 
Diet  for  infants  and  children,  I.  58-61 
errors  of,  in  anaemia,  I.  14 


30 


A    SYSTEM  OF  TREATMENT. 


Diet  (cuntd.') — 

in  acute  bronchitis,  I,  1051 

dysentery.  III.  429 

endocarditis,  I.  1191 

fevers,  II.  202 

gout.  I.  434 

rheumatism,  I.  270 
in  amoebic  dysentery,  III.  43D 
in  arterio-sclerosis.  I.  1290 
in  arthritis  deformans,  I.  393 
in  ascites,  II.  626 
in  asthma.  I.  1036 
in  atony  of  the  stomach,  II.  289 
in  broncho-pneumonia,  I.  1068 
in  calculous  disease,  II.  207,  753 
in  cancer  of  the  stomach,  II.  297 
in  childhood,  II.  202 
in  chlorosis,  II.  29 
in  cholelithiasis,  II.  683 
in  chorea,  II.  1261 
in  chronic  bronchitis,  I.  1055 

diffuse     parenchymatous    nephritis, 
II.  794 

dilatation  of  the  stomach,  II.  313 

gastritis,  II.  350 

gout,  I.  455 
in  constipation,  II.  212 

in  adults,  II.  441 
in  diabetes  mellitus,  I.  409 
in  diarrhoeal  diseases  in   children,  II. 

474 

in  diphtheria,  I.  188 
in  disease.  II.  202 
in  diseases  of  the  heart,  I.  1206 

of  the  intestines,  II.  208 

of  the  stomach,  II.  208 
in  eczema,  III.  1032 
in  epilepsy.  II .  !>'.''.' 
in  exophthalmic  goitre,  II.  55 
in  gastric  neurasthenia,  II.  355 
in  gastroptosis,  II.  320 
in  gout,  II.  207 

alimentary  tract  factors,  I.  450 

animal  food,  I.  451 

articles  to  be  avoided,  I.  455 

digestibility  of  food,  I.  448 

fruits  in,  I.  454 

general  principles,  I.  447 

meals,  selections  for,  I.  455 

purin-free,  I.  452 

saccharine  food,  I.  453 

starchy  food,  I.  453 
in  gouty  conditions,  I.  446 
in  gynecological  surgery,  IV.  488 
in  haemophilia,  II.  35 
in  haemorrhoids,  II.  616 
in  hill  diarrhoea,  III.  438 
in  infectious  diseases,  I.  158 
in  inflammation  of  the  stomach,  II.  345 
in  jaundice,  II.  671 
in  later  infancy,  II.  231 
in  marasmus,  1.  465 
in  measles,  I.  244 
in  melancholia,  II.  1292 
in  membranous  colitis,  II.  566 


Diet  (co/itd.')— 

in  myelitis.  II.  1216 

in  nephritis,  II.  204 

in  normal  puerperium,  IV.  269 

in  obesity,  I.  470,  472  ;  II.  212 

in  osteo-arthritis,  I.  400 

in  pericarditis,  I.  1180 

in  peritonitis,  II.  640 

in  pernicious  anaemia,  II.  2 

in  plague,  III.  403 

in  pleurisy,  I.  1094 

in  pregnancy,  IV.  (> 

in  psoriasis,  III.  1110 

in  pulmonary  tuberculosis,  I.  1119 

in  rheumatism  (chronic),  I.  486 

in  rickets,  I.  479 

in  scarlet  fever,  I.  283 

in  scurvy,  I.  475 

in  secretory  disorders  of  the  stomach, 
II.  361 

in  simple  digestive  disorders,  constipa- 
tion and.  II.  231 

in  sprue,  III.  442-443 

in  treatment  of  contracted   pelvis   in 
labour,  IV.  174 

in  the  tropics,  III.  378 

in  tuberculosis,  II.  203 

in  typhoid  fever,  I.  340  ;  II.  202 

in  typhus  fever,  I.  366 

in  ulcer  of  the  stomach,  II.  376 

in  ulcerative  stomatitis.  II.  122    . 

in  whooping  cough,  I.  379 

modifications  of,   in   simple    digestive 
disorders.  II.  230 

purin-free.  in  epilepsy,  II.  1000 

regulation  of,  before  abdominal  opera- 
tions, II.  258 

tables  of,  for  diabetics,  I.  414 

vomiting,  and,  II.  231 
Dietary,  sick  room.  I.  42 
Dietetics,  principles  of,  II.  190-213 

proportion  of  different  foods  in,  II.  200 
Diets.  Chittenden's  tables  of,  II.  200 
Dieulafoy  on  surgical  treatment  of  hsema- 

temesis,  II.  332 
Digestion,  aids  to,  II.  289,  291,  315,  322 

care  of,  in  infants  and  children,  I.  45 

disorders  of,  due  to  excessive  drugging, 

I.  64 

electro-therapeutics  in,  III.  110 
massage  and,  III.  211 
modifications  of  diet  in,  II.  230 
symptoms  of,  II.  370-374 
in  rickets,  I.  479 

milk  as  a  cause  of  disorders  of,  I.  61 
Digestive  organs,   disorders  of,   massage 

and,  III.  211 
Zander  treatment  in,  III.  372 

system,  climate  for,  III.  98 

effect  of  excess  of  food  on,  I.  8 
Digitalis  in  art  eric-sclerosis,  I.  1294 

in  chlorosis,  II.  27 

in  diseases  of  the  heart,  I.  1213 

in  exophthalmic  goitre,  II.  55 

in  heart  failure,  I.  260 


31 


A    SYSTEM   OF   TREATMENT. 


Digitalis  (contd.)  — 

method  of  administration  of,  I.  1219 
poisoning  by,  I.  533 
preparations  of,  I.  1219 
Digits,  supernumerary,  in  newborn  child, 

IV.  363 

union  of,  in  newborn  child,  IV.  362 
Dilatation,  therapeutic  significance  of,  I. 

U 

Dilating  bag,  use  of,  in  accidental 
haemorrhage  during  pregnancy,  IV. 
25 

Dilator,  glass,  in  vagiuismus,  IV.  862 
graduated  metal,  IV.  623 
for  retained  placenta,  IV.  226 
modified  Sims',  IV.  623 
Dionin  in  iritis,  III.  586 
Diphtheria,  I.  187-202 
acute   inflammation  of    middle  ear  in, 

III.  902 

age  as  a  factor  in,  I.  190 
antitoxin  treatment  of,  I.  189-192 

dosage  of,  I.  190;  111.275 

intravenous  injection  of,  I.  191 

method  of  administration,  I.  191 

prophylactic  use  of,  I.  192 

sequelae  of,  I.  193 

standardisation  of,  III.  274 

therapeutic  value  of,  III.  276 

value  of,  in  prophylaxis,  III.  279 
bacj:erio-therapeutics  of,  III.  273-279 
bacteriology  of,  I.  188,  189 
complications  of,  cardiac,  I.  199 

effect  of  anti-toxin  in,  III.  278 

otitis  media,  I.  202 

paralysis,  I.  200 

pregnancy,  IV.  49 

renal  affections,  I.  201 
conjunctivitis  in,  III.  557     . 
diet  in,  I.  188 

drugs  in  treatment  of,  I.  193 
general  management  of,  I.  187 
hsemorrhagic,  I.  187,  199 
isolation  in,  duration  of,  I.  187 
laryngeal,  I.  194-199 

intubation  in,  I.  198 

tracheotomy  in,  I.  195 
local  treatment  of,  I.  193 
measles  associated  with,  I.  243 
nasal  discharge  in,  I.  190 
neuritis  after,  II.  1138 
of  the  meatus,  III.  883 
of  the  vulva,  IV.  523 
remedial  treatment  of,  I.  189-194 
return  cases  of,  I.  188 
serum,  dangers  and  ill-effects  of,  III. 
297 

limitations  of,  III.  300 
stimulants  in,  use  of,  I.  193 
Diplopia,  paralytic,  of  ocular  muscles.  III. 

649 
Dipsomania.  I.  497 

pseudo-,  I.  498 
Discussion     needle     for     cataract,     III. 

611 


Disease,  acute,  I.  20 

indications  for  treatment,  I.  20 
causes  of,  complexity  of,  I.  6 

control  of,  I.  3 

specific,  avoidance  and  removal  of,  I. 

6,  7 

natural  reaction  to,  I.  8 
chronic,  I.  21 

indications  for  treatment,  I.  20 
climatic  requirements  in,  III.  91 
clinical  phenomena  of,  I.  15 
complications  and  sequelae  of,  I.  22 
diet  in,  II.  202 
incipient,  mineral  waters  and  baths  in, 

III.  146 
insect-borne,   protection    from,   in   the 

tropics,  III.  379 
intercurrent     complicating    pernicious 

anaemia.  II.  11 

local,  of  obscure  origin,  III.  465-469 
malignant,  X-rays  in,  III.  362 
natural  resistance  to,  I.  3,  5 
prevention  of,  methods  of.  I.  4 
principles     of    the    treatment    of,    I. 

1-25 

processes  of,  conservative,  I.  10 
specific  causes  of,  I.  4 
terminations  of,  I.  21 
X-ray  treatment  of,  III.  360-368 
Disinfectants,  definition  of,  I.  161 
for  typhoid  cases,  I.  339 
poisoning  by,  I.  527 
Disinfection  by  spraying,  I.  103 
in  amputations,  I.  797 
in  plague,  III.  401,  402 
of    bedrooms    during  and    after    con- 
tagious complaints.  I.  164 
of  clothes,  I.  161 
of  leather  goods,  I.  162 
of  premises,  I.  162 
of  stools.  I.  164 
of  utensils,  1 .  40 
preparatory  to  operation,  methods  of, 

I.  27,  30 
with  hot  air,  I.  162 

See  also  Sterilisation. 
Dislocations.  I.  713-733 

congenital,  of  the  elbow,  I.  936 
in  newborn  child,  IV.  366 
nerve  injuries,  complicating,  II.  1102 
of  ankle  and  foot,  I.  731-733 
of  the  clavicle,  I.  714 
of  the  elbow,  I.  721 
of  the  fingers,  I.  723,  938 
of  the  head  of  the  radius,  I.  936 
of  hip.  I.  724,  943 
of  the  jaw,  II.  104 
of  the  knee,  I.  728,  949 
of  the  shoulder-joint,  I.  715,  935 
of  the  spine,  I.  902-905 
of  the  teeth,  III.  1177 
of  the  ulnar  nerve,  II.  1113 
of  the  wrist,  1.  723,  937 
reductions    of,     anaesthetics    for,    III. 
33 


32 


A    SYSTEM   OF  TREATMENT. 


Distension,  flatulent,  complicating  gynae- 
cological surgery,  IV.  4!)<) 
Diuretic  waters,  III.  120 
Diuretics  in  ascites,  II.  627 
Diver's  paralysis,  I.  130(5 
Diverticula,  of  the  oesophagus,  II.  189 

vcsical.  II,  8(>4 
Dixon  (W.  E.)  on  drills  in  haemorrhage,  I. 

12U1 
Dobbie  (Nina  L.).  physical  exercises,  III. 

•2:>  7 
Ddderlein's    method    of   pubiotomy,   IV. 

44S,  44!) 
Dominici   (H.),  radium  therapy,  III.  303- 

816 
Dominici's  tubes  in  radium  therapy,  III. 

3i  C, 

Donovan's  solution  in  syphilis,  I.  321 
Dosage  of  medicines  for  children,  I.  66 
Douche  bath,  III.  127 

for  infants  and  children,  I.  48 
sub-thermal,  III.  127 
hot-air,  in   hyperasinic  treatment,  III. 

66 

in  chronic  synovitis  and  arthritis,  I.  746 
in  meuorrhagia,  IV.  756 
in  metrorrhagia,  IV.  756 
in  puerperal  sepsis,  IV.  310-311 
in  rctroversion  of  the  uterus,  IV.  673 
in  vaginal  leucorrhcea,  IV.  561 
Scotch,  in  gouty  joints,  I.  439 
tube,  intra-uterine,  IV.  298 
vaginal,  I.  39 
Douglas,   pouch  of,  in  posterior  cervical 

fibroid,  IV.  652 
Dover's  powder  in  pneumonia,  I.  259 

in  sleeplessness,  I.  159,  186 
Dowsing  radiant  heat  bath,  I.  747 
Doyen's  gag.  III.  7:i5 

serum  in  cancer.  I.  152 
Doyne  (R.  W.),  amblyopia  and  functional 

diseases  of  the  eye,  III.  543 
diseases  of  the  choroid,  III.  597 
of  the  conjunctiva,  III.  547-562 
of  the  optic  nerve,  III.  645 
of  the  orbit,  III.  661-663 
of  the  retina.  III.  642-644 
glaucoma,  III.  602-606 
injuries  of  the  eyeball,  III.  656 — 660 
Dracontiasis  (infection  by  guinea-worm 

tilaria  mediuensis),  III.  501 
prophylaxis  of,  III.  501 
Drainage  of  the  pericardium,  I.  1188 
of  wounds,  I.  551  > 

after  amputation,  I.  802 
surgical,  methods  of  in  acute  abscess, 

1.  167,  170 
tubes,  cyanide  gauze  to  be  used  with, 

I.  80 

See  also  Lumbar  puncture. 
Draughts,  avoidance  of  in  nurseries,  I.  45 

witli  young  children.  I.  ~>'2 
Dressings  after  abdominal  operations,  II. 

266 
application  of,  I.  86 


Dressings  (c»nt<l.)  - 

in  burns  and  scalds,  I.  541,  ">48 

in  gynaecological  surgery,  IV.  488 

in  ovariotomy,  IV.  804 

in  wounds,  I.  554 

of  wounds  after  amputation,  I.  802 

surgical  choice  of  materials  for,  I.  79 

materials  for,  I.  74-80 
Drink,  cold  water,  in  fevers,  I.  158 
imperial,  composition  of,  I.  258 
in  the  tropics,  III.  378    ' 
in  typhoid  fever,  I.  343 
Droitwich  spa,  III.  150 
Dropped  finger,  II.  1329 
Dropsy  due  to  heart  failure,  digitalis  in, 

I.  1220 

epidemic,  III.  416 
of  the  gall  bladder,  II.  710 
Drowsiness,  condition  of,  and  anaesthetics, 

III.  23 

Drug  eruptions,  III.  1031 
Drugs    after    abdominal    operations,   II. 

270 
allied  narotic,  use  of  and  anaesthetics, 

III.  22 

anti-pyretic,  in  typhoid  fever,  I.  351 
antiseptic,  in  plague,  III.  406 
collapse  following  sudden  suppression 

of,  I.  516 

diabetes  mellitus,  I.  423 
dosage  of,  for  children,  I.  66 
during  pregnancy,  IV.  9 
hypnotic,  I.  500 

in  insomnia,  II.  1021 
impotence  due  to  use  of,  I.  231 
in  acute  catarrhal  pharyngitis,  III.  766- 
767 

diarrhoea  in  adults,  II.  480 

dysentery,  III.  429 

laryngitis,  III.  833 

nephritis,  II.  796 

rheumatism,  I.  270 

yellow  atrophy  of  the  liver,  II.  657 
in  alcoholic  neuritis,  II.  1135 
in  alcoholism,  I.  495,  497,  500 
in  amoebic  dysentery,  III.  430 
in  amenorrhcea,  IV.  727 
in  arthritis  deformans,  I.  395 
in  ascariasis,  III.  494 
in  ascites,  II.  627 
in  atony  of  the  stomach,  II.  290 
in  bilharzia  disease,  III.  499 
in  blackwater  fever,  III.  388 
in  broncho-pneumonia,  I.  1068 
in  cancer,  I.  148 

of  the  stomach,  II.  298,  299 
in  cardiac  ascites,  II.  631 

diseases,  I.  1211-1227,  1243 
in  catarrhal  jaundice,  II.  673,  674 
in  chancre  of  the  tongue,  II.  134 
in  chorea,  II.  1257 

in  chronic  dilatation  of  the  stomach,  II. 
314 

diarrhoea  in  adults,  II.  482 

dysentery,  III.  435 

33  3 


A    SYSTEM   OF   TREATMENT. 


Drags,  in  chronic  (contd.) — 

gastritis,  II.  351 

interstitial  nephritis,  II.  792 

laryngitis,  III.  836 

simple  ulcer  of  the  stomach,  II.  328 
in  colic,  I.  512 

in  conjunctival  diseases,  III.  548 
in  constipation  in  adults,  II.  4f4 

in  children,  II.  436 
in  cystitis,  IV.  274,  275 
in  diabetes  insipidus,  I.  429 
in   diarrhoeal  diseases  in  children,  II. 

472,  475 

in  disseminated  sclerosis,  II.  1073 
in  dysmenorrhrea,  IV.  745 
in  eczema,  III.  1032 
in  epilepsy,  II.  997 
in  exophthalmic  goitre,  II.  55 
in  food  fever,  II.  239 
in  gastric  atony.  II.  290 
in  gastric  neurasthenia,  II.  356 
in -gastroptosis,  II.  321 
in  goitre,  II.  62 
in  gonorrhoeal  arthritis,  I.  783 
in    haemorrhagic    tendency    of    portal 

cirrhosis  of  the  liver.  II.  663 
in  haemorrhoids,  II.  616 
in  headache,  I.  514 
in  hill  diarrhoea,  III.  438 
in  hypersecretion  of  the  stomach,  II. 

367 
in   hypertrophic    biliary  cirrhosis,   II. 

664 

in  hysteria,  II.  1012 
in  impotence,  II.  912 
in   infantile   hypertrophic   stenosis    of 

the  pylorus,  II.  339 

in  inflammation  of  the  stomach,  II.  346 
in  insanity  of  lactation,  IV.  279 
in  insomnia,  II.  988 
in  jaundice,  II.  671 
in  Kala  Azar,  III.  391 
in  laryngeal  spasm  in   children,   III. 

828 

in  laryngitis  stridulosa,  III.  829 
in  leprosy,  III.  449,  450 
in  malaria,  III.  392 
in  mania,  II.  1287, 1288 
in  marasmus,  I.  466 
in  meningitis,  I.  253 
in  menorrhagia,  IV.  754 
in  metrorrhagia,  IV.  754 
in  migraine,  II.  1029 
in  morphinism,  I.  519 
in  myelitis,  II.  1215 
in  obesity,  I.  470 
in  Oriental  sore,  III.  455 
in  osteo-arthritis,  I.  401 
in  oxyuriasis,  III.  495 
in  paralysis  agitans,  II.  1270 
in  pellagra,  I.  522 
in  pernicious  anaemia,  II.  3 
in  ponos,  III.  440 

in  portal  cirrhosis  of  the  liver,  II.  660 
in  pruritus  ani.  II,  595 


Drugs  (contd.) — 

in  pruritus  of  the  vulva,  IV.  517 

in  puerperal  sepsis,  IV.  313 

in  pulmonary  embolism,  IV.  325 

in  pyelonephritis,  infective.  II.  808 

in  rheumatism  in  childhood,  I.  278 
(chronic)  I.  490 
(muscular)  I.  493 

in  rhinorrhoea,  III.  689 

in  rickets,  I.  479 

in  salivary  diseases,  II.  130 

in  secretory  disorders  of  the  stomach, 
II.  363 

in  simple  acute  rhinitis,  III.  701 
parotitis,  II.  157 

in  splenomegaly,  II.  82 

in  sprue,  III.  444 

in  sympathetic  ophthalmitis,  III.  600 

in  syphilitic  cirrhosis  of  the  liver,  II. 
665 

in  syphilis,  I.  317,  319,  324 

in  tabes  dorsalis,  II.  1088 

in  tetanus  in  puerperium,  IV.,  327 

in  tinnitis,  III.  972 

in  trachoma,  III.  557 

in  trichiniasis,  III.  526 

in  trichocephaliasis,  III.  496 

in  trigemiual  neuralgia,  II.  1116 

in  tuberculous  peritonitis,  II.  645 

in  tumours  of  the  spinal  cord,  II.  1222 

in  typhoid  fever,  I.  351 

in  ulcer  of  the  stomach,  II.  378 

in  uraemia,  II.  837 

in  urethritis  in  the  puerperium,  IV.  329 

in  uterine  fibroids,  IV.  634 
inertia,  IV.  253 

in  vasomotor  neuroses,  II.  1242 

in  vomiting.  I.  512 

in  whooping  cough,  I.  380 

in  yellow  fever,  III.  412 

for  albuminuria  during  pregnancy.  IV. 
31 

for  chilblains,  III.  1019 

for  paralytic  distension  after  abdominal 
operations,  II.  271 

for  stone  in  the  ureter,  II.  846-851 
Dubois'  apparatus  for  anaesthetics,  III.  14 

method  of  hypnotism,  III.  166 
Dubreul's  method  of    disarticulation  at 

wrist  joint,  I.  815 
Dunbar's  pollantin  antitoxic  serum,  III. 

286-287 
Duodenum,  ulcer  of,  II.  375-381 

diet  in,  II.  211 

surgical  treatment,  II.  391-394 

with  perforation,  II.  396-398 
Dupuytren's  contraction,  I.  942 

exercises  in,  I.  490 

enterotome,  II.  489 

fracture,  I.  629 

splint,  I.  630 
Dura  mater,  incision  of  in  compression 

I.  883-885 
Durham's    tracheotomy    tubes,    use    of. 

I.  196 


34 


A    SYSTEM   OF   TREATMENT. 


Dust  and  pulmonary  tuberculosis,  I.  1118 
carrier  of  typhoid,  I.  336 
inhalation  of,  causing  pneumokoniosis, 

I.  1115 
Dusting  powders  for  intertrigo,  IV.  529 

for  vulvitis,  IV.  520 
Dyschezia,  electricity  in,  II.  464 
enemata  in,  II.  457 

with   weak    abdominal   muscles,    elec- 
tricity in,  II.  465 
Dysentery,  acute,  III.  428-432 
general  treatment  of,  III.  428 
medicinal  treatment  of,  III.  429 
serum  treatment  of,  III.  430 
amoebic,  III.  430 
calomel  in,  III.  432 
diet  in,  III.  430 
general  treatment  of,  III.  430 
medicinal  treatment  of,  III.  430 
other  treatments  of,  III.  431 
prophylaxis  of,  III.  4:52 
bacillary,  III.  428 
chronic,  III.  433-436 

serum  treatment  of,  III.  279 
vaccine  treatment  of,  III.  279,  280 
Dysmenorrhcea,  IV.  736-750 
drugs  in,  IV.  745 
in  puberty,  IV.  501 
membranous,  IV.  738 

palliative  treatment,  IV.  742 
prophylaxis  of,  IV.  742 
spasmodic,  sterility  in,  IV.  847 
surgical  treatment,  IV.  746 
Dyspareunia,  IV.  839-842 

carunclo  of  urethra  in,  IV.  841 

in  diseases  of  the  fallopian  tubes,  IV. 

841 

in  diseases  of  uterus,  IV.  844 
Dyspepsia,  acute,  or  acute  gastric  catarrh, 

I.  506-507 

ami  tropical  liver,  II.  678 
appendix,  II.  4()'.i 
atonic,  of  stomach,  II.  286 
complicating  artificial    pneumothorax, 

I.  1170 

diet  in,  II.  208 
forms  of,  I.  388 
gouty,  and  acidity,  I.  442 
in  acne  vulgaris,  III.  Stss 
in  the  menopause,  IV.  ">(|l 
infant  ilc.  <-aiiM'>  of.  I.  54 
mineral  waters  and  baths  in,  III.  139 
IUTVOUS,  1 1.  354 
Dysphonia  spastica,  III.  841 
Dyspnoea  and  ana'sthetics,  III.  23 

complicating  acute  endocarditis,  1. 1193 
in  emphysema,  I.  1087 
in  goitre,  II.  67 

in  pulmonary  tuberculosis,  I.  1138 
Dystrophy,  muscular,  II.  12.">o-1251 

Ear,  application  of  vibration  to,    111.  '2\~> 

cough    in    pulmonary    tuberculosis,    I. 

1145 


Ear  (coidd.) — 

diseases  of,  III.  876"-889 

brain  abscess  in,  III.  939-941 
complicating  typhoid  fever,  I.  363 
int  racranial    complications    in,  III. 

937-943 
intra-venous   complications   in,    III. 

937-943 

meningitis  in,  III.  937-939 
thrombosis  of  the  sigmoid  sinus  in, 

III.  941-943 
See  alto  Otitis  Media, 
external,  burns  of,  III.  888 
diseases  of,  III.  876-889 
foreign  bodies  in,  III.  889-890 
frost-bite  of,  III.  888 
haematoma  of,  III.  888 
malformations  of,  III.  876 
wounds  of,  III.  887-888 
fistulas  of,  III.  877 
internal,  syphilis  of,  III.  978 
middle,    diseases    of,    non-suppurative 
and  Eustachian  obstruction,  III. 
944-953 
patency  of  Eustachian  tubes  in,  III. 

947-951 
dry  catarrh  of,  in  Eustachian  tube, 

III.  944 

inflammation  of,  acute,  III.  894-903 
before     perforation    of    tympanic 

membrane,  III.  894 
in  diphtheria,  III.  902 
in  enteric  fever,  III.  902 
in  measles,  III.  902 
in  scarlet  fever,  III.  902 
local  treatment,  III.  894 
paracentesis  in,  III,  895 
perforation  of  tympanic  membrane 

in,  III.  896 
secondary    to    infectious  diseases, 

III.  902 
suppuration  of  antrurn  in,  III.  897 

of  mastoid  cells  in,  III.  897 
chronic,  atticotomy  in,  III.  917 
aural  polypi  and,  III.  909 
cauterisation  in,  III.  908 
epitympanic  suppuration,  III.  912 
granulations  in,  III.  908 
ossiculectomy  in,  III.  913 
removal  of  incus  in,  III.  915 
of  malleus  in,  III.  914 
of  malleus,  incus  and  outer  attic 

wall  in,  III.  913 

of  stapes  in,  III.  916 

suppurative,  III.  904-918 

complicating  influenza,  I.  239 

polypi  of,  III.  909 

after-treatment  of ,  III.  911 
suppuration  of,  paroxysmal,  vertigo  of 

labyrinth  and,  III.  960-961 
telephone,  III.  880 
tuberculosis  of,  III.  935-!»3i> 
Ears,  care  of,  in  infants  and  children,  I.  48 
examination  of,  in  epilepsy,  II.  991 
projecting,  III.  878 


35 


3—2 


A    SYSTEM   OF   TREATMENT. 


Eaux-Bonnes  spa,  III.  150 
Eaux-Chaudes  spa,  III.  150 
Eberth  coli  bacilli  in  typhoid  fever,  I.  345 
Ecchymoses  of  the  tympanic  membrane, 

III.  891 

Echinococcus  disease,  alveolar,  III.  523 
Echolalia  in  psychasthenia,  II.  1045 
Eclampsia,  Bossi's  metallic  dilator  in,  IV. 

39 
Caesarean  section  in,  IV.  384 

abdominal,  IV.  40 
chloroform  in,  IV.  36 
cold  baths  in,  IV.  37 
decapsulation  of  kidneys  in,  IV.  37 
forceps  in,  IV.  421 
in  pregnancy,  IV.  34-41 
incision  of  cervix  in,  IV.  40 
lumbar  puncture  in,  IV.  38 
massage  of  the  heart  in,  IV.  37 
morphia  in,  IV.  36 
nitro-glycerine  in,  IV.  37 
obstetrical  treatment  of,  IV.  38 
oxygen  in,  IV.  37 
pilocarpine  in,  IV.  37 
rectal  injection  of  glucose  in,  IV.  37 
saline  infusion,  intravenous  in,  IV.  35 

subcutaneous  in,  IV.  35 
thyroid  extract  in,  IV.  37 
venesection  in,  IV.  36 
veratrum  viride  in.  IV.  37 
Ectopia  of  the  testis,  II.  904 
vesicse.  II.  866-867 
diversion  of  the  urinary  stream  in, 

II.  866 

plastic  closure  of  bladder  in,  II.  866 
Ectropion  of  the  eyelids,  III.  581 
Eczema,  III.  1032-1036 
chronic.  X-rays  in.  III.  351 
complicating  diabetes  mellitus,  I.  425 
diet  in,  III.  1032 

in  gout  and  gouty  conditions,  I.  445 
infantile,  III.  1035 
local  treatment  of,  III.  1033 
medicines  for,  III.  1032 
occupations  causing,  I.  117 
of  the  auricle,  III.  880 
of  the  meatus,  III.  886 
of  the  nails,  III.  1082 
vulva,  ointments  for,  IV.  530 
Edmunds    on    auricular    fibrillation,    I. 

1232 

Effervescent  baths,  III.  131 
Effleurage  in  massage,  III.  203 
Effusion,  aspiration  in,  755 
Egg  diet  in  gastric  ulcer,  II.  210 

wine  preparation  of,  I.  43 
Eggs,  chemical  composition  of,  II.  194,  206 

children's  dietary  to  include,  I.  59 
Egypt  as  a  winter  resort,  I.  461 
Erblich's  '•  606  "  in  syphilitic  affections  of 

the  vulva,  IV.  521 
specific  for  syphilis,  I.  322 
Eicken  (Carl  von),  foreign  bodies  in  the 
air-passages,    with    a    description    of 
bronchoscopy,  III.  803-821 


Einhorn's    spray    apparatus    in    chronic 

gastritis,  II.  349 
Elastic   constriction,  passive   hypertemia 

induced  by,  III.  46 
oesophageal  bougie,  II.  172 

conical-ended  black,  II.  172 
Elbow,  congenital  dislocation  of,  I.  936 
dislocations  of.  I.  721 
posterior  moulded  splint  for,  I.  600 
tuberculous  disease  of,  I.  777-779 
Elbow-joint,   disarticulation    at,   I.   820- 

824 

by  anterior  elliptical  incision,  I.  820 
by  a  circular  incision,  I.  823 
by  a  racket  incision,  I.  821-823 
fracture  of,  I.  596 
Electric  baths,  III.  104 

in  joint  affections,  I.  747 
conjunctivitis,  III.  560 
light,  exposure  to,  I.  548 

in  gout  and  goutj'  conditions,  I.  439 
methods  in  cancer.  I.  153 
shock,  I.  547 
Electricity  in  acute  anterior  polio-myelitis, 

II.  1056 

in  arthritis  deformans,  I.  398 
in  atony  of  the  stomach,  II.  288 
in  cancer,  I.  153 

in  constipation  in  adults,  II.  464 
in  craft  palsies,  II.  1268 
in  diabetes  insipidus,  I.  428 
in  disseminated  sclerosis,  II.  1074 
in  dyschezia,  II.  464 

with   weak   abdominal    muscles,  II. 

465 

in  facial  paralysis,  II.  1094 
in  gastric  neurasthenia,  II.  354 
in  intestinal  constipation,  II.  464 
in  melancholia.  II.  1294 
in  menorrhagia,  IV.  762 
in  metrorrhagia,  IV.  762 
in  neurasthenic  constipation,  II.  465 
in  paralysis  of  lead  poisoning,  I.  513 
in  paraplegia,  II.  1198 
in  pruritus,  III.  1101,  1104 
in  rheumatism  (chronic),  I.  488 
in  sterility,  IV.  857 
in  tabes  dorsalis,  II.  1091 
injuries  and  burns  from,  I.  547-549 
local  in  electrotherapeutics,  III.  106 
Electro-therapeutics,  III.  103-110 
in  chronic  synovitis    and  arthritis,   I. 

448,  746-748 

in  digestive  disorders,  III.  110 
in  disorders  of  circulatory  system,  III. 

109 

in  nervous  disorders,  III.  108-109 
in  skin  diseases,  III.  110 
localised  electrisation  in.  III.  106 
statical  treatment  in,  III.  106 
Electrolysis   in   adenoma  sebaceum,  III. 

<)!>! 

in  hypertrichosis,  III.  1048 
in  small  capillary  naevi,  III.  1079 
of  the  Eustachian  tube,  III.  950 


36 


A    SYSTEM   OF    TRK.ITM li\~I . 


Elephantiasis  arabuni  of  the  vulva.   l\'. 

611 
of  leg,  III.  516 

palliative  treatment  of,  III.  516 
radical  treatment  of,  III.  516 
of  vulva,  III.  615;  IV.  511 
scroti,  III.  504-516 

bandage  for  after  operation,  III.  515 

cardinal  rules  in,  III.  504 

flaps  to  penis  in  operation  for,  III. 

511 
operating  without  the  cord  in,  III. 

513 

operation  for,  III.  504 
dressing  in,  III.  513 
naps  in,  III.  509 
penis  dressing  in,  III.  513 
perineal  dressings   in  operation   for, 

III.  513 
pubic  dressings  in  operation  for,  III. 

513 

sutures  in  operation  for,  III.  513 
X-rays  in.  III.  353 

Elliotson  (J.   M.)   and  practice  of  mes- 
merism, III.  159 
Elster  spa,  III.  150 
Embolism,  air,  complicating  labour,  IV. 

161-162 

by  bacillary  plugs,  I.  1306 
by  fibrinous  particles,  I.  1306 
by  parenchymatous  cells,  I.  1 306 
by  tumour-cells,  I.  1306 
cerebral,  II.  1167 
excluding   cerebral   embolism,  I.  1306- 

1308 

fat,  I.  1306 
gangrene  due  to  sudden  obliteration  of 

arteries  by,  I.  215 
of  arteria  centralis  retina,  III.  644 
of  the  kidneys,  I.  1308 
of  the  mesenteric  arteries,  I.  1307 
of  the  spleen,  I.  1307 
pulmonary.  I.  1307 

after  abdominal  operations,  II.  275 
complicating  gynaecological  surgery, 

IV.  494 

the  puerpeiium,  IV.  324-325 
prevention  of,  IV.  324 
Emetics  in  chlorosis,  II.  28 

in  poisoning,  I.  529 
Emphysema,  acute  vesicular,  I.  1088 
atrophic,  I.  1088 
compensatory,  I.  1088 
hypertrophic,  palliative  treatment  of,  T. 

1084 

preventive  treatment  of,  I.  1082 
interstitial,  I.  1089 
physical  exercises  in.  I  IF.  251 
varieties  of,  I.  1082-1089 
Empirical  remedies  for  cancer,  I.  147 
Empiricism,  reasons  for,  I.  1 
Empyaema.  I.  1099-1100 

anesthetics  in  operations  for,  III.  3n 
complicating  pulmonary  tuberculosis.  I. 
1158 


Empyaema  (contd.)— 
double.  I.   1  Hit; 
failure  to  heal  of  an,  I.  Hot! 
•  fistulous  tracks  in,  injections  in,  I.  1110 
following  injury  of  the  chest,  I.  1027 
generalised,  after-treatment  of,  I.   1104 
drainage  in,  I,  11  <>4 
in  the  lower  part  of  the  thorax,  1. 1 101 
operation  for,  I.  1103 
localised,  I.  1106 
of  the  gall  bladder,  II.  710 
ruptured  into  a  bronchus,  I.  1106 
simple,  of  gall  bladder,  II.  702 
treatment  of,  I.  90 
tuberculous,  I.  1108 
want  of  expansion  of  lung  in,  I.  1107 
Ems  spa,  III.  150 
Encephalocele     of     foatus    complicating 

labour,  IV.  180 
of  newborn  child,  IV.  357 
Encephalopathy,  saturnine,  in  lead  poison- 
ing, I.  514 

Endocarditis,  acute,  I.  1190-1193 
after-care  of,  I.  1192 
complications  of,  I.  1193 
medicinal  measures  in,  I.  1191 
in  acute  rheumatism,  I.  272-274 
infective,  malignant  or  ulcerative, 
bactericidal  sera  in,  I.  20 
bacterial  vaccines  in,  I.  206 
drugs  in,  I.  204 

non-specific  measures  in,  I.  203-207 
prophylaxis  of,  I.  202 
sero-vaccines  in,  I.  206 
specific  measures  in,  I.  204,  207 
synopsis  of  treatment  of  a  case,  I.  207 
Endomastoiditis,  purulent,  III.  920 
suppurative,    chronic    indications    for 

operation  in,  III.  922 
Endometritis,  IV.  620-631 
acute,  IV.  620 

curettage  in,  IV.  621 
irrigation  in,  IV.  620 
leucorrhrea  in.  IV.  568 
amputation  of  vaginal  portion  of  cervix 

in,  IV.  630 
cervical,  IV.  627 

vaccine  treatment  in,  IV.  630 
chronic,  IV.  622 

curettage  in,  IV.  622 
leucorrhoea  in,  IV.  569 
corporeal,  vaccine  treatment  in,  TV.  630 
gonorrhoeal,  leucorrhcea  in,  IV.  569 
importance  of  general  treatment,  IV. 

630 

Schroeder's  operation  in,  IV.  629,  630 
senile,  leucorrhoea  in,  IV.  57u 
sterility  in,  IV.  845 
Endothelioma  of  the  prostate,  II.  932 

operability  of,  I.  122 
Endotoxins  in  serum  therapy,  III.  259 
Enemata  as  solvents   in  constipation   in 

adults,  II.  456 

before  abdominal  operations,  II.  261 
chemical  stimulation  of,  II.  452 


A    SYSTEM  OF  TREATMENT. 


Enemata  (eontd.) — 

general  indications  for,  in  constipation 

in  adults,  II.  457 

high,  in  constipation  in  adults,  II.  454 
in  children,  II.  436, 437 
in  chronic  dysentery,  III.  433 
in  constipation  in  adults,  II.  452 
in  dyschezia,  II.  457 
in  removal  of  impacted  faeces,  II.  459 
low,  in  constipation  in  adults,  II.  455 
mechanical  stimulation  of,  II.  452 
methods  of  giving,  1.  31 
of  cold  water  in  typhoid  fever,  I.  355 
rectal,    in   constipation   in   adults,   II. 

454 

thermal  stimulation  of,  II.  452 
varieties  of,  in  constipation  in  adults, 

11.454 
various,  I.  32 

Engine-driver's  eczema,  I.  117 
English  (T.  Crisp),  affections  of  the  nip- 
ples, II.  977-978 
appendicitis,  11.401-425 
diseases  and  affections  of  the  breast,  II. 

952-981 
operative  diagnosis  of  doubtful  tumours 

of  breast,  II.  979-980 
the  preparation  of  patients  for  abdomi- 
nal operations,  II.  257-261 
the  treatment  of  patients  after  abdomi- 
nal operations,  II.  262-276 
tuberculosis  of  the  breast,  II.  981 
Enteric.     See  Typhoid  Fever. 
Enteritis,  acute,  in  adults,  II.  479-480 
chronic,  in  adults,  II.  480-482 
infective,  in  newborn  child,  IV.  367 
Enteroclysis  in  haemorrhage,  I.  1268 
Enteroptosis,    general    treatment    of,    I. 

430 
(Glenard's  disease),  I.  430 

surgical  treatment  of,  I.  431 
mechanical  support  in,  I.  430 
Enterotome,  Dupuytren's,  II.  489 

with  key,  Groves',  II.  489 
Enterotribe,  Gray's,  I.  1258 
Entropion  of  the  eyelids,  III.  580 
Enuresis.  nocturnal,  II.  75-77 
belladonna  in,  II.  75 
minute  supervision  in,  II.  75 
peripheral  irritation  and,  II.  75 
thyroid  extract  in,  II.  76 
Epidemic  dropsy,  III.  416 

gangrenous  proctitis,  III.  437 
Epidermolysis  bullosa,  III.  1036 
Epididymitis,  II.  906 

complicating  adenoma  of  the  prostate, 

II.  945 

gonorrhoea,  I.  227 
tubercular,    complicating     pulmonary 

tuberculosis.  I.  1157 
Epiglottis    punch,    Lake-Bar  well's,    III. 

875 

Epilation  in  hypertrichosis,  III.  1048 
Epilepsy,  II.  990-1007 
acute  exhaustion  after  fit  in,  II.  1005 


Epilepsy  (<wtf<7.) — 

alcoholic,  I.  499  ;  II.  993 

and  anesthetics,  III.  25 

arrest  of  fit  in,  II.  1003 

associated  conditions  in,  II.  991 

automatism  in,  II.  1005 

belladonna  in,  II.  998 

bromides  in,  II.  993 

coma  in,  II.  983 

combinations   of    bromides  and   other 

remedies  in,  II.  996 
complications  of,  II.  1002 
confirmed,  II.  1006 
diet  in,  II.  999 
drugs  in,  II.  997 
duration  of  treatment  of,  II.  998 
examination  of  ears  in,  II.  991 
eyes  in,  examination  of,  II.  991 
features  of,  unfavourable  for  treatment, 

II.  1006,  1007 

genital  organs,  examination  in,  II.  992 
hygienic  treatment  of,  II.  1001 
idiopathic,  II.  990 
introspection  in,  II.  990 
mania,  acute,  in,  II.  1005 
marriage  in,  II.  1002 
mental  aspects  of,  II.  1310-1312 
miscellaneous  methods  of  treatment  of, 

II.  999 
new   preparations  of    bromine   in,   II. 

997 

nose  examination  in,  II.  991 
of  infective  origin,  II.  992 
of  recent  origin,  II.  993 
of  toxic  origin,  II.  993 
opium  in,  II.  998 
organotherapy  in,  II.  999 
perversion  of  functions  of  alimentary 

tract  in,  II.  1018 
viscera  in,  II.  1018 
prodromata  in,  II.  1002 
purin-free  diet  in,  II.  1000 
reflex,  II.  991 
seizure  of  fit  in,  II.  1003 
self -abuse  in,  II.  992 
serotherapy  in,  II.  999 
solanum  carolineuse  in,  II.  998 
stomach  examination  in,  II.  992 
strychnine  in,  II.  998 
surgical  treatment  of,  II.  1007 
teeth  examination  in,  II.  992 
tobacco  intoxication  in,  1 1.  993 
zinc  salts  in,  II.  998 
Epileptiform  convulsions  in  electric  shock, 

I.  848 
Epiphora  in  fractures  of    the  jaws,  II. 

100 
Epiphysial    line    of   knee-joint,  primary 

disease  at,  I.  768 
Epiphysis,    separation    of,    in    fractures, 

I.  590,  599 

in  newborn  child,  IV.  366 
Epiphysitis,  acute,  I.  698 
Episiotomy   in   second    stage  of    labour, 
IV.  115 


38 


A  'SYSTEM  OF  TREATMENT. 


Epispadias  in  congenital  malformations  of 

the  penis,  II.  875 
Epistaxis,  III.  G(i4-66<; 

complicating  typhoid  fever,  I.  357 

due   to   constitutional   conditions,  III. 

664 

severe  organic  nasal  disease,  III.  665 
immediate  arrest  of,  III.  666 
in  chronic  Bright's  disease,  I.  15 
permanent  arrest  of,  III.  666 
relief  from  high  blood-pressure  by,   I. 

10 

Epithelial  odontomes  of  the  jaws,  II.  112 
Epithelioma,   embryonic,    radium    treat- 
ment of,  111.  309 
in  X-rays,  III.  348 
of  the  lip,  II.  97 
of  the  scalp,  I.  892 
of  the  scrotum,  II.  900 
of  the  skin,  III.  1037-1038 
of  the  tongue,  II.  138-144 
of  the  vulva,  IV.  515 
primary,  of  the  umbilicus,  II.  281 
Epitympanic    suppuration  with  perfora- 
tion of  membrana  tlaccida,  III.  912 
Epulis,  cause  of,  I.  113 
myeloid,  of  jaw,  II.  110 
of  the  gums,  III.  1193 
Erasion  in  lupus,  III.  1149 

in   tuberculous   disease    of    the    knee- 
joint,  I.  769,  770 

Ergot,  acute  poisoning  by,  I.  510,  533 
dosage  of  in  children's  diseases,  I.  68 
gangrene,  I.  219 
in  rnenorrhagia,  IV.  754 
in  metrorrhagia,  IV.  754 
Ergotism.  I.  510.  533 
Erichsen  (Sir  J.  E.)  on  shock  from  burns 

and  scalds,  I.  540 
Ernst's  kidney  truss,  II.  787 
Erysipelas,  I.  209-211 

complicating  pregnancy,  IV.  49 

typhoid  fever,  I.  357 
constitutional  treatment  of,  I.  211 
ichthyol in,  I.  210 
iron  perchloride  in,  I.  211 
Kraske's  method  in,  I.  210 
lead  lotion  in,  I.  210 
local  treatment  of,  I.  209 
multiple  incisions  in,  I.  210 
of  scalp,  I.  888 
of  the  auricle,  III.  880 
of  the  vulva,  IV.  524 
prophylaxis  of,  I.  209 
vaccine  therapy  of,  I.  I'll 
Erythema  induration,  III.  1151 
multiforme,  III.  1038 
nodosum,  I.  212-213 
convalescent  stage,  I.  213 
eruptive  stage,  I.  212 
prodromal  stage,  I.  212 
Erythrasma,  III.  475,  1039 
Erythromelalgia,  II.  1230-1231 
Escharotics  in    Framboesia    tropica,   III 
402 


Esdaile  (James),  and  mesmerism,  III.  160 

method  of  hypnotism,  III.  163 
Eserine  or  physostigmine,  poisoning  by, 

I.  533 
Esmarch's  bandage,  I.  798 

compression  with,   in   haemorrhage,   I. 

1259 

Esophoria  of  ocular  muscles,  III.  646 
Essences,  food,  preparation  of,  I.  42 
Esthiomene  of  the  vulva,  IV.  508 
Estlander's    operation    for    empyema,   I. 

1107 
Ether,  closed  method  of  administration, 

III.  7 

drop-bottle,  III.  11 
ethylic,  as  anaesthetic,  III.  6 
open  method  of  administration,  III.  9 
preceded    by  ethyl  chloride  as  anaes- 
thetic, III.  11 

nitrous  oxide  as  anesthetic,  III.  11 
semi-open   method    of    administration, 

III.  11 

Ethmoidal  sinus,  III.  727-728 
Ethyl  chloride,  administration   of,   from 

small  bag  and  face  piece,  III.  18 
preceded  by  ether  as  anassthetic,  1 1 1. 1 1 
ether  as  anaesthetic,  III.  6 
oxide  as  anaesthetic,  III.  6 
Eucaine  in  sciatica,  II.  1026 
Eucalyptus  in  ankylostomiasis,  III.  491 
in  bronchitis,  I,  245 
oil,  inunction  of  in  scarlet  fever,  I.  288 
Europeans,  physiological  effect  of  tropical 

regions  on,  III.  375 
Eustachian  bougies  in  patency  of  Eusta- 

chian  tube,  III.  949 
catheter  for  patency  of  Eustachian  tube, 

III.  948 

tube,  electrolysis  of,  III.  950 
mucous  membrane  of,  III.  951 
obstruction  of,  and  adenoid  post-nasal 

growths,  III.  947 
and  adhesions  in  naso-pharynx,  III. 

947 
and  chronic  catarrhal  otitis  media, 

III.  944 

hypertrophic  rhinitis,  III.  946 
mucopurulent  nasal  catarrh,  III. 

946 

iKiso-pharyngeal  catarrh,  III.  946 
non-suppurative       middle       ear 

disease,  III.  944-953 
and  dry  catarrh  of  middle  ear,  III. 

944 
and  naso-pharyngeal  catarrh,  III. 

91.-) 

and  oto-fibrosis,  III.  944 
and  tumours  of  the  naso-pharynx, 

III.  947 

functional  tests  in,  III.  944 
general  treatment,  III.  945 
nasal  catarrh  and,  III.  945-947 
prophylaxis,  III.  945 
patency   of,  and   diseases  of   middle 
ear,  III.  947-951 

39 


A    SYSTEM   OF   TREATMENT. 


Evaux  les-Bains  spa,  III.  150 

Eve's  operation  for  gastroptosis,  II.  323 

Evian-les-Bains  spa,  III.  150 

water  in  obesity,  I.  470,  471 
Evisceration  of  foetus,  IV.  416 
anaesthetic  in,  IV.  416 
difficulties  in,  IV.  416 
operation  for,  steps  of,  IV.  416 
Ewart's  treatment  in  typhoid  fever,  I.  34- 
Excision.  centra-indications  to  in  tuber 
culous  disease  of  the  knee-joint,  1. 770 
in    tuberculous  disease    of    the    knee 

joint,  I.  769 

of  joints  in  gunshot  wounds,  I.  562 
of  the  knee-joint,  deformity  after,  I.  771 
Excitement   in  general  paralysis  of  the 

insane,  II.  1079 
sleeplessness  caused  by,  I.  54 
Excretal  diseases  and  their  dissemination 

in  the  tropics,  III.  383 
Exercises,  abdominal,  in  defective  meta- 
bolism, III.  255 
after  spinal  injury,  I.  908 
after  the  administration  of  tuberculin, 

I.  1139 

amount  of  food  in,  II.  199 
and  constipation  in  adults,  II.  459 
breathing,  III.  227 
during  arthriiis  deformans,  I.  392 
excessive,  a  cause  of  strain,  I.  8 
for  flat  foot,  I.  968       . 
for  infants  and  children,  I.  51 
for  spinal  curvature  in  children,  I.  57 
Fraenkel's,  in  tabes  dorsalis,  II.  1091 
fundamental,  III.  225 
graduated,  in  pulmonary  tuberculosis. 

I.  1159 

in  adhesions  of  the  colon,  II.  559 
in  arterio-sclerosis,  I.  1291 
in  diabetes,  I.  422 
mellitus,  I.  422 

in  diseases  of  the  heart,  I.  1208 
in  pregnancy,  IV.  7 
in  pulmonary  tuberculosis,  I.  1123 
in  treatment  of  rheumatism  (chronic"), 

1.489 

of  obesity,  I.  469 
influence  of,  in  dietetics,  II.  199 
introductory,  III.  224 
muscular,  physiological  effect  ol ,  III.206 
physical,  III.  222 

arch-flexions  in,  III.  225 

derivative,  III.  226 

double  curves  in  for  scoliosis,  III.  247 

for  knock-knee,  III.  235 

for  kyphosis,  III.  236 

for  lordosis,  III.  239 

for  scoliosis,  III.  241 

for  spinal  curvature,  III.  236 

for  talipes,  III.  233 

for  wry-neck.  III.  233 

four-footed,  III.  248 

in  asthma,  III.  251 

in  cardiac  affections,  III.  249 

in  chronic  bronchitis,  III.  251 


Exercises,  physical  (contd.)  — 

in  chronic  nervous  diseases,  111.  2.">ij 

in  defective  metabolism.  III.  254 

in  emphysema,  III,  251 

in  flat-foot,  III.  234 

in  orthopaedic  cases,  III.  233 

in  pulmonary  affections,  III.  249-254 

movements    to  exercise    muscles   in 

scoliosis,  III.  248 
passive  stretching  movements  in,  for 

scoliosis,  III.  247 
remedial,  III.  227 
respiratory,  necessary  in  voung  children, 

1.50 

stage  in  sanatorium  treatment  of  pul- 
monary tuberculosis,  I.  1129.  1135 
Exertion  in  acute  rheumatism.  I.  273 
Exhaustion,  acute,  after  fit   in  epilepsy, 

II.  1005 

and  anesthetics.  III.  24 
in  sanatorium  treatment  of  pulmonary 

tuberculosis,  I.  1138 
psychosis,  II.  1299-1300 
Exophoria  of  ocular  muscles,  III.  647 
Exostoses  of  the  meatus,  III.  883 
Exotoxins  in  serum  therapy,  III.  259 
Expectoration,   serous  or  albuminous  in 

hydrothorax,  I.  1092 
Extension,    method    of,    in    tuberculous 

disease  of  the  hip-joint,  I.  753 
External  applications  in  diseases  of  chil- 
dren, I.  69 

Extremities.     See  Limbs. 
Eye,   accommodation    and   refraction   of, 

errors  of,  III.  528-542 
spectacles  for.  III.  542 
application  of  vibration  to.  III.  215 
care  of,  in  measles,  I.  246 
diseases  of,  III.  528-573 

complicating  small-pox,  I.  309 
functional,  III.  543-546 
examination  of,  in  cataract,  III.  617 

in  epilepsy,  II.  991 
excision  of,  anesthetics  for,  III.  30 
liquid  pollantin  serum  for,  III.  287 
muscles  of,  diseases  of,  III.  646-655 
powdered  pollantin  serum  for,  III.  287 
spasm  of  accommodation  in,  III.  542 
Eyeball,  enucleation  of,  III.  658 

mules,  operation  for.  III.  660 
gunshot  wounds  of,  III.  657 
injuries  of,  non-perforating,  III.  656 
operation  for  enucleation  in,  III.  658 
perforating,  III.  657 
wounds  of,  III.  656-660 
Eyelids,  blepharitis  of,  III.  577 
chalazia  of,  III.  578 
diseases  of,  III.  577-582 
ectropion  of,  III.  581 
entropipn  of.  III.  580 
hordeola  of,  III.  579 
ptosisof,  III.  579 
trichiasis  of,  III.  580 
xanthelasma  of,  III.  582 
Eyestrain,  III.  534 


A    SYSTEM   OF   TREATMENT. 


Face,  application  of  vibration  to,  III.  220 
deformity  in  fractures  of  jaw,  II.  99 
dressings  for,  I.  88 
gunshot  wounds  of,  I.  563 
hemorrhage  from,  I.  1275 
hemiatrophy  of,  II.  1232 
operations  on,  and  auajsthetics,  III.  26 
palsy  of,  in  newborn  child,  IV.  365 
paralysis  of,  II.  1093-1095 
presentation  in  labour,  IV.  140-143 
spasm  of,  II.  1047 
Facial  nerve,  injuries  of,  II.  1108 

neuralgia  II.  1127:  III.  170 
Faecal  fistula;,  IV.  535 
Faeces,  analysis  of,  II.  190 

impacted,  in  constipation  in  adults,  II. 

452 

removal  of  by  enemata,  II.  4.")9 
substances  which  increase  the  bulk  of, 

in  constipation  in  adults,  II.  450 
Fallopian  tubes,  actinomycosis  of,  IV.  800 
cancer  of,  IV.  801-803 
chorion-epithelioma  of,  IV.  804 
diseases  of,  IV.  799-819 
il\  sjmreunia  and,  IV.  841 
lia'inatosalpinx  of,  IV.  810 
hernia  of,  IV.  804 
hydrosalpinx  of,  IV.  824 
inflammation  of,  IV.  805-814 
salpingostomy  in,  IV.  825 
sterility  in,  IV.  845 
leucorrhcea  from,  IV.  571 
papilloma  of,  IV.  816 
removal  of,  sterility  in,  IV.  856 
salpingitis  of,  acute,  IV.  810 
chronic,  IV.  813 
complicating   cancer  of   the   uterus, 

IV.  S14 

septic  infection  of,  in  salpingitis,  IV.  807 
tuberculous  diseases  of,  IV.  817-819 
Familial  diseases,  II.  1244 
Family  amaurotic  idiocy,  II.  1244 
Fango   baths    in   arthritis   deformans,  -I. 

398 
Farabceuf's  method  of  amputation  of  the 

toes,  I.  835 

through  the  leg,  I.  855,  858 
subastragaloid  disarticulation,  I.  843 
comments  on,  I.  845 
incision  in,  I.  843 
Faradism  of  kidneys  in  diabetes  insipidus, 

I.  429 

use  of,  in  sprains,  I.  739 
Farinaceous  food  for  children,  I.  59,  62 

in  gout,  I.  452 

Fasciae,  affections  of,  II.  1321 
Fat  diet  in  diabetes,  I.  419 
embolism,  I.  1306 
food  in  rickets,  I.  479 
foods  arranged  in  order  of  value  in,  II. 

197 

in  dietary  of  children,  I.  CO 
milk  modified  by,  II.  223 
processes  in  lipoma,  I.  107 
value  of,  in  dietetics,  11.  201 


Fatigue  in  children  to  be  avoided,  I.  56 

in  migraine,  II.  1027 
Fats,  digestion  of,  II.  191 
inunction  of,  I.  70 
not  digentible  during  typhoid  fever,  I. 

342 
Fauces,  ulceration  of,  in  scarlet  fever,  I. 

284 
Favus,  III.  1040 

of  the  nails,  III.  1082 
Feeble-mindedness,  II.  1318—1320 
Feeding  after  abdominal  operations,  II. 

265 

after  operation,  directions  for,  T.  29 
artificial,  of  infants,  I.  59 

methods  of,  I.  29,  33 
forced,  when  to  avoid,  I.  64 
improper,   and    diarrhceal    diseases    in 

children.  II.  471 
of    newborn  child,   frequency  of,   IV. 

341 
subcutaneous,  in  shock,  I.  103 

See  also  Diet,  Food. 
Feet,  care  of,  in  children,  I.  57 

in  infants  and  children,  I.  46,  48 
protection  of,  in  children,  I.  50 
Femoral  artery,  injuries  of,  I.  1276 

thrombo-phlebitis  in  puerperal   sepsis, 

IV.  321 
thrombosis,  complicating  gynaecological 

surgery,  IV.  494 
Femur,  Bryant's  suspension  apparatus,  in 

fracture  of,  I.  616 
fractures  of,  I.  609-620 

condyle  of,  I.  619 

great  trochanter  of,  I.  612 

in  children,  I.  577 

in  newborn  child,  IV.  366 

neck  of,  I.  609,  611 

produced  by  direct  violence,  I.  670 

separation  of,  epiphyses  in,  I.  612,  620 

torsion  or  spiral,  I.  664 

T-shaped  or  inter-condyloid,  I.  619 
osteo-sarcoma  of,  I.  870 
rotation  of,  after  reposition  of  the  head, 

I.  946 

Fenton's  uterine  dilator,  IV.  478 

vulsellum,  IV.  476 
Fenwick     (W.    Soltau),     atony    of    the 

stomach,  II.  286-292 
atrophy  of  the  stomach  (achylea),  II. 

293-295 

cancer  of  the  stomach,  II.  296-301 
chronic     dilatation     of    the     stomach 

(pyloric  stenosis),  II.  312-315 
dilatation  of  the  stomach,  II.  310-311 
displacements  of  the  stomach,  II.  318- 

322 
hemorrhage  from  the  stomach,  II.  325- 

330 

inflammation  of  the  stomach,  II.  353 
nervous  diseases  of   the  stomach,   II. 

:;:.4-358 

parasites   and  concretions  of  stomach, 

II.  3.V.I 


11 


A    SYSTEM   OF   TREATMENT. 


Fenwick  (W.  Soltau)  (contd.) — 
sea-sickness,  II.  395 
secretory  disorders  of  the  stomach,  II. 

360-369 
symptoms   of  disordered    digestion   in 

the  stomach,  II.  370-371 
ulcer  of  the  stomach  and  duodenum,  II. 

375-381 
Fermentation,  gastric,  prevention  of,  II. 

627 

Ferments  in  treatment  of  cancer,  I.  151 
Fetor  in  cancer  of  cervix,  IV.  617 
Fever,  acute  early,   in   puerperal   sepsis, 

IV.  317 

blackwater,  III.  386-389 
breast,  in  puerperal  sepsis,  IV.  315 
continued,  in  puerperal  sepsis,  IV.  317 
dengue,  III.  390 
early  slight,   in   puerperal    sepsis,  IV. 

314 

enteric.     See  Typhoid, 
food,  II.  233-241 
in  measles,  I.  244 
intermittent  hepatic,  in  cholelithiasis, 

II.  684 

Japanese  river,  III.  390 
malarial,  III.  392-398 
Malta,  111.  399-400 
Mediterranean,  III.  399 
non-septic,  in  puerperal  sepsis,  IV.  315 
phlebotomus,  III.  400 
puerperal.     See  Puerperal  Sepsis, 
rheumatic.     See  Rheumatism, 
"sand  fly,"  111.400 
tropical,  undefined,  III.  410-411 
undulant,  III.  399 
yellow,  III.  412-413 
Fevers,  acute,  diet  in,  II.  202 

subinvolution  of  uterus  in,  IV.  720 
eruptive,  cold  sponging  contraindicated, 

I.  160 

general  treatment  of,  I.  157-160 
infections,   management    of    convales- 
cence, I.  65 
relapsing,  1.  266-267 
tropical,  III.  386-422,  410 
Fibrinous  particles,  embolism  by,  I.  1306 
Fibro  adenomata  of  the  breast,  II.  955 
Fibrocystic  disease  of  the  jaws,  JI.  112 
Fibroids  of  broad  ligament,  IV.  653 
false,  hysterectomy  in,  IV.  654 
true,  enucleation  in,  IV.  653 
cervical  anterior  hysterectomy  in,  IV. 

651 

central  hysterectomy  in,  IV.  648-649 
complicating  labour,  IV.  159 
hysterectomy  in,  IV.  649 
posterior,  hysterectomy  for,  IV.  652 
Paget's  recurrent,  I.  114 
pedunculated,  abdominal  myomectomy 

in,  IV.  658 
polypi,  uterine,  IV.  658-661 

vaginal  enucleation  in,  IV.  660 
sessile,  abdominal  hysterectomy  in,  IV. 
658 


Fibroids  (c-ontd.) — 
uterine,  IV.  634.  <;<;;{ 
drugs  in,  IV.'<>34 
hysterectomy  in,  IV.  639 
abdominal,  in,  IV.  641 
indications  for,  IV.  637 
sub-total  in,  IV.  643 
total,  in,  IV.  647 
leucorrhcea  in,  IV.  570 
myomectomy  in.  IV.  658-G63 
pain  in,  IV.  638 

preliminary  considerations,  IV.  634 
pressure  symptoms  in,  IV.  638 
removal  of,  IV.  C>35 
should  ovaries  be  removed  in  ?   IV. 

639 
vaginal   hysterectomy   in,    IV.    655- 

658 
Fibrolysin  in  adhesions  of  the  colon,  II. 

660 

in  cheloids,  I.  113 
in  chronic  rheumatism.  I.  -I'.io 

synovitis  and  arthritis,  I.  748 
in  disseminated  sclerosis,  II.  1074 
in  tabes  dorsalis,  II.  1086 
Fibroma  of  the  female  urethra,  IV.  872 
of  the  gums,  III.  1193 
of  the  prostate,  II.  950-951 
Fibromata  mollusca,  characteristics  of,  I. 

112 

of  muscle,  II.  1325 
of  the  auricle,  III.  879 
of  the  jaw,  II.  109 
pharyngeal,  I.  113 
simple,  of  the  scalp,  I.  893 
situation  of,  I.  Ill 
subcutaneous,  I.  Ill 
varieties  of,  I.  112 
Fibrosis,  arterio-capillary,  I.  1288 
Fibrositis,  I.  483 

rheumatic,  II.  1121 
Fibrous  ankylosis  of  the  jaws,  II.  106 

•  epalis  of  the  jaw,  II.  109 
Fibula,  congenital  defects  of,  I.  950 
fracture  of,  I.  622-632 

involving  the  ankle-joint,  I.  628 
Pott's  fracture  of,  I.  629 
torsion  or  spiral  fracture  of,  I.  657 
Filaria  lymphangiectasis,  III.  r>lii 
medinensis  in  the  tropics,  III.  384 

infection  by,  III.  501 
volvulus  in  chappa,  III.  466 
Filariasis,  III.  503 
chyluria  in,  III.  503 
complicating  pregnancy,  IV.  T>1 
hydrocele  in,  III.  516 
lymph  scrotum  in,  III.  503 
lymphangitis  in,  III.  503 
oichitis  in,  III.  503 
Fingers,  amputations  of,  I.  804-813 
sites  for,  I.  804 
steps  for,  I.  808-810 
congenital  contraction  of,  I.  938 

dislocation  of,  I.  !>H<S 
contractures  of,  I.  911 


42 


A    SYSTEM  OF   TREATMENT. 


Fingers  (contd.) — 
disarticulation  of,  by  racket  incision, I. 

806 

dropped,  II.  1329 
infective  abscess  of,  I.  16'J 
paralysis  of,  in  lead  poisoning,  I.  513 
supernumerary,  in  new-born,  IV.  363 
surgery  of,  I.  170-171 
Finney's  operation  for  pyloric  stenosis,  II. 

316 
Finsen,  red  liuht  treatment  of  small-pox, 

I.  307 
light  in  lupus.  III.  1117 

in  lupus  erythematosus,  III.  1071 
in  rodent  ulcer.  III.  1134 
Fires  in  sick  room,  I.  26 

open,  in  nurseries,  I.  1 1 
Fish,  chemical  composition  of,  II.  193 
in  dietary  of  children,  I.  60,  61 
inspection  of,  in  the  tropics,  III.  385 
Fissure,  anal.  II.  .V.»7 

Fistula  and  sinus,  general  and  local  treat- 
ment of,  I.  299-301 
Fistulae,  aerial,  of  neck,  II.  166 
anal,  II.  606-610 
aural,  III.  877 

between  bladder  and  intestine,  II.  491 
intestine      and     female     generative 

organs,  II.  491 
biliary,  II.  698,  6!)!» 

gastric,  II.  699 
branchial,  of  neck,  II.  166 
cervical,  II.  166-167 
complicating  operation   for  goitre,  II. 

69 

faecal,  IV.  .~>35 
gastro-colic,  II.  490 

intervisceral,  and  cholelithiasis,  II.  695 
intestinal,  II.  483-492 
median  cervical,  II.  167 
mucous,  of  the  gall-bladder,  II.  698 
pathological  surface,  II.  699 
peri-renal,  II.  767-769 
peritoneal,  II.  280 
recti-urethral,  and  acute  prostatitis,  II. 

923 
renal,  II.  767-769 

treatment  of,  II.  768 
resulting   from    infective   processes    of 

uterus,  IV.  r,r,s 
salivary,  and  inflammation  of  parotid 

gland,  II.  160 

supra-pubic,  failure  of  closure  of,  com- 
plicating adenoma  of  prostate,  II.  915 
tlivn>-i:los-:il.  of  neck,  11.167 
thyroid.  II.  lf,7 
tracheal,  III.  799 
umbilical,  acquired,  II.  281 
mvteral,  II.  842-845  ;   IV.  6C.7 
uretcro-vaginal,  IV.  5:i4 
urinary,  IV.  .":$."> 

at  the  umbilicus,  in  adults,  II.  279 

in  infants.  II.  278 
uterine.  IV.  664-668 

from  malignant  growths,  IV.  668 


Fistulse  (conttl.)— 

utero-iutestinal.  IV.  667 
utero-vesical.  IV.  666 
vaginal.  IV.  :>:tt-536 
vesico-cervical.  IV.  737 
vesico-vagiual,  IV.  533  ;  IV.  878-881 

operation  for,  IV.  736 
vitello-intestinal,  II.  278 
Fits  in  tumours  of  the  brain,  II.  1202 
Flannel  underclothing  for  children,  I.  50 
Flaps,  amputation,  1/791,  800 

vitality  of,  in  amputations,  I.  791 
Flat-foot.  1.  967 
exercises  for,  I.  968 
inflammatory,  I.  969 
in  rickets,  I.  482 
physical  exercises  in,  III.  234 
traumatic,  I.  970 
Flatulence,   after  abdominal   operations, 

II.  264 

from  foods  containing  curds,  II.  231 
in  disordered  digestion  of  the  stomach, 

11.371 

Flexner's  anti-meningitis  serum,  clinical 
results  of,  III.  276 

in  meningococcus  infection,  III.  275 
serum  in  meningitis,  I.  254 
Flies,  carriers  of  typhoid  fever.  I.  336 
Flour,  starch-free,  I.  421 
Flours,  chemical  composition  of,  IT.  195 
Floury  foods  in  infant  feeding,  II.  229 
Fluid  diet  in  infectious  diseases,  I.  158 

food  necessary  for  young  children,  I.  53 
Flushing  curette,  IV.  621 
Foetor  oris,  II.  127 
Foatus,    amencephalus    of,    complicating 

labour,  IV.  180 
body  of,  extraction  of  in  craniotomy, 

IV.  411 

chondrodystrophia  of,  II.  1227 
condition  of,  forceps  in,  IV.  425 
congenital  septic  disease  of  kidney  in, 

complicating  labour,  IV.  180 
goitre  of,   complicating  labour,   IV. 

180 
ceptic      hygroma      of,       complicating 

labour,  IV.  180 
death  of,  IV.  14 

induction  of  premature  labour  in,  IV. 

436 

decapitation  of,  413-415 
deformities  of,   causing  obstruction  to 

labour,  IV.  176-181 
diseases     of,     causing    obstruction    to 

labour,  IV.  176-181 
distress  of.  forceps  in,  IV.  421 
encephalocelc  of,  complicating  labour 

IV.  180 
enlargement  of,   complicating    labour, 

IV.  179-181 

general,  complicating  labour,  IV.  176 
evisceration  of,  IV.  416 

in    impacted    shoulder    presentation, 

IV. 416 
extraction  of,  in  craniotomy,  IV.  406 

43 


A    SYSTEM   OF   TREATMENT. 


Foetus  (contd.') — 

forceps  to  hasten  delivery  in  interests 

of,  IV.  421 
head  of,  position  of  blades  of  forceps  to, 

IV.  431 
hydrocephalus  of,  complicating  labour, 

IV.  179 

indications  of,   for  induction   of  pre- 
mature labour,  IV.  434 
large,   induction  of  premature   labour 

and,  IV.  436 

malposition  of,  forceps  in,  IV.  421 
measures   for  resuscitating,  in  forceps, 

IV.  425 
monstrosities  of,  complicating  labour, 

IV.  180 

presentations  of,  forceps  in,  IV.  421-422 
syphilis  of,    complicating    pregnancy, 

IV.  77 
urethra   of,   imperforate,  complicating 

labour,  IV.  180 

Fb'hn  wind  of  Switzerland,  III.  75 
Folliclis,  III.  1151 

Fomentations,    anodyne,   in   acute  rheu- 
matism, I.  269 

in  chronic  rheumatism,  I.  486 
and  stupes,  I.  35 
Food,    administration    of,    in     aphthous 

stomatitis,  II.  121 
amount  and  character  of,  bodily  health 

and,  I.  451 

amount  required   in   different  circum- 
stances, II.  199 
animal,  in  gout,  I.  451 
articles  to  be  avoided  by  gouty,  I.  455 
canned,   chemical   composition    of,   II. 

192 

carrier  of  typhoid,  I.  337 
daily  quantity  of,  for  children,  I.  63 
digestibility  of,  in  gout,  I.  448 
excess  of,  effect  on  digestive  system,  I. 

8 
gastro-intestinal  derangement  due   to, 

II.  232-241 

in  the  tropics,  III.  378 
in  typhoid  fever,  I.  341 
materials,  chemical  composition  of,  II. 

192 

nitrogenous,  causing  gout,  I.  448 
preserved,  chemical  composition  of,  II. 

192 

purin-free,  I.  452 
refusal  of,  in  general   paralysis  of  the 

insane,  II.  1079 

requirements  in  muscular  work,  II.  200 
solid,  forbidden  before  an  operation,  I. 

27 
starchy,  effect  on  young  children,  I.  58- 

61 

total  value  of,  II.  199 
fever,  II.  233-241 

drugs  in,  II.  239 
poisoning,  I.  506-511 

bacterial  or  ptomaine,  I.  507-510 
from  tinned  food,  I.  510 


Foods,  analyses  of,  II.  1!)2 
animal  (Buuge),  II.  7-15 
ash  percentage  in,  II.  745 
caloric  value  of,  II.  1 98 
common,  arranged  according  to  value  in 
protein,    carbohydrate   and   fat,   II. 
197 

composition  of,  II.  192 
containing  no  starch  in  infant  feedinsr, 

II.  229 

floury,  in  infant  feeding,  II.  2:?'.) 
oxalic  acid  in,  II.  744 
prepared,  in  infant  feeding,  II.  227 
proportion  of,  in  dietetics,  II.  200 
tables  of,  showing  percentage  of  carbo- 
hydrates, I.  411 

tinned,  metallic  poisoning  from,  I.  510 
Foot,  amputations  of,  I.  836-850 
dislocations  of,  I.  733 
everted,  I.  967 
Faraboeuf's  subastragaloid   disarticula- 

tion  of,  I.  844  ' 
hollow  or  contracted,  I.  963 
hot-air  apparatus  for,  III.  325 
inversion  exercise  for  flat  foot,  III.  235 
madura,  III.  485 

suction  glass  for,  in  hypersemic  treat- 
ment, III.  59 
weak,  I.  967 

Foramen  ovale,  neuralgia  in,  II.  1119 
rotundum,  alcohol   injection   into    for 

neuralgia,  II.  1020 
neuralgia  in,  II.  1118 
Forceps,  action  of,  IV.  431 
anaesthesia  and,  IV.  425 
Attie  punch,  III.  916 
axis-traction,  IV.  429-431 
Bonney's  dissecting,  IV.  476,  477 
Briinings',  III.  808 
capsule,  for  cataract,  III.  626 
choice  of,  IV.  422 
condition  of  cervix  and,  IV.  424 
the  child,  and,  IV.  425 
uterus  and,  IV.  424 
craniotomy,   cranioclast  used    as,    IV. 

407 

dangers  of  delivery  by,  IV.  430 
dental,  III.  1180-1187 
for  delay  in  labour,*IV.  418 
for  grasping  the  tonsil,  III.  753 
for  oblique  head,  IV.  431 
for  removal   of  foreign   bodies   in  the 

gullet,  II.  184 
Hartmann's,  III.  908 
in  abnormal   obliquity  of   uterus,  IV. 

420 

in  ante-partum  hasmorrhage,  IV.  420 
in  brow  presentation,  IV.  422 
in  craniotomy,  IV.  411 
in  delay  of  after-coming  head,  IV.  422, 

430 

in  eclampsia,  IV.  421 
in  exhaustion  of  mother,  IV.  420 
in  expression  of  the  cord,  IV.  421 
in  foetal  distress,  IV.  421 


44 


A    SYSTEM   OF   TREATMENT. 


Forceps  (contd.}— 

in  heart  disease  during  labour,  IV.  -120 

in  locked  twins.  IV.  422 

in  malposition  of  child,  IV.  421 

in  measures  for  resuscitating  the  child, 

IV.  425 
in  mento-anterior  presentation  of  face, 

IV.  421 
in   occipito-posterior  presentation,   IV. 

421 

in  post-partum  haemorrhage,  IV.  42ti 
in  prolapse  of  child's  arm,  IV.  422 
in  prolapse  of  the  cord.  IV.  421 
in  rigidity  of  pelvic  floor,  IV.  420 
in  threatened  rupture  of  perineum,  IV. 

420 

in  transverse  head,  IV.  432 
Lake's  larjngeal  punch,  III.  874 
Lane's  tissue,  I.  1256 
long  curved,   application   of,    IV.   426, 

J2S 

Luc's  nasnl,  III.  IW3 
Mackenzie's  luryngeal,  III.  847 
methods  of  applying.  IV.  I2»!-430 
ossophageal,  II.  184-185 
I'aterson's  laryngeal,  III.  848 
position   of   blades   of,  to   foetal  head, 

IV.  431 
position  of  blades  of,  to  maternal  pelvis, 

IV. 431 

position  of  child  and  patient,  IV.  424 
pressure.  IV.  476 
relative  advantages  of,  IV.  432 
ring.  IV.  475,  47>; 
round  ligament,  IV.  481 
scissors,  De  Wecker's,  III.  639 
Thomson  Walker's,  for  calculus,  II.  760 
to  assist  delivery  in  the  interests  of  the 

mother.  IV.  419-420 
toothed    dissecting    in    lacerations    of 

cervix,  IV.  189 

in  operations  on  tonsil,  III.  752 
use  of,  in  disproportion  between  child 

and  maternal  pelvis,  IV.  417-419 
indications  for,  IV.  417 
uterine,  with  pledget  of  wool,  IV.  625 
Walchers  position  in,  IV.  424 
Whistler's  laryngeal,  III.  848 
Forearm,  amputation  through,  I.  816-820 
circular  amputation  through,  I.  819 
fractures  of  the  bones  of,  I.  596-603 
modified  circular  amputation  of,  I.  816 
paralysis  of  extensor  muscles  of,  electro- 
therapeutics in,  III.  107 
suction  glass  for,  in  hyperaemic  treat- 
ment, III.  58 
varix  of,  I.  1321 
Foreign  bodies  in   the  air-passages.   III. 

803-821 

cocainisation  in.  III.  81(5 
general  anu'sthesiu  in.  III.  S13 
instruments  for  removal  of,  III.  80(» 
introduction  of  the  bronchoscope,  TIT. 

816 
local  anaesthesia  in.  III.  813 


Foreign  bodies  (contd.) — 

position    of    patient    in    the    direct 

method,  III.  814 

technique  of  direct  method  for,  III. 
814,  818 

in  the  auricle,  III.  888 

in  the  bronchus,  abscess  due  to,  I.  1061 

in  the  chest,  I.  1027 

in  the  external  ear,  III.  888-889 

in  the  female  bladder,  IV.  875-876 

in  the  intestines,  II.  493-497 

in  the  meatus,  III.  888 

in  the  nose,  III.  667 

in  the  oesophagus,  II.  184-189 

in  the  stomach,  II.  285 

in  the  urethra,  II.  884 

in  the  vagina,  IV.  537 

introduction  of,  in  aneurysm,  I.  1302 
Forlauini's  method  of  artificial  pneumo- 

thorax,  I.  1170 

Formalin  gas,  fumigation  by  means  of,  I. 
163 

spray,  disinfection  by,  I.  120 
Formamint  tabloids  in  diphtheria,  I.  194 
Foruncles.     See  Furuncles. 
Fothergill  (W.  E.),  cysts  of  the  vagina, 
IV.  531-532 

fistula;  of  the  vagina,  IV.  533-536 

foreign  bodies  in  the  vagina,  IV.  537 

infections  of  the  vagina,  IV.  538-539 

injuries  of  the  vagina,  IV.  540 

malformations  of  the  vagina,  IV.  541-544 

prolapse  of  the  vagina,  IV.  545-552 

tumours  of  the  vagina,  IV.  553-554 
Foulerton  on  thymus  extract  in  cancer, 

I.  150 
Fournier  (Prof.),  on  treatment  of  syphilis, 

I.  317 

Fowler's  position   for  administration   of 
fluids  per  rectum  in  peritonitis,  II.  635 

solution,  dosage  of  in  children's  diseases, 

1.68 
Fox  (R.Fortescue),  hydrology,  III.  111-147 

index  of  spas,  III.  147-158 
Foz  (Wilfrid  S.),  adenoma  sebaceum,  III. 
991 

blastomycetic  dermatitis,  III.  1005 

cheloid  or  acne  cheloid,  III.  1018 

chilblains,  III.  1019-1020 

corns,  III.  1024-1025 

Darier's  disease.  III.  1026 

epithelioma,  III.  1037-1038 

erythrasma,  III.  1039 

favus.  III.  1040 

hydradenomata,    or    adenoma    of   the 
sweat  glands,  III.  1044 

icthyosis  and  xeroderma,  III.  1053 

innocent  t  umours  of  the  skin  (myomata), 

in.  ior>7 

K  a  post's    disease    (xeroderma  pigmen- 

tosuin).  III.  1057 
lentigo  (freckles),  III.  1058 
inolluscum  contagiosum,  III.  1073 
molluscum    fibrosum :    von    Reckling- 

hausen's  disease,  III.  1074 


A    SYSTEM   OF   TREATMENT. 


Fox  (Wilfrid  S.)  (contd.)— 

mycosis  fungoides,  III.  1076 

naevi  moles,  birth  marks.  III.  1077-1081 

pediculosis,  III.  1086-1087 

pityriasis  versicolor,  III.  1095 

ringworm,  III.  1125-1131 

rodent  ulcer,  III.  1132-1134 

rosacea.  acne  rosacea  rhinophyma,  III. 
1135-1136 

scabies,  III.  1137-1138 

sebaceous  cysts.  III.  1140 

seborrhrea,  III.  1141-1142 

seborrhoeic  dermatitis,  III.  1142 

tuberculides,  III.  1146-1152 

urticaria  angioneurotic  oedema,  lichen 
urticatis,  urticaria  pigmentosa,  III. 
1154-1156 

warts  (verrncae),  III.  1157-1159 

xanthoma,  III.  1160 

X-ray  dermatitis.  III.  1161-1163 
Fracture-dislocations  of  the  spine,  I.  902- 

905 
Fractures,  I.  568-633 

accurate  apposition  of  fragments  in,  I. 
639 

badly  united,  operative  treatment  of,  I. 
650 

callus  formation  in,  I.  579 

causes  of  displacement  in,  I.  570 

Collis',  I.  578 

complications,  &c.,  of,  Zander  treatment 
in,  III.  374 

compound,  general  principles  of  treat- 
ment of,  I.  581-583 

extension  principle  in,  I.  577 

fragments  in,  apposition  of,  I.  642 

gangrene  following,  I.  582 

general  principles  of  treatment  of,  I. 
568-~633 

greenstick,  I.  570 

gunshot,  I.  561 

immobolisation  in,  I.  572 

impacted,  I.  570 

instruments  used  in  the  operative  treat- 
ment of,  I.  637-651 

local  treatment  of,  I.  569 

massage  and  passive  movements  in,  I. 
577 

nerve  injury  in,  II.  1101 

redema  in,  I.  578 

of  bone  in  extraction  of  teeth,  III.  1188 

of  the  head  in  infants,  I.  886 

of  the  larynx,  III.  825 

of  the  long  bones  in  newborn  child,  IV. 
365 

of  the  teeth,  III.  1177,  118& 

operative  treatment  of,  I.  634-693 

painful  action  of  tendons  in,  I.  578 

pelvic,  I.  605 

pulley  extension  apparatus  for,  I.  576 

reduction  of,  I.  569,  571 

retentive  apparatus,  forms  of,  I.  573 

septic,  I.  561 

septicaemia  following,  I.  581 

setting  of,  I.  571 


Fractures  (contd.}— 

splints  for.  various.  I.  573-575 
spontaneous,  in  cancer,  I.  146 
stiff  joints  following,  massage  in,  III. 

207 

suppuration  following,  I.  582 
water  pillows  for,  I.  31 
Fraenkel's  exercises  in  tabes  dorsalis,  II. 

1091 

Fragilitas  ossium,  I.  712 
Framboesia  tropica,  III.  461 

constitutional  treatment  of,  III.  4»V2 
local  treatment  of,  III.  462 
prophylaxis  of,  III.  461 
Frank's  operation  for  malignant  stricture 

of  the  oesophagus,  II.  177 
Frankau  (C.  H.  B.),  affections  of  the  tendon 

sheaths.  II.  1330-1333 
cranial  meningocele,  II.  1194 
diseases  and  affections  of    bursae,   II. 

1334-1335 

hernia  cerebri,  II.  1190 
inflammatory  affections  of  muscles,  II. 

1324-1325 

injuries  of  muscles,  II.  1321-1323 
injuries  of  tendons,  II.  1326-1329 
new  growths  of  muscle,  II.  1325 
surgical    treatment    of    aneurysm,    I. 

1301-1305 
surgical     treatment    of    epilepsy,    II. 

1007 

urethritis,  chronic  (gleet),  II.  877-879 
Franzenslad  spa. III.  150 
Fraser    (J.   S.),    eustachian    obstruction 
and  chronic  non-supurative   middle- 
ear  disease.  III.  944-953 
otosclerosis.  III.  954-957 
Freckles,  lenrigo,  III.  1058 
Freeland   (J.  B.),    management    of    the 

newborn  child,  IV.  337-372 
Freeman  (John),  on  vaccine  therapy  of 

whooping  cough,  I.  383 
Freezing,  destruction  of  rodent  ulcer  by, 

I.  115 
French    (Herbert),    Addison's   pernicious 

anaemia.  II.  1-12 
anaemia  due  to  actual  loss  of  blood,  II. 

18-19 
anaemia  due  to  some  definite  malady, 

II.  13-17 

aplastic  anaemia,  II.  37 
chlorosis,  II.  20-31 
chorea,  II.  1257-1263 
haemophilia,  II.  31-36 
mental  diseases  in  pregnant  women,  IV. 

4(5-58 

Friction  and  massage,  II.  204 
Friedreich's  disease,  II.  1248 
Frontal  sinus,  III.  728-730 

inflammation  of  complicating  influenza, 

I.  239 

suppuration  of,  III.  729 
Frost-bite  of  the  external  ear,  III.  888 
Fruit,  digestion  of,  in  young  children,  I. 
53,  62 


46 


A    SYSTEM   OF   TREATMENT. 


Fruit  (i-initif. ) 

incautious  use  of,  in  children,  I.  53 

in  gout,  I.  454 

in  sprue,  III.  443 

in  typhoid  fever.  I.  344 
Fruits,  chemical  composition  of,  II.  196 
Fuchs'  myoputhic  ptosis,  III.  650 
Fuel-workers'  era-ma,  I.  117 
Fulguration  in  cancer,  I.  1.">1 

of  cervix  uteri,  l\T.  617 
Fumigations  in  asthma,  I.  1039 

with  formalin  gas,  I.  163 

with  sulphurous  acid  gas,  I.  162 
Fundal  grip  in  palpation  in  normal  labour. 

IV.  98 

Funic  souffle  in  normal  labour,  IV.  104 
Furuncles  or  boils,  III.  1006-1011 


Gag  in  operation  for  cleft  palate,  II.  150 

powerful  screw,  in  fractures  of  the  jaw, 

II.  Ki7 
Galactocele  in  the  puerperium,  IV.  336 

of  the  breast,  II.  953 
Galbiati's  knife  for  symphysiotomy,  IV. 

4."i  7 
Gall  bladder,  actinomycosis  of,  II.  711 

catarrh  of,  chronic,  II.  700 

cirrhosis  of,  hypertrophic,  II.  664 

croupous  inflammation  of,  II.  701' 

diseases  of,  II.  680 

distension  of,  II.  710 

dropsy  of.  If.  710 

cmpvema  of,  II.  710 

fistula?  of,  II.  698 

gangrene  of,  II.  7n| 

liydatidsof.  II.  711 

hydrops  of,  II.  710 

hypertrophy  of,  II.  710 

inflammation  of,  II.  699-709 
followed  by  cancer,  I.  119 

injuries  of,  II.  680 

mucous  fistula?  of,  II.  698 

new  growths  of,  II.  711 

perforation  of,  II.  707 

sarcoma  of,  II.  712 

simple  empyema  of,  II.  702 

stricture  of,  II.  706 

tumours  of,  II.  710-712 
Gall-stone  scoop,  II.  688 
Gallant's  corset  for  movable  kidney,  II. 

789 

Gallic  acid  in  haemorrhage,  I.  1261 
Galvanism  in  gout.  I.  l:i'.i 

in  s| trains.   I.  73H 

of  kidneys  in  diabetes  insipidus,  I.  429 
Galvano-cautery  in  chronic  infections  of 
the  tonsil,  III.  751 

in  haemorrhage,  I.  12.">8 
Game,  chemical  composition  of.  II.  193 
Games  for  young  children.  I.  ."•:.' 
Ganglion  of  tendon  sheaths,  II.  1332 
Gangrene.  I.  214-220 

acute  spreading  traumatic.  I.  219 

after  injuries  of  arteries,  I.  1279 


Gangrene 

amputation  in,  I.  216,  790 
carbolic,  I.  219 
diabetic,  I.  217,  426 
"due  to  ergot,  I.  219 

to  gradual  obliteration  of  the  main 

arteries,  I.  215 
to  mechanical  obstruction  of  a  main 

arterial  trunk,  I.  215 
to  sudden  obliteration  of   the  main 

arterial,  I.  215 
following  carbolic  fomentations,  I.  168, 

170 

fractures,  I.  582 
from  direct  crushing,  I.  214 
general  treatment  of,  I.  214 
in  arterio-sclerosis,  I.  1296 
in  Kaynaud's  disease,  II.  1240 
moist,  complicating  diabetes  mellitus, 

1.426 

of  the  gall  bladder,  II.  704 
of  the  lung,  I.  1090 
senile,  I.  215 
symmetrical,  I.  218 
Gangrenes,  specific,  I.  219 
Gangrenous  proctitis,  epidemic,  III.  437 
Gardiner     (F.),     cheiropompholyx,     III. 

1015-1016 

chloasma,  III.  1017 
dermatitis  artefacta,  III.  1027 
herpetiforms,  III.  1028 
(occupation),  III.  1029-1030 
diseases  of  the  nails,  III.  1082 
drug  eruptions,  III.  1031 
eczema,  III.  1032-1036 
epidermolysis  bullosa,  III.  1036 
erythema  multiforme,  III.  1038 
herpes  febrils,  III.  1042 

zoster,  III.  1043 
melanoderma,  III.  1073 
milium,  III.  1073 
monilithrix,  III.  1075 
morphcea,  III.  1075 
pemphigus,  III.  1088,  1089 
pityriasis  rubra,  III.  1093 

pilaris,  III.  1092 
prurigo,  111.  1096 
purpura,  III.  1124 
sclerodermia,  III.  1139 
sycosis,  III.  1144,  1145 
trichorrhexis  nodosa,  III.  1145 
tylosis,  III.  1153 
vitiligo,  III.  1159 
Garrod     (A.   E.),     urinary    disorder,    II. 

730-750 

Gaseous  poisons,  treatment  of,  I.  534-535 
Gasserian   ganglion,  excision   of,  for  tri- 

geminal  neuralgia,  II.  1117,  1128 
injection  of  alcohol,  II.  1119 
Gastem  spa,  III.  150 
Gastrectomy  in  gastric  cancer,  I.  140 
partial,  for  cancer  of  the  stomach,  II. 

308 

for  hour-glass  stomach,  II.  334,  336 
statistics  of,  II.  303 


47 


A    SYSTEM   OF   TREATMENT. 


Gastric  juice,  diminution  of,  II.  293 
Gastritis,  acute  simple,  II.  345,  348 

toxic,  II.  348 
alcoholic,  II.  353 
chronic,  II.  294,  348 

general  treatment  of,  II.  348 

'medicinal  treatment  of,  II.  351 
diet  in,  II.  345,  350 
general  treatment  in,  II.  345 
medicinal  treatment  of,  II.  346 
phlegmonous,  II.  353 
Gastro-enterostomy  for  hour-glass  stomach, 

II.  334 
for  hypertrophic  pyloric    stenosis,    II. 

342,  343 
for  relief  of  obstruction   in  cancer  of 

alimentary  system,  I.  140 
in  ulcer  of  the  stomach,  II.  386 
statistics  of,  II.  302 
Gastro-gastrostomy  for  hour-glass  stomach, 

II.  334 
Gastro-intestinal  antiseptics  in  pernicious 

anaemia,  II.  6 
derangements   due    to  food,    II.    233- 

241 

form  of  gout,  I.  447 
post-operative  haemorrhage,  I.  1276 
temperature  in  pulmonary  tuberculosis, 

I.  1139 

Gastro-jejunostomy   for  pyloric   stenosis, 

II.  316 

in  haematemcsis,  II.  333 
Gastroliths,  II.  359 

Gastrolysis  for  hour-glass  stomach,  II.  334 
for  pyloric  stenosis,  II.  316 
simple,  II.  336 
Gastroplasty  for  hour-glass  stomach,  II. 

334 
Gastroptosis,  II.  319 

accompanied  by  myasthenia,  II.  321 
belt  for,  II.  320 
diet  in,  II.  320 

medicinal  treatment  of,  II.  321 
surgical  treatment  of,  II.  323-324 
Gastrostomy,  feeding  after,  method  of,  I. 

33 

for  malignant  stricture  of  the  oesopha- 
gus, II.  176 
for   relief  of  obstruction  in  cancer  of 

alimentary  system,  I.  139 
mortality  of,  II.  305 
Gastrotomy   for    foreign    bodies    in    the 

oesophagus,  II.  187 
in  the  stomach,  II.  285 
Gaurain's    portable    stand,    with    spinal 

board,  I.  751 

method  in  abscesses,  I.  757 
Gauze,  antiseptic,  use  of  in  operations,  I. 

85-86 
for  surgical  dressings,   varieties  of,   I. 

74-78 
plugging  after  abdominal  operations, 

11.267 

strips  in  drainage  of  acute  abscess,  I. 
167,  170 


Gelatine  in  hasmorrhage,  I.  1262 
injection  of,  in  haamophilca,  II.  34 
subcutaneous    injections  of,    in  aortic 
aneurysm,  I.  1298 

Genital  organs,  care  of,  in  children,  I.  48 
examination  of,  in  epilepsy.  IV.  992 
female,  and  intestine  fistulas  between, 

II.  491 

obesity  and,  I.  473 
male,  diseases  of,  II.  874 

passages,    dilation    of,    in    symphysio- 

tomy,  IV.  454 

tract,  lacerations  of,  amputation  of  cer- 
vix in,  IV.  194 
Clover's  clutch  in,  IV.  188 

complicating  labour,  IV.  188-213 
non-haemorrhagic    discharges     from, 

IV.  555-574 

re-sterilisation  of,  after  piobable  in- 
fection in  puerperal  sepsis,  IV.  290 
slower  sterilisation  of,  in   puerperal 

sepsis,  IV.  289 
Genito-urinary  organs,  physical  defects  of, 

I.  231 
passages,  anaesthetics  in  operations  on, 

III.  32 

symptoms  in  paraplegia,  II.  1199 
system  in  typhoid  fever,  I.  361 
Genu  recurvatum,  I.  949 

valgum,  or  knock-knee,  I.  959 
varum  and  bow-leg,  I.  U62 
Geographical  pathology,  III.  375-516 

tongue  (annulus  migrans),  II.  126-129 
Gibbons  (K.  A.),  dysmenorrhoea,  IV.  73(5- 

750 

dyspareunia,  IV.  839-842 
sterility,  IV.  843-859 
vaginismus,  IV.  860-864 
Gigli's  saw  in  pubiotomy,  IV.  447,  450 
wire  saw  in  fractures  of  the  jaws,  II. 

106 
Gingivitis  in  svphilis,  I.  318 

marginal,  III.  1191 
Glanders,  III.  670 
acute,  I.  222 
chionic,  I.  222 
differential  diagnosis,  I.  221 
incubation  period,  I.  222 
parotid  inflammation  of,  II.  157-163 
Glands,  adrenal,  diseases  of,  II.  46-48 
axillary,  removal-  of  in  malignant  dis- 
ease of  the  breast,  II.  972 
carcinoma  of,  I.  1350 

of,  metastatic  growths,  I.  124, 126 
caseating  tuberculous,  in  mediastina, 

I.  1177 
enlarged,  application   of   vibration  in, 

III.  218 
cervical,   complicating    influenza,    I. 

239 

lymphatic,  diseases  of,  I.  1339-1340 
diseases  secondary  to   infective  pro- 
cesses, I.  1339 

tuberculous  disease  of,  I.  1344 
lymphosarcoma  of,  I.  1350 


48 


A    SYSTEM   OF   TREATMENT. 


Glands  (contd.)— 

new  growths  of,  I.  1350 

salivary,  diseases  of,  II.  130-131, 157-163 
injuries  of,  II.  157-163 

sublirigual,  inflammation  of,  II.  158 

submaxillary,  inflammation  of,  II.  158 

supra-clavicular,  enlargement  in  malig- 
nant disease  of  the  breast,  II.  96-1 

tuberculous,  operative  procedures  for, 

I.  1348 

surgical  treatment  of,  I.  1348 
Glandular  affections  in  measles,  I.  246 
Glaucoma,  III.  602-606 

acute  idiopathic,  III.  602 

chronic,  III.  604 

intermittent,  III.  604 
Gleason'a  operation  on  the  nasal  septum, 

III.  681 

Gleet,  II.  877-870 
Glenard's  disease  (enteroptosis),  I.  430 

general  treatment,  I.  430 

mechanical  support  in,  I.  430 

surgical  treatment  of,  I.  431 
Glenoid  cavity,  fracture  of,  I.  585 
Glossina   palpalis  and  sleeping  sickness, 

III.  :?s;{ 
Glossitis,  acute  parenchytnatous,  II.  133 

inveterate  chronic,  in   syphilitic  affec- 
tions of  the  tongue,  II.  136 
Glottis,  oedema  of,  complicating  cut  throat, 

II.  165 

Gloves,  sterilised  rubber,  use  of,  in  labour, 

IV.  288 

use  of  in  operations,  I.  81 
Glucose,  rectal  injection  of,  in  eclampsia, 

IV.  37 

solution  in  hemorrhage,  I.  1267 
Gluteal  arteries,  injuries  to,  I.  1276 
Glycerine  and    belladonna  in   glandular 

affections,  1.  i-Mii 
enema,  I.  32 
suppositories  in  constipation  in  adults, 

II.  4.-.:< 

Glycosuria  in  diabetes,  diet  in,  I.  413-416 
in  gout  and  gouty  conditions,  I.  446 
mineral  waters  and  baths  in,  III.  140 
Goat's    milk,    micrococcus   melitensis   in, 

III.  384 
Goitre,  II.  62-71 

application  of  vibration  in,  III.  216 
complications  after   the  operation  for, 
11.68 

during  operation  for,  II.  68 
cystic,  congenital,  complicating  labour, 

IV.  180 
exophthalmic,  II.  54 -.~>7 

after-treatment  of,  II.  60 

climate  in,  II.  56:    III.  99 

complicating  pregnancy,  IV.  57 

diet  in,  II.  55 

drugs  in,  1 1.  "> 

Mot-bius's  anti-thyroid  serum  in,  II. 
56 

rest  in,  II.  54 

results  of  surgical  treatment  of,  II.  60 


I 
4'J 


Goitre,  exophthalmic  (contd.) — 

surgical  treatment  of,  II.  57,  58-61 

X-rays  in,  III.  366 
general  treatment  of,  II.  62 
indications  for  operation  in,  I.  67 
local  treatment  of,  1 1.  63 
medicinal  treatment  of,  II.  62 
operations  for,  details  of,  II.  65,  70 
operative  treatment  of,  II.  63 
resection-enucleation  for,  II.  65 
results  of  operative  treatment  of,  II.  70 
Gonococcus  in  salpingitis,  IV.  815 
infections,  serum  therapy  of,  III.  280- 

281 
Gonorrhoea,  I.  223-230 

abscesses  complicating,  I.  226 

acute,  vaccine  therapy  of,  III.  280 

chronic,  vaccine  therapy  of,  III.  281 

complications  of,  I.  225-230 

epididymitis  in,  I.  227 

injections  in,  I.  224 

Janet's  method  of   urethral   irrigation 

in,  I.  224 

lymphangitis  in,  I.  226 
oedema  of  prepuce  in,  I.  225 
of  cervix  uteri,  leucorrhcea  in,  IV.  566 
sterility  due  to,  I.  227 
urethral  irrigations  in,  I.  224 

complicating  the  puerperium,  IV.  329 
urethritis  in,  I.  281 
vaccine  therapy  of,  I.  225,  III.  280 
zinc  astringent  solutions  in,  I.  224 
Gonorrhoeal  arthritis,  I.  781-783 

local  treatment,  I.  781 

serum  therapy  in,  I.  783 

vaccine  therapy  in,  I.  782,  III.  281 
endometritis,  leucorrhosa  in,  IV.  569 
ophthalmia,  I.  228 

in  the  adult,  III.  555 
peritonitis,  II.  642 
rheumatism,  I.  228 
salpingitis  in  children,  IV.  807 
vaginitis,  IV.  564 
vulvitis,  IV.  524 

chronic,  IV.  561 

general  measures  in,  IV.  524 

in  women,  IV.  560 

local  treatment,  IV.  525 

treatment  of  by  vaccines,  IV.  527 
warts  complicating  gonorrhoea,  I.  226 
Gooch's  splinting,  I.  573 
Goodall  (E.  W.),  measles,  I.  243-247 

rubella,  I.  280 
Gossage     (Alfred     M.),     achondroplasia 

(chrondrodystrophiafoetalis),  II.  1227 
acroniegaly,  II.  1226-1227 
angioneurotic  oedema,  II.  1228-1229 
cerebellar,  conditions  in   children,   II. 

1165-1166 

chronic  basilar  meningitis,  I.  253 
erythromelalgia.  II.  1230-1231 
hvpertrophic    pulmonary   osteo-arthrc- 

pathy, II.  1233 

infantile  convulsions,  II.  986-989 
leontiasis  ossea,  II.  1236 


A    SYSTEM   OF   TREATMENT. 


Gossage  (Alfred  M.)  (contd.*) — 

osteitis  deformans,  Paget's  disease,  II. 

1237 

osteogenesis  imperfecta,  II.  1237 
Raynaud's  disease,  II.  1238-1241 
Goulard's  lotion  in  sprains,  I.  738 
Goundou, III.  469 
Gout,  I.  432-461 
acidity  in,  I.  442 
acute,  calomel  in,  I.  432 

colchicum  in.  I.  433 

diet  in,  I.  434 

lotions  in,  I.  433 

massage  in  contra-indicated,  I.  438 
affections  of  the  throat  in,  III.  775 
alcohol  in,  I.  456 
angina  pectoris  in,  I.  443 
cardiac  form,  I.  447 

manifestations,  I.  443 
cataphoresis  in,  I.  441 
causes  of,  I.  448 
cerebral  form  of,  I.  447 
chronic,  baths  in,  I.  439 

diet  in,  I.  455 

salts  and  solvents  in,  I.  434-436 
climate  for,  III.  93 
complications  of,  I.  442-447 
diabetes  in,  I.  446 
diet  in,  II.  207 

alimentary  tract  factors,  I.  450 

animal  food,  I.  451 

articles  to  be  avoided,  I.  455 

digestibility  of  food,  I.  448 

fruits  in,  I,  454 

general  principles,  I.  447 

meals,  selections  for,  I.  455 

purin-free,  I.  452 

saccharine  food,  I.  453 

starchy  food.  I.  453 
dyspepsia  in,  I.  442 
eczema  in,  I.  445 
electric  light  baths  in,  I.  439 
gastro-intestinal  form  of,  447 
general    principles    of    treatment,    I. 

432 

glycosuria  in,  I.  446 
hepatic  torpor  in,  I.  442 
hyperchlorhydria  in,  I.  442 
insomnia  of,  I.  444 
irregular,  I.  442-447 
lithium  salts  in,  I.  435 
local  treatment  of  joints  in,  I.  438 
metastatic,  I.  447 

mineral  waters  in,  classification  of  value 
of,  I.  460 

and  baths  in,  III.  140 
neuritis  in,  I.  444  ;  II.  1130 
phlebitis  in,  I.  444,  1330 
preventive  treatment  of,  I.  437-461 
prostatitis  in,  II.  926 
pseudo-angina  in,  I.  444 
retrocedent,  I.  447 
sciatica  in,  I.  444 
subacute,  I.  434-436 

colchicum  in,  I.  434 


Gout  (contd.} — 

superheated  air  baths,  I.  440 

uric  acid  solvents  in,  I.  436 
von  Graefe's  cataract  knife,  III.  623 
Grafting,  epithelial  in  avulsion  of  scalp, 

I.  875 

Grain  poisoning,  I.  506,  510 
Grant  (Dundas),  on  injection  of  alcohol 

for  relief  of  pain,  I.  135 
Granulating  surfaces  in  burns  and  scalds, 
treatment  of,  I.  542 

wounds,  I.  554 
Granulations  in  chronic  inflammation  of 

the  middle  ear,  III-.  908 
Granuloma,  infective,  III.  447 

ulcerating,  of  the  pudendum,  III.  457- 

"458 

Granulosis  rubra  nasi,  III.  1041 
Graves'  disease.    See  Goitre,  exophthalmic. 
Grawitz  method  in  pernicious  anaemia,  1 1. 9 
Gray's  enterotribe,  I.  1258 
Green  protective,  value  of,  I.  79 
Greenstick  fracture,  I.  570 
Greville  non-luminous  bath,  I.  747 
Grey  oil  injections  in  syphilis,  I.  319 
Griffith's  mixture  in  chlorosis,  II.  22 
Grimsdale     (Harold     B.),    diseases     and 
affections  of  the  cornea,  III.  563-573 

diseases  and  affections  of  the  eyelids, 
III.  577-582 

diseases  and  affections  of  the  lacrymal 

gland,  III.  556-558 
Gritti's        transcondyloid        amputation 

through  thigh,  I.  862 
Groves  (Ernest  W.  Hey),  affections  of  the 
umbilicus,  II.  277-281 

fistulas  of  the  intestines,  II.  483-492 

foreign  bodies  in  the  intestines,  II.  493- 
497 

fractures  of  the  jaws,  II.  99-119 

perforation   of  the   intestine,  II.   550- 

558 

Groves'  enterotome  with  key,  II.  489 
Gruel,  preparation  of,  I.  42 
Grunbaum  (Otto),  diseases  of  the  adrenal 

glands  (Addison's  disease),  II.  46-48 
Guaiacum  in  osteo-arthritis,  I.  401 

resin  in  chronic  rheumatism,  I.  490 

in  gout,  I.  435,  438 
Guerin's  fracture  of  the  jaw,  II.  100 
Guillotine,  removal  by,  in  chronic  affec- 
tions of  the  tonsil,  III.  751 
Guinea  worm,  infection  by,  III.  501 
Gullet,   forceps  for  removal   of    foreign 

bodies  in,  II.  184 

Gumma,    intra-cranial,   in  cerebro-spiual 
syphilis,  II.  1067 

of  the  trachea,  III.  801 
Gums,  care  of,  in  scarlet  fever,  I.  294 

dental,  cysts  of,  III.  1193 

diseases  of,  dental  origin,  III.  1191 

epulis  of,  III.  1193 

fibroma  of,  III.  1193 

laceration  of,  in  extraction  of  teeth,  III. 
1188 


50 


A    SYSTEM   OF   TREATMENT. 


Gunshot  wounds.     See  under  Wounds. 
Gunzberg's  test  in  poisoning,  I.  526 
Gurjem  oil  in  leprosy,  III.  450 
Guthrie  (Thomas),  syphilis  of  the  larynx, 

III.  868-869 

of  the  naso-pharynx,  III.  743 
of  the  nose,  III.  714-715 
of  the  pharynx,  III.  791-792 
Guyon's    supra-malleolar  amputation,   I. 

850 

Gymnastics,  educational.  III.  223 
in  deformities  of  the  spine,  I.  981 
remedial,  III.  227 
Swedish,  in  constipation  in  adults,  II. 

459,  460 

Si't-  iilxo  Kxercises. 

Gynaecological  operations,  antiseptic  solu- 
tions in,  IV.  484 
directions  to  nurse  in,  IV.  485 
examination  of  patent  before,  IV.  474 
garb  of  surgeon  and  assistants  in,  IV. 

4  S3 

instruments  for,  IV.  475 
ligature,  material  for,  IV.  482 
retentive  apparatus  for,  IV.  481 
special  apparatus  for,  IV.  481 
sterilisation  in,  IV.  483 
swabs  in,  IV.  483 
technique  of,  IV.  474-486 
surgery,  after-treatment,  IV.  487-489 
bladder  in,  IV.  487 
bladder,  complications  of,  IV.  496 
bowels  in,  IV.  487 
cardiac  failure  in,  IV.  494 
cellulitis  in,  IV.  493 
complications  in  parietal  wound  in, 

IV.  495 

of,  post-operative,  IV.  489-497 
diet  in,  IV.  488 
distension  in,  IV.  490 
dressings  in,  IV.  488 
femoral  thrombosis  in,  IV.  494 
haemorrhage  in,  IV.  491 
insomnia  in,  IV.  490 
intestinal  obstruction  in,  IV.  493 
pain  in,  IV.  490 
parotitis  in,  IV.  495 
peritonitis  in,  IV.  492 
position  of  patient  in,  IV.  487 
pulmonary  complications  of,  IV.  494 
pulse  in,  IV.  487 
respiration  rate  in,  IV.  487 
rest  in  bed  in,  IV.  489 
shock  in,  IV.  491 
temperature  in,  IV.  487 
vomiting  in,  IV.  489 
Gynaecology,  light  treatment  in,  III.  201 

Habits,     vicious,    natural    resistance    to 
disease  lowered  by,  I.  5,  9 

Hsematemesis.      gastro-jejunostomy,     II. 

333 

in  cancer  of  the  stomach,  II.  300 
medicinal  treatment  of,  II.  328 


Haematemesis 

post-operative,  complicating  abdominal 

operations,  II.  275 
surgical  treatment  of,  II.  332 
Hsematocele,  II.  913 
Haematoma  and  contusions,  I.  545-546 
complicating  operation  for  goitre,  II.  69 

wound  after  abdominal  operations,  II. 

272 
increasing     diffused,     in     injuries     of 

arteries,  I.  1278 
in  varicose  veins,  IV.  90 
of  the  external  ear,  III.  888 
of  the  scrotum,  II.  900 
of  the  spermatic  cord,  II.  917 
of     the    sterno-mastoid     in     newborn 

child,  IV.  305 
of  the  vulva,  IV.  522 

Haematomata,  subaponeurotic,  in   contu- 
sions of  the  scalp,  I.  873 
Haematomyelia,  I.  904  ;  II.  1210-1211 
acute  stage  of,  II.  1210 
stage  of  repair  in,  II.  1211 
Haematoporphyrinuria,  II.  735 
Haematosalpinx  of  Fallopian  tube,  IV.  810 
Haematuria,  II.  736 
and   chronic   interstitial  nephritis,   II. 

799 

in  acute  nephritis,  II.  797 
in  scurvy,  I.  475,  477 
post-operative,  in  renal  calculus,  II.  762 
renal,  and  calculus,  II.  755 
Haemophilia,  II.  31-36 
arthritis  in,  I.  786 
diet  in,  II.  35 
encouragement  of  coagulation  locally, 

II.  32 

internal  remedies  for,  II.  34 
iron  in,  II.  36 
local  pressure  in,  II.  33 
local  vaso-constriction  in,  II.  33 
Haemoptysis  in  pulmonary  tuberculosis,  I. 

1150 

mild,  in  pulmonary  tuberculosis,  1. 1150 
moderate,  in  pulmonary  tuberculosis,  I. 

1151 

severe  cases  of,  in  pulmonary  tubercu- 
losis, I.  1154 

Haemorrhage,  accidental  after  labour,  IV. 
28,  29 

complicating  pregnancy,  IV.  23-2!) 
after  amputations,  I.  803 
after  extraction  of  teeth,  III.  1189 
after  ovariotomy,  IV.  793 
angiotripsy  in,  I.  1257 
ante-partum,  forceps  in,  IV.  420 

podalic  version  in,  IV.  466 
antiseptic  action  of,  I.  7 
arterial,  I.  1255-1277 
as  symptom  of   cancer  of    cervix,  IV. 

585 

cerebellar,  II.  1174 
cerebral,  II.  1168-1176 

coma  in,  II.  !i*l 

effects  of,  II.  1169 

51  4—2 


A    SYSTEM  OF  TREATMENT. 


Haemorrhage,  cerebral  (eontd.*) — 

factors  underlying  production  of.  II. 
1169 

in  asphyxia    of   newborn  child,  IV. 
353 

in  newborn  child,  IV.  364 

meningeal,  II.  1072 

results  of,  I.  880 

superficial,  II.  1170 

traumatic,  II.  1170 
cold  in,  I.  1260 

complicating  adenoma  of  the  prostate. 
II.  945 

gynaecological  surgery,  IV.  491 

operation  for  goitre,  II.  68 

perineal  prostatectomy   in    adenoma 
of  prostate,  II.  948 

pernicious  anaemia,  II.  10 
concealed,  after  labour,  IV.  28 

before  labour,  IV.  27 
severe,  IV.  28 

control  of,  in  amputations,  I.  798 

in  disarticulation  at  hip  joint,  I.  866 

in  inoperable  cancer,  I.  136 

in  malignant  disease  of  upper  jaw, 

II.  116 

cutaneous,  in  jaundice,  II.  671 
effect  of  decreased  coagulability  on,  I. 

128 

Esmarck's  bandage  in,  1. 1259 
external,  severe,  in  labour,  IV.  27 

slight,  after  labour,  IV.  28 

before  labour,  IV.  26 
extradural,  in  injuries   of  the  head,  I. 

880 

forci -pressure  in,  I.  1256 
from  the  ear,  III.  886 
from  varicose  vein,  I.  1276 
from  wounds,  arrest  of,  I.  550 
gastric.  II.  325-330 

complications  of,  II.  331 

surgical  treatment  of,  II.  331-333 
gastro-intestinal  post-operative,  1. 1276 
general  treatment  of,  I.  15-29 
haemorrhoids  and,  II.  616 
heat  in,  I.  1260 
horse  serum  in,  III.  262 
immobility  in,  I.  1262 
in  aortic  aneurysm,  I.  1300 
in  cancer  of  cervix,  IV.  617 
in  chronic  simple  ulcer  of  stomach,  II. 

327 

in  colitis,  II.  574 

in   contusions  and  haematoma,  limita- 
tion of,  I.  545 
in  cut  throat,  II.  164 
in  gunshot  wounds,  I.  559 
in  naevi  of  the  lips.  II.  97 
in  operation  for  cleft  palate,  II.  150 
in  portal  cirrhosis  of  the  liver,  II.  663 
in  uterine  fibroids,  IV.  637 
in  Wertheim's  operation,  IV.  607 
in  wounds  of  parotid  gland,  II.  162 

of  the  scalp,  I.  874 

of  the  tongue,  II.  132 


Haemorrhage  (co/itd.') — 

internal,  in  abdominal  injuries,  II.  244 

signs  of,  I.  29 
intestinal,  complicating  typhoid  fever, 

I.  359 
into  the  spinal  canal  in  injuries  of  the 

spine,  I.  904 
intra-cerebral,  purgation  in,  II.  1171 

treatment  of,  general,  II.  1171 
surgical,  II.  1173 

venesection  in,  II.  1172 
intra-cranial,  in  head   injuries   in   the 
infant,  I.  886 

in  infants,  I.  886 

treatment  of,  surgical,  II.  1175 
intra-dural,  in  injuries  of  the  head,  1. 882 
intra-peritoneal,   complicating  abdomi- 
nal operations,  II.  275 
laryngeal,  III.  824 
meningeal,  I.  880  ;  II.  1170 
mixed,  after  labour,  IV.  28 

severe,  in  labour,  IV.  28 
mucous,  in  jaundice,  II.  671 
parenchymatous,  I.  1272 
pharyngeal,  III.  776-777 
pontine,  II.  1175 
position  in,  I.  1262 
post-operative,  treatment  of,  I.  87 
post-partum,  IV.  29 

bi-inanual  compression  of  uterus  in, 
IV.  220 

complicating  labour,  IV.  214-223 

compression  of  fundus  in,  IV.  219 

Crede's  method  of  expression  in,  IV. 
218 

exciting  causes  of,  IV.  215 

external,  IV.  216 

forceps  in,  IV.  426 

in  placenta  prsevia,  IV.  68 

predisposing  causes,  IV.  215 

severe  anaemia  in,  IV.  222 

shock  in,  IV.  222 

primary,  of  arterial  origin,  I.  1270 
reactionary,  I.  1272 
rest  in,  complete,  I.  1262 
rubber  tourniquet  for,  I.  1258 
saline  infusion  in,  I.  1262 
secondary,  I.  1272 

in  gunshot  wounds,  I.  559 

in  haemorrhoids,  II.  619 

of    the  cord  in  newborn   child,   IV 

370 

special,  I.  1274-1277 
styptics  in,  I.  1261 
surgical  methods  in,  I.  1255 

varieties  of,  1270-1277 
torsion  in,  I.  1257 
transfusion  of  blood  in,  I.  1269 
vaginal,  in  newborn  child,  IV.  371 
venous,  I.  1271 
Hsemorrhagic  diphtheria,  I.  187-199 

small-pox,  I.  310 
Haemorrhoids,  II.  615-620 
cautery  in,  II.  619 
clamp  for,  II.  619 


52 


A    SYSTEM  OF   TREATMENT. 


Haemorrhoids  (contd.')— 

complicating  pregnancy,  IV.  42 

diet  in,  II.  616 

external,  II.  615 

haemorrhage  and.  II.  616 

in  the  female  urethra,  IV.  729 

internal,  II.  615 

operations  in,  II.  618 
pregnancy,  IV.  42 

pain  in,  II.  617 

radical  operation  for,  II.  620 

secondary  haemorrhage  in,  II.  619 

thrombosed,    complicating   pregnancy, 

IV.  42 

Haemostasis  in  amputation  through   the 
arm,  I.  824 

in    disarticulation     through    shoulder- 
joint,  I.  827 
Haemostat.  Ion<*.  for  faucial  and  pharyn- 

geal  use,  III.  784 
Haemothorax,  1. 1090 

amylnitritc  in,  I.  564 

in  injuries  of  the  thorax.  I.  1029 
Hair,  care  of,  in  sick  room,  I.  28 

growth  of,  excessive,  III.  1046 

piedra  disease  of,  III.  476 
Hairballs,  gastric,  II.  359 
Hair-follicles,     alopecia    dependent     on 

morbid  conditions  of,  III.  1000 
Hall    (Arthur  J.),   diseases    of    salivary 
glands,  II.  130-131 

geographical  tongue  (annulus  migrans), 

II.  126-129 
stomatitis,  II.  120-125 

Hallux  flexus,  I.  965 

valgus,  I.  965 
Halsted's  operation  for  inguinal  hernia, 

II.  507 
Hamel  (Gustav),  massage.  III.  203-212 

the  Zander  treatment,  III.  369-374 

treatment  by  radiant  heat  and  hot  air, 

III.  316-326 

Hamilton  Irving's  box,  II.  943,  944 
Hamman-Meskoutine  spa,  III.  150 
Hamman-B'irha  spa,  III.  151 
Hammerman's  cramp,  II.  1267 
Hammerschlag  on  pubiotomy,  IV.  449 
Hammer  toe,  I.  966 

cause  of,  I.  57 
Hands,  contractures  of,  I.  941 

disinfection  of,  in  normal  labour,  IV. 

106 
hot-air    chamber    for,    in    hyperaemic 

treatment,  III.  63 
sterilisation  of,  I.  81 

in  puerperal  sepsis,  IV.  288 
Hanging  in  physical  exercises,  III.  230 
Handley  (Sampson),  on  lymphangioplasty, 

I.  144 
on    open-air    methods    in    inoperable 

cancer,  I.  133 

on  spread  of  mammary  cancer,  I.  126 
on  trypsin   treatment    in    ossophageal 

cancer,  I.  140 
Hanot's  disease.  II.  664 


•'  Hardening  "  of  children,  dangers  of,  I. 

46.  50 
Harelip,  II.  85-95 

after-treatment   in   operations  for,   II. 

93 
double,  11.89 

premaxillary  bones  in,  II.  92 
in  newborn  child,  IV.  357 
nostril  and,  II.  90 
operations  and  anaesthetics,  III.  28 
preliminary  considerations  of,  II.  85 
secondary  operations  for,  II.  94 
single,  II.  86 

premaxillary  bones  and,  II.  91 
Harris  (Wilfred),  neuralgia,  II.  1114-1126 
nystagmus,  II.  1140-1141 
occupation  neuroses,  and  craft  palsies, 

II.  1264-1268 
tetany,  II.  1271 
tics  and  spasms,  II.  1047-1049 
Harrison's  rubber  tooth  cleanser,  II.  128 
Harrogate  spa,  III.  151 
Hartmann's  forceps,  III.  908 
Haward  (J.   Warrington),  phlebitis  and 

thrombosis,  I.  1328-1338 
on  embolism  following  operation  for 

appendicitis,  II.  274 

Hay  (John),  arterio-sclerosis,  I.  1287-1295 
Hay  fever,  III.  690 
Hazeline  suppository  in  haemorrhoids,  II. 

617 

Head,  diathetic  neuralgia  of,  II.  1024 
diseases  and  injuries  of,  I.  873-887 
foetal,  after-coming,  delay  of,  forceps  in, 

IV.  422,  430.  432 
injuries  of,  in  the  infant,  I.  886-887 

infection  following,  I.  884-885 
level  of,  to  be  lowered  in  shock,  I.  97 
neuralgia,  diathetic,  affecting,  II.  1122 

toxic,  affecting,  II.  1122 
oblique,  forceps  in,  IV.  431 
pain  in,  hypnotism  in  case  of,  III. 

172 
position   of,  in   X-ray  application   for 

ringworm.  III.  356 
preparation  of  for  operation,  I.  87 
toxic  neuralgia  of,  II.  1024 
transverse,  forceps  in,  IV.  432 
varix  of,  I.  1321 

Headache  from  cerebral  syphilis,  II.  1034 
from  chronic  hydrocephalus,  II.  1034 
from  disease  of  nasal  accessory  cham- 
bers, II.  1033 
of  skull  bones,  II.  1033 
from  errors  of  refraction,  II.  1033 
from    gross    intra-cranial    disease,    II. 

1034 

from  high  arterial  tension,  II.  1034 
from  inter-cranial  tumour,  II.  1034 
from  ocular  conditions,  II.  1033 
from  renal  disease,  II.  1034 
from  uraemia,  II.  1034 
in  fever,  relief  of,  I.  159 
in  lead  poisoning,  I.  514 
in  yellow  fever,  III.  412 


53 


A    SYSTEM   OF   TREATMENT. 


Headache  (contd.) — 
neuralgic,  accompanied  by  soreness  of 

the  scalp,  II.  1116 
periodic,  II.  1027-1035 

forms  of,  II.  1033 

Head-nodding  in  nystagmus,  II.  1141 
Heart  affections  complicating  influenza, 

I.  241 

scarlet  fever,  I.  293 
block,  I.  1237 

congenital  affections  of,  I.  1 254 
continuous  irregularity  of,  I.  1231 
dilatation  of,  I.  1240 

compensatory,  I.  10 
diseases  of,  climate  for,  III.  97 

complicating  pregnancy,  IV.  52 
rheumatism,  acute,  I.  272 

consciousness  of,  I.  1245 

dropsy  in,  I.  1243 

drugs  in,  I.  1211,  1243 

during  labour,  forceps  in,  IV.  420 

following  diphtheria,  I.  193 

in  anaemia,  II.  15 

in  typhoid  fever,  I.  364 

physical  exercises  in,  III.  249,  253 

principles  of  treatment  of,  I.  1194- 
1254 

remedial  measures  in,  I.  1203-1211 

subjective  phenomena  in,  I.  1245 

symptoms  as  indications  for  treat- 
ment, I.  1227 

vascular,  mineral  baths  in,  III.  137 

what  to  treat,  I.  1194 
effect  of  lithium  salts  on,  I.  435 

thyroid  extract  upon,  II.  49 
extra  systoles  of,  I.  1230 
failure,  I.  1195 

causes  of,  I.  13 

complicating  gynaecological  surgery, 
IV.  494 

difficulty    in    estimating    effects    of 
remedies  in,  I.  1197 

in  chronic  simple  ulcer  of  the  stomach, 

II.  329 

in  diphtheria,  I.  199 

in  pneumonia,  I.  260 

threatened,   in    acute    bronchitis,    I. 

1052 

fatty  degeneration  of,  1. 1 242 
febrile  affections  of,  acute,  I.  1242 
gout  and  gouty  conditions  of,  I.  443, 

447 

gunshot  wounds  of,  I.  565 
hypertrophy  of,  I.  1241 
irregular  action  of,  I.  1228-1237 
irregularity   of,   in   arterio-sclerosis,   I. 

1295 
lesions  in  rheumatism  in  childhood,  I. 

278 

massage  of,  in  eclampsia,  IV.  37 
myocardial  affections  of.  I.  1240 
right,  dilatation  of,  complicating  acute 

endocarditis,  I.  1193 
rupture  of,  I.  1030 
sinus  irregularity  of,  I.  1228 


Heart  (contd.') — 

stimulation  of.  by  massage,  III.  254 

valvular  defects  of,  I.  1239 
diseases  of.  and  anaesthetics,  III.  23 

wounds  of,  I.  1030 

Heat,   excessive,   and    tropical   liver,   II. 
677 

baths  in  osteo-arthritis,  I.  403 

exhaustion,  I.  537 

flushes  in  the  menopause,  IV.  502 

in  haemorrhage,  I.  1260 

iritis  and,  III.  585 

prickly,  III.  470 

radiant,  treatment  by,  III.  316-326 
indications  of,  III.  324 

treatment  of   chronic    rheumatism,   I. 
486 

use  of,  in  sprains,  I.  737 

value  of  foods,  II.  191,  198 
Heath's  tonsil  guillotine,  III.  752 
Heat-shock.  I.  537 
Heat-stroke,  I.  538 

coma  in,  II.  985 
Heated  air,  hyperaemic  treatment  by,  III. 

61 

Hebosteotomy  in  contracted  pelvis,  com- 
plicating labour,  IV.  171 
Hebra,   pityriasis    rubra   gravis  of,   III. 

1151 

Hectine  in  syphilis,  I.  323 
Heel.  big.  III.  465 

painful,  II.  1025 

neuralgia  in,  II.  1123 

raising  exercise  for  flat  foot,  III.  235 
Hegar's  dilators  in  hypertrophic  pyluric 

stenosis,  II.  343 
Hellebore,  black,  poisoning  by,  I.  533 

white  or  green,  poisoning  by,  I.  533 
Hellier  (J.  B.),   diseases,  affections  and 
injuries  of  the  vulva,  IV.  505-530 

infections  of  tuberculous  or  doubtful 
nature  of  vulva,  IV.  508 

injuries  of  vulva,  IV.  509-510 

innocent  tumours  of  vulva,  IV.  511-512 

malformations  of  vulva,  IV.  513-514 

malignant  disease  of  vulva,  IV.  515-516 

pruritus  vulvas,  IV.  517-519 

syphilitic  affections  of  vulva,  IV.  520- 
521 

varix  and  haematoma  of  vulva,  IV.  522 

vulvitis  and  forms  of  dermatitis  affect- 
ing the  vulva,  IV.  523-529 
Helouan  spa,  III.  151 
Hemiatrophy.  facial,  II.  1232 
Hemiplegia,  II.  1181-1190 

arthritic  adhesions  in,  II.  1187 

ataxis  in,  II.  1188 

contractures  in,  II.  1187 

general  considerations  of,  II.  1181 

involuntary  movements  in,  II.  1188 

length  of  treatment  in,  II.  1189 

muscular  atrophy  in,  II.  1187 

of  children,  II.  1181-1190 

pain  in,  II.  1188 

paralysis  in,  II.  1184 


54 


A    SYSTEM   OF   TREATMENT. 


Hemiplegia  (contd.)— 

spastic,  of  upper  limb,  II.  1064 
spasticity  in,  II.  1186 
symptomatic  treatment  of,  II.  1184 
vasomotor  disturbances  in,  II.  1189 
Henbane,  poisoning  by,  I.  532 
Hepatitis,  amrebic,  II.  676 
Hepatoptosis  of  the  liver,  II.  659 
Hereditary  alopecia,  III.  998 
spastic  paraplegia,  II.  li'l'.i 
Hermaphroditism,  IV.  865-867 
in  newborn  child,  IV.  362 
pseudo-,  IV.  865-867 
uterus  masculinus  in,  IV.  881 
Hernia,  II.  498-527 
cerebri,  II.  1190 
diaphragmatic,  1. 1028  ;  II.  515 
direct  inguinal,  II.  508 
femoral,  II.  509-511 

operation  for,  II.  509,  510 
>t  rangulated,  II.  522 
general  considerations,  II.  498 
gluteal,  II.  514 
in  newborn  child,  IV.  358 
inllamed,  IT.  515 
inguinal,  II.  500-509 

external  incision  in  operation  for,  II. 

501 
ligature  of  sac  in  operation  for,  II. 

503 

of  newborn  child,  IV.  359 
operations  for,   other  than   Bassin's 

method,  II.  507 
sac  of  direct,  II.  503 
separation  of  external  oblique  apo- 

neurosis  in  operation  for,  II.  502 
separation  of  sac  from  cord  in  opera- 
tion for,  II.  502 
strangulated,  II.  521 
suture  of  conjoined  tendon  to  Pou- 
part's   ligament  in    operation  for, 
II.  504,  505 
interstitial,  II.  508 
labial,  IV.  512 
lumbar,  II.  515 
obstructed,  II.  515 
obturator,  II.  514 
of  muscular  fibres,  II.  1323 
of  the  Fallopian  tube,  IV.  804 
of  the  lung,  I.  1027 
of  the  ovary,  IV.  767 
of  the  testis,  II.  901 
operative  treatment,  II.  498 
palliative  treatment  of,  II.  523 

by  trusses,  II.  498 
perincal,  II.  515 
preventive  treatment,  II.  499 
scar   complicating   gynaecological   sur- 
gery, IV.  496 
sciatic,  II.  514 
strangulated,  II.  516-523 
after-treatment  of,  II.  519 
causes  of,  II.  520 
of  newborn  child,  IV.  359 
umbilical,  II.  511-514 


Hernia,  umbilical  (contd.~) — 

after-treatment  of  operations  for,  1 1. 

513 

of  newborn  child,  IV.  358 
operation  for,  II.  512 
strangulated,  II.  523 
vaginal,  II.  515 
ventral,  II.  514 

Hernial  sac,  appendix  in,  II.  410 
Herpes  complicating  pregnancy,  IV.  56 
febrils,  III.  1042 
frontalis  and  cornea,  III.  571 
of  the  auricle,  III.  880 
of  the  meatus,  III.  885 
of  the  pharynx,  III.  778 
of  the  tympanic  membrane,  III.  891 
post,  neuralgia,  II.  1122 
zoster,  II.  1096-1097  ;  III.  1043 
acute  stage,  II.  1096 
pain  in,  III.  1043 
prodromal  stage,  II.  1096 
pustulation  in,  III.  1043 
sequelae  of,  II.  1096 
Herringham  (W.  P.),  nephritis,  acute,  II. 

796-797 
nephritis,  chronic  diffuse  parenchyma- 

tous,  II.  794-795 
chronic  interstitial,  II.  792-793 
uraemia,  II.  837-839 
Hertz  (Arthur  F.),  constipation  in  adults, 

II.  439-469 
Heterophoria    of     ocular    muscles,    III. 

646 
Hett  (G.  Seccombe),  acute  tonsillitis,  III. 

747-749 
chronic   infections  of   the  tonsil,   III. 

750-759 
diseases  and  affections  of   the  lingual 

tonsil,  III.  760-763 
diseases  and  affections  of  the  uvula 

III.  744-746 
syphilis,   tuberculosis  and  tumours  of 

tonsil,  III.  756-759 
Hewitt's  artificial  airway,  III.  8 

modification  of  Clover's  inhaler,  III.  7 
Key's  modification  of  Lisfranc's  amputa- 
tion, I.  840 

Hiccough  after  ovariotomy,  IV.  792 
in  peritonitis,  II.  639 
spasm,  II.  1048 

High-frequency  and  static  wave  currents 
in  chronic  synovitis  and  arthritis,  I. 
746 

currents,  III.  105 
Hill  diarrhoea,  III.  438 
Hill's  (Leonard),  manometer,  I.  1281 
Hilton's  method  in  acute  abscess,  I.  167 
Hip,  congenital  dislocation  of,  I.  943 
deformities  of  in  cerebral  palsies  of  in- 
fancy, II.  1160 
dislocations |of,  I.  724 
flexion  deformity  of,  II.  1062 
internal  rotation  of,  II.  1062 
joint,  disarticulation  at,  I.  866-872 

by  anterior  racket  incision,  I.  871 
55 


A    SYSTEM   OF   TREATMENT. 


Hip  joint,  disarticulation  at  (contd.} — 
indications  for,  I.  866 
Jordan's  modified  method,  I.  868 
tuberculous  disease  of,  I.  752-765 
Hodge's  pessary  in  retroflexion  of  uterus, 

IV.  680 

Hodgen's  splint,  I.  614 
Hodgkins'  disease,  I.  1340-1343 
general  treatment  of,  I.  1341 
medicines  for,  I.  1343 
surgical  treatment  of,  I.  1341 
X-rays  in,  I.  1342 
Holland   (Eardley),   management   of  the 

normal  puerperium,  IV.  256-271 
Holmes  (Gordon),  amaurotic  family  idiocy, 

II.  1244 

amyotonia  congenita,  II.  1245 
cerebral   palsies  of  infancy,   II.   1153- 

1156 
chronic      disorders     with      cerebellar 

symptoms,  II.  1246 
family   form   of    muscular   atrophy  in 

children,  II.  1247 
family  periodic  paralysis,  II.  1247 
Friedreich's  disease,  II.  1248 
hereditary     spastic      paraplegia,      II. 

1249 

Huntingdon's  chorea,  II.  1249 
muscular  dystrophies,  II.  1250,  1251 
myotonia  atrophica,  II.  1252 
myotonia  congenita,  II.  1252 
pcroneal  muscular  atrophy,  II.  1253 
sub-acute    combined    degenerations  of 

the  spinal  cord,  II.  1083-1084 
syringomyelia,  II.  1219-1220 
Holt  (Emmett),  on  atropine  in  bed-wetting, 

11.75 
on  modified   milk  in    infant    feeding, 

II.  225 
on    phenazone    in    whooping     cough, 

1.382 

Homatropine  in  cataract,  III.  618 
Homburg  spa,  III.  151 
Hood  (Wharton),   on  sprained   joints,  I. 

739 

Hookworm  disease,  III.  487 
Hopogan  in  hyperchlorhydria,  I.  442 
Hordeola  of  the  eyelids,  III.  579 
Border  (T.  J.),  infective  endocarditis,  I. 

203-208 

purulent  meningitis,  I.  249-253 
tuberculous  meningitis,  I.  248-249 
Horn's  catgut,  sterilisation  of,  I.  72 

sebaceous,  I.  109 
Horsehair  sutures,  I.  86 
Horse  serum  in  haemophilia,  I.  787 
in  serum  therapy,  III.  261 
irritating  effects  of,  I.  193 
normal,    in    infective    endocarditis,  I. 

207 
Hot  air  apparatus  for  the  back,  III.  323 

for  the  shoulder,  III.  323 
baths,  I.  38  ;  III.  128 
chambers  for  hyperaemic  treatment,  III. 
62-64 


Hot  air  (contd.) — 

disinfection  by  means  of,  I.  lf>2 
douche  in  hyperaemic  treatment,  III.  65 
thermal  douche  bath,  III.  127 
treatment  by,  III.  316-326 
Hot  bottles,  use  of,  I.  29,  34 
,  pack,  use  of,  I.  38 

water  bottles,  use  of,  I.  29,  34 
Houseworkers'  dermatitis.  III.  1030 
Housing  in  the  tropics,  III.  379 
Huggard  (William  R.),  climatology,  III. 

69-102 

Hullux  rigidus,  I.  965 
Humerus,  fractures  of,  I.  586-592 
anatomical  neck  of,  I.  587 
capitellum  of,  I.  595 
condyles  of,  I.  592-594 
in  newborn  child,  IV.  365 
lower  extremity  of,  I.  592 
separation  of  epiphyses  in,  I.  590.  593, 

599 

shaft  of,  I.  590,  681 
surgical  neck  of,  I.  589 
T-shaped,  I.  595 
tuberosities  of,  I.  588 
Hunger,  sleeplessness  caused  by,  I.  54 
Huntingdon's  chorea,  II.  1249 
Hutchinson  (Jonathan),  affections  of  the 

tongue,  II.  132-146 
Hutchison  (R.)  on  food  values,  II.  198 
Hydatid  cysts  of  the  breast,  II.  954 

of  the  broad  ligaments,  IV.  820-821 

of  the  gall  bladder,  II.  711 

of  the  liver,  II.  669 

of  the  lung,  surgical  treatment  of.  I. 

1175 

of  neck,  II.  169 
of  the  scalp.  I.  892 
of  the  skull,  'I.  894 
disease,  prophylaxis  of.  III.  521 

of  the  spine,  I.  918-919 
Hydatidiform  mole.  IV.  59 
Hydradenomata  of  the  sweat  glands,  III. 

1044 

Hydramnios.    acute,    complicating    preg- 
nancy, IV.  44 

chronic,  in  pregnancy,  IV.  43 
complicating  pregnancy,  IV.  43-44 
olego,  complicating  pregnancy,  IV.  44 
Hydrarthrosis,  intermittent,  I.  748 
Hydrastis  canadensis,  in  menorrhagia,  IV. 

771 

in  metrorrhagia.  IV.  771 
Hydrencephalocele  of  newborn  child,  IV. 

357 
Hydrocele,  II.  914-916 

encysted  of  the  spermatic  cord,  II.  917 
filarial.  III.  516 
of  the  canal  of  Nuck,  IV.  512 
of  neck,  II.  169 
of  newborn  child,  IV.  360 
palliative  treatment,  II.  914 
radical  cure  by  open  operation,  II.  916 
Hydrocephalus,  II.  1191-1192 
chronic,  headache  from,  II.  1034 


56 


A    SYSTEM   OF   TREATMENT. 


Hydrocephalns  (contd.'} — 

cranial  puncture  on,  II.  1191 

in  spina  bih'da.  I.  915 

lumbar  puncture  in,  II.  1191 

medicinal  treatment  of,  II.  1191 

of  fietus  complicating  labour,  IV.  179 

of  newborn  child,  IV.  3,">i! 

operation  in.  II.  1193 

surgical  treatment  of,  II.  1193 

various  drainage  devices  in,  II.  1191 
Hydrochloric  acid,  effect    in  gastric  func- 
tion. II.  291 

in  gastric  neurasthenia,  II.  386 

in  typhoid  fever,  I.  355 
Hydrocyanic   acid    poisoning,    treatment 

.-,f.  I.  .-,30 
Hydro-electric   baths  in   arthritis   defor- 

mans.  I.  31(8 
Hydrology.  III.  111-147 

(Miit  ra-indications  for,  III.  137 

doctrine  of  ions  in.  III.  1 14 

indications  for,  I II.  137 

medical,  definition  of,  III.  Ill 
Hydronephrosis.  II.  770-779 

congenital.  II.  772 

due  to  obstruction  in  bladder,  II.  773 
to  obstruction  in  bony  pelvis,  II.  772 
to  obstruction  in  the  urethra,  II.  772 

general  observations  on,  II.  777 

nephrostomy  for,  II.  779 

results  of  plastic  operations  for,  II.  779 

with  aberrant  vessels  of  kidney,  II.  773 

with  calculus,  II.  773 

with  movable  kidney,  II.  772 
Hydropathy  in  disseminated  sclerosis,  II. 
1(174 

in  tabes  dorsalis,  II.  1092 
Hydropericardium,  I.  1185 
Hydroperitoneum,  complicating  cancer,  I. 

146 
Hydrophobia.  I.  264,  265 

antirabic  serum  in,  I.  265 

Pasteur's     inoculation    method    in,    I. 

264 

Hydrops  of  the  gall  bladder,  II.  710 
Hydrosalpinx  of  Fallopian  tube,  IV.  808 
Hydro-therapy  in  chronic   synovitis  and 
arthritis,  I.  745 

in  constipation  in  adults,  II.  459 

in  insomnia,  II.  985,  1017 

in  pruritus.  III.  1100 

in  rickets,  I.  478 
Hydrothorax,  I.  1091.  1092 

and  arterio-sclerosis,  I.  1294 

complicating  cancer.  I.  146 

paracentesis  in.  I.  1091 
Hygiene  and  care  of  infants  and  children, 
I.  44-70 

personal,  in  cholera,  III.  424 
in  the  tropics,  III.  375-385 
Hygroma,  cystic,  of  foetus,  complicating 
labour,  IV.  180 

of  lymphatic  vessels,  I.  1351 

of  neck,  II.  Hi'.t 

of  newborn  child,  IV.  358 


Hymen,  atresia  of,  IV.  513 

im  perforate,  IV.  541 
Hyoscine  in  morphinism,  I.  517 
Hyoscyamine  or  hyoscine  (scopolamine), 

poisoning  by,  I.  532 
Hyperacidity  of  the  stomach,  II.  360 
Hypersemia,  active,  in  joint  affections,  I. 
747 

Bier's  treatment,  III.  40-68 

of  the  labyrinth,  III.  967 

of  the  larynx.  III.  822 

passive.     See  Bier's  treatment. 
Hypersemic  treatment.     See  Bier's  hyper- 

agmic  treatment. 
Hypersesthesia  of  the  labyrinth,  III.  967 

laryngeal,  III.  845 

of  'the  phaiynx,  III.  782 
Hyperchlorhydria,  I.  519 

in  gout  and  gouty  conditions,  I.  442 
Hyperidrosis.  or  excessive  sweating,  III. 
1044,  1045 

X-rays  in,  III.  359 
Hypermetropia,  III.  536 

atropine  in,  III.  536 
Hyperopia.  III.  536 

atropine  in,  III.  536 

Hyperphoria  of  ocular  muscles,  III.  647 
Hyperplasia.     chronic,     of    the    mucous 

membrane    of    the    upper    respiratory 

tract,  III.  774 

Hyperpyrexia,  cold  water  sponging  in,  I. 
160 

complicating  acute  rheumatism,  I.  273 
scarlet  fever,  I.  289 

in  injuries  of  the  spine,  I.  908 

in  typhoid  fever,  cold  bath  treatment, 

I.  348 

Hypersecretion  of  the  stomach,  II.  364 
Hypertension.  I.  1281 

case  of,  I.  1282 

causes  of.  in  arterio-sclerosip,  I.  1289 
Hypertonic  salt  waters,  III.  119 
Hypertrichosis,  III.  1046-1052 

depilatories  in,  III.  1047 

electrolysis  in,  III.  1048 

epilation  for,  III.  1048 

Rontgan  rays  in, III.  1047 
Hypertrophy  of  the  breasts,  II.  957 

of  the  heart,  I.  1241 

promotion  and  maintenance  of,  I.  13 

recuperative  process  of,  I.  10 
Hypnotics  in  alcoholism,  I.  500 
Hypnotism  and  treatment  by  suggestion, 

III.  159-179 
cases  of,  III.  177 
conclusions,  III.  175 

author's   method    (J.   F.  Woods),    III. 
166 

Beaunis'  method  of,  III.  164 

Bernheim's  method  of,  III.  164 

Braid's  method  of,  III.  163 

Bramwell's  method  of,  III.  165 

brief  historical  introduction,  III.  159 

Dubois'  method  of,  III.  166 

Esdaile's  method  of,  III.  163 


57 


A    SYSTEM   OF   TREATMENT. 


Hypnotism  (contd.) — 
in  alcoholism,  I.  498 
in  insomnia,  II.  989,  1021 
in  morphinism,  I.  519 
Liebault's  method  of,  III.  164 
Luy's  method  of,  III.  165 
Mesmer's  method  of,  III.  163 
methods  of  inducing.  III.  163 
Richet's  method  of,  III.  165 
stages  of,  III.  177 
Vorsin's  method  of,  III.  165 
Wetterstrand's  method  of,  III.  164 
Hypochondriasis,    sexual,  in    impotence, 

I.  232  ;  II.  912 
Hypodermic  injection  in  vaccine  therapy, 

III.  265 

syringe  in  cases  of  collapse,  I.  28,  37 
Hypodermoclysis,  continuous,  in  haemor- 
rhage, I.  1268 
in  haemorrhage,  I.  1267 
Hypogastrium,  prominence    of,   in  third 

stage  of  labour,  IV.  120 
Hypospadias,  in  congenital  malformations 

of  the  penis,  II.  875 
in  newborn  child,  IV.  362 
Hypothermal  baths,  III.  126 

douche  bath,  III.  127 
Hypotonic  waters,  III.  115 
Hysterectomy,     abdominal,     in     uterine 

fibroids,  IV.  641 
instruments  for,  IV.  642 
preparation  of  patient  in,  IV.  641 
total,  in  cancer  of  cervix,  IV.  600 
bladder  reflected  in,  IV.  645 
broad  ligaments,  clamped  in,  IV.  642 

divided  in,  IV.  646 
Cassarean,  IV.  398-402 
mortality  from,  IV.  401 
operation  of,  IV.  399 
for  anterior  cervical  fibroid,  IV.  651 

precautions  in,  IV.  652 
for  central  cervical  fibroid,  IV.  648,  649 

precautions  in,  IV.  650 
for  cervical  fibroid,  IV.  649 
for  false  broad   ligament   fibroid,  IV. 

654 

for  posterior  cervical  fibroid,  IV.  652 
for  uterine  fibroids,  indications  for,  IV. 

687 

in  accidental,  haemorrhage  during  preg- 
nancy, IV.  25 
in  menorrhagia,  IV.  763 
in  metrorrhagia,  IV.  763 
in  puerperal  sepsis,  IV.  302 
in  tubal  pregnancy,  IV.  87 
in  uterine  fibroids,  IV.  639 
sub-total  in  uterine  fibroids,  IV.  643 

precautions  in,  IV.  646,  648 
total   abdominal   in  cancer  of   uterus, 

IV.  579 

in  uterine  fibroids,  IV.  647 
uterine  vessels,  clamped  in,  IV.  643 
uterus  amputated  in,  IV.  644 
vaginal,  cancer-cell  infection  of  opera- 
tion area,  IV.  600 


Hysterectomy,  vaginal  (contd.') — 

division  of   broad   ligament   in,    IV. 

598,  599 
in    accidental     haemorrhage    during 

pregnancy,  IV.  26 
in  cancer  of  cervix,  IV.  593 

results  of,  IV.  597 
in  cancer  of  uterus,  IV.  578 
in  fibroids,  IV.  655-658 
in  prolapse  of  uterus,  IV.  693 
instruments  for,  IV.  655 
limits  of  operation  and   percentage 

operability,  IV.  597 
opening  utero-rectal  pouch  in,  IV.  ~>W 

utero-vesical  pouch  in,  IV.  595 
operation  by  ligature  only,  IV.  655 
precautions  in,  IV.  657 
reflecting  mucous  membrane  in,  IV. 

594 

results  of,  IV.  599 

transfixing  lower  part  of  broad  liga- 
ment in,  IV.  597 
Hysteria,  II.  1008-1013 
aphasia  in,  II.  1147 
association  method  in,  II.  1011 
drugs  in,  II.  1012 
mental  aspects  of,  II.  1306-1308 
persuasion  method  in,  II.  1012 
physical  methods  in,  II.  1012 
prophylactic  treatment  of,  II.  1012 
psycho-analysis  in,  II.  1010 
spasm  of,  II.  1049 
suggestion  in,  II.  1009 
Hysterical  joint  disease,  I.  787 
Hystero-vaginectomy  in  cancer  of  uterus, 

IV.  580 

operation,  complications  of,  IV.  612 
dangers  of,  IV.  612 
difficulties  of,  IV.  612 
limits  of,  IV.  613 
results  of,  IV.  613 
technique  of,  IV.  612 
radical,  in  cancer  of  cervix,  IV.  611 


ice-bags,  application  of,  I.  36 

in  chronic  simple  ulcer  of  the  stomach, 

II.  328 
Ice  compressors,  I.  36 

poultice  in  pneumonia,  I.  259 

uses  of,  in  sprains,  I.  738 
Ichthyol  in  erysipelas,  I.  210 

in  pruritus,  III.  1099 
Icterus,  II.  670-675 

in  the  newly  born,  II.  672  ;  IV.  369 

See  also  Jaundice. 
Icthyosis,  III.  1053 
Ictus  laryngea,  III.  841 
Ideas,  imperative,  II.  1313 
Idiocy,  II.  1318-1320 

amaurotic  family,  II.  1244 
Ileo-oolostomy  in  cancer  of  colon,  I.  141 
Ileo-sigmoidostomy  in  cancer  of  colon,  I. 
141 

for  chronic  constipation,  II.  470 


58 


A    SYSTEM   OF   TREATMENT. 


Immunity,   insufficiency   and   loss  of,   I. 

8,  11 
Impetigo,  III.  1054-1056 

general  remarks  on,  III.  1054 
local  treatment  of,  III.  1054 
Implanation  cysts.  I.  110 
Impotence,  II.  !» 11 -HI 2 

physical  causes,  I.  231  ;  II.  911 
physical,  1.231  ;  II.  911 
sexual  hypochondriasis  in,  II.  ill 2 
symptomatic,  I.  231  ;  II.  911 
Incandescent  light,  concentrated,  III.  1% 
blue,  III.  197 
red,  III.  l'.)S 
use  of,  III.  186 
Incisors,  lower,  extraction  of,  III.  1183 

upper,  extraction  of,  III.  1181 
Incubation  period  of  whooping  cough,  I. 

377 
Incus,  removal  of,  in  chronic  inflammation 

of  middle  ear,  III.  915 
Index  finger,  amputation   at   metacarpo- 

phalangeal  articulation  of,  I.  811 
Indicanuria,  II.  737 
Indigestion.     Xee  Dyspepsia. 
Individuality  of  patient,  appreciation  of, 

1.25 
Industrial  plumbism,  prevention  of,  I.  514 

See  also  Occupations. 
Inebriety,  chronic,  I.  499-502 
Infantilism,  II.  71 
Infants,  artificial  feeding  of,  I.  58 
biliary  cirrhosis  in,  III.  439 
breast  feeding  of.  II.  215 
care  of  the  mouth  in,  II.  120 
cerebral  palsies  of,  II.  1055-1058,  1153- 

1156 
surgical  treatment  of,  II.  1059-1066, 

1157-11154 
treatment  of  lower  limbs  in,  II.  1159 

of  upper  limbs  in,  II.  11(52 
convulsions  of,  II.  986-989 
rapidly  repeated,  II.  988 
eczema  in,  III.  1035 
exercise  for,  I.  51 
feeding  of,  II.  214-232  ;  IV.  344 
breast  feeding  best  in,  II.  215 
citrated  milk  in,  II.  225 
condensed  milk  in,  II.  227 
cream  in,  II.  227 
diluted  milk  in,  II.  222 
dried  milk  in,  II.  228 
floury  foods  in,  II.  229 
in  marasmus,  I.  46(5 
milk  composition  in,  II.  221 

diluted  by  adding  fat  in,  II.  223 

by  adding  sugar  in,  II.  223 
predigested  milk  in,  II.  226 
prepared  foods  in,  II.  227 
sterilisation  of  milk  in,  II.  220 
top  milk  diluted  by  adding  lactose,  II. 

224 

whey  in,  II.  227 
whole  milk  in,  II.  221 
with  cow's  milk.  II.  219 


Infants,  feeding  of  (contd.~) — 

with  foods  containing  no  starch,  II. 

229 

hygiene  and  care  of,  I.  44,  70 
•  hypertrophic  stenosis  of  pylorus  in,  II. 

338 
inflammation  of  the   umbilicus   in,   II. 

279 

injuries  to  the  head  in,  I.  886-887 
management  of  during  anaesthetics,  III. 

25 

mastitis  in,  II.  960 
newborn,   absence  of  half   diaphragm 

in,  IV.  361 

ancncephalus  of,  IV.  357 
angioma  of  the  umbilicus  in,  IV.  370 
asphyxia  of,  IV.  350-355 

cerebral  hemorrhage  in,  IV.  353 
atelectasis  in,  IV.  361 
bath  of,  IV.  337 
birth  injuries  of,  IV.  363-366 
brachial  palsy  in,  IV.  365 
breast,  feeding  of,  IV.  340 
cephalhaematoma  in,  IV.  363 
cerebral  haemorrhage  in,  IV.  364 
cleft  palate  in,  IV/357 
congenital  defects  of,  IV.  355-363 

syphilis  in,  IV.  369 
constipation  in,  IV.  368 
convulsions  in,  IV.  371 
cystic  hygroma  of,  IV.  358 
dextrocardia  in,  IV.  361 
diseases  of,  IV.  366-372 
dislocations  in,  IV.  366 
encephalocele  of,  IV.  357 
epiphyseal  separation  in,  IV.  366 
extrophy  of  bladder  in,  IV.  360 
facial  palsy  in,  IV.  365 
feeding  of,  IV.  341 
fracture  of,  clavicle  of,  IV.  354 

long  bones  in,  IV.  365 

ribs  in,  IV.  354 

skull  of,  IV.  364 
frequency  of  feeding  of,  IV.  341 
hpematoma  of  the  sterno-mastoid  in, 

IV.  365 

harelip  in,  IV.  357 
hermaphroditism  in,  IV.  362 
hernia  in,  IV.  358 
hydrencephalocele  of,  IV.  357 
hydrocele  in,  IV.  360 
hydrocephalus  of,  IV.  .356 
hypospadias  in,  IV.  362 
icterus  in,  II.  672 
imperforate  anus  in,  IV.  362 
infective  enteritis  in,  IV.  367 
intussusception  in,  IV.  371 
jaundice  in,  IV.  369 
management  of,  IV.  337-372 
marasmus  in,  IV.  370 
mastitis  in,  IV.  371 
melasna  in,  IV.  370 
meningocclc  of,  IV.  357 
naevus  in,  IV.  3(53 
non-descent  of  the  testicle  in.  IV.  360 


59 


A    SYSTEM   OF    TREATMENT. 


Infants,  newborn  (contd.*) — 

ophthalmia  neonatorum  in,  IV.  366 

phimosis  of,  IV.  360 

prepuce  of,  IV.  339 

rickets  in,  IV.  371 

rupture  of  the  cord  in,  IV.  366 

scurvy  in,  IV.  371 

secondary   hemorrhage   of   the  cord 
in,  IV.  370 

sepsis  of  the  cord  in,  IV.  370 

spina  bifida  in,  IV.  361 

strophulus  in,  IV.  371 

supernumerary  digits  in,  IV.  363 

talipes  in,  IV.  362 

tongue  tie  in,  IV.  358 

union  of  digits  in,  IV.  362 

vaginal  haemorrhage  in,  IV.  371 
paralysis  of,  nerve  anastomosis  in,   II. 

1059-1060 
pyelitis  in,  II.  805 
urinary  fistulas  at  the  umbilicus  of,  II. 

278 
weaning  of,  II.  218 

<Se«  also  Children. 
Infection,  avoidance  of  at  operations,  I.  83 

a  principle  of  treatment,  I.  7 
following  head  injuries,  I.  885 
in  gunshot  wounds,  I.  557 

prevention  of,  I.  557 
means  of,  in  tetanus,  I.  329 
of  wounds,  I.  555 
puerperal,  IV.  282-323 
Infectious  cases,  nursing  of,  I.  41 

diseases,  acute  inflammation  of  middle 
ear,  secondary  to,  III.  902 

cold  water  drink  in,  I.  158 

diet  in,  I.  158 

general  treatment  of,  I.  157-160 

nursing  of,  I.  41 

remediable  treatment  of,  I.  159 
Infective  lesions  of  bones,  I.  889 

of  the  scalp,  I.  888 
Inflammation,     conservative     factor    of, 

I.  10 

in  non-operative  appendicitis,  II.  423 
Influenza,  I.  233-242 

bronchial  catarrh  in,  I.  239 

cardiac  affections  complicating,  I.  241 

chronic,  I.  237 

complications  of,  I.  239-242 

conjunctivitis  complicating,  I.  239 

convalescent  stage  of,  I.  235 

drugs  in,  I.  233,  234 

enlarged  cervical  glands  in,  I.  239 

frontal  sinusitis  complicating,  I.  239 

gastric,  I.  236 

inflammation  of  trachea  in,  III.  798 

jaundice  complicating,  I.  241 

mastoiditis  in,  III.  933 

meningitis  complicating,  I.  241 

middle  ear  disease  in,  I.  239 

nephritis  complicating,  I.  241 

neuralgia  following,  I.  242 

neuritis  complicating,  I.  241 

pharyngitis  complicating,  I.  239 


Influenza  (contd.*) — 

pneumonia  complicating,  I.  240 
prophylaxis  of,  I.  237 
relapsing,  I.  235 
vaccine  therapy  in,  I.  235,  238 
Infra-orbital  foramen,   alcohol   injection 

into  for  neuralgia,  II.  1118 
Infusion,  apparatus  for,  I.  99,  100 
in  shock^  I.  98-103 

human  blood,  I.  102 

intra-peritoneal,  1.  101 

normal  saline,  I.  98 

rectal,  I.  99 

subcutaneous,  I.  99 
methods  of,  I.  98,  100 
Injections,  intramuscular  in  malaria,  III. 

395 

intra-spinal,  in  labour,  IV.  379 
intra-tracheal,  I.  1149 
Injuries.     See,  Wounds. 
Inman  (A.    C.),   bacterio-therapeutics   of 

diphtheria,  III.  273-279 
meningococcus  infection,  serum  therapy 

of,  III.  282-283 
micrococcus      catarrhalis       infections, 

serum  therapy  of,  III.  282-283 
pneumococcus  infections,  III.  285-286 
staphylococcus       infections,       vaccine 

therapy  of,  III.  288-289 
tuberculosis,  III.  290-295 
tumours,  malignant,  III.  298-299 
typhoid  fever,  III.  299-300 
Inoculation  of  plague,  point  of,  III.  405 
preventive,  in  plague,  III.  284 

in  typhoid  fever,  I.  348  ;  III.  299 
treatment  of  rabies,  Pasteur's  method, 

I.  264 

Insane,  general  paralysis  of,  II.  1077 
Insanity,  II.  1274-1283 
and  anaesthetics,  III.  25 
of  lactation,  IV.  279 
of  pregnancy,  IV.  45 
puerperal,  IV.  277-278 
Insecticides  in  the  tropics,  III.  383 
Insects,  diseases  disseminated  by,  in  the 

tropics,  III.  379 
Insomnia,  IT.  1014-1024 
aetiology  of,  II.  1014 
after  abdominal  operations,  II.  265 
application  of,  vibration  in,  III.  221 
cardio-vascular  disease  and,  II.  1019 
chloralamide  in,  I.  286,  366 
complicating    gynaecological     surgery, 

IV.  490 

constipation  in,  II.  1018 
general  measures  in,  II.  1016 
hydrotherapeutic     measures     in,      II. 

1017 

hypnotic  drugs  in,  II.  1021 
hypnotism  in,  II.  1021 
in  children,  causes  of,  I.  54 
in  gout  and  gouty  conditions.  I.  444 
in  pneumonia,  I.  259 
in  the  menopause.  IV.  502 
simple,  hypnotics  for,  I.  159 


60 


A    SYSTEM  OF   TREATMENT. 


Insomnia  (cantd.)— 

special  causes  of,  II.  1018 
toxic,  causes  of,  II.  1015 
Instruments  employed  in  amputations  of 

fingers,  I.  804 

for  abdominal  operations,  IV.  482 
for  decapitation,  IV.  418 
forgynascologicaloperati.ins.  IV.  175 
for  mastoid  operation,  III.  921 
for  ovariotomj',  IV.  776 
•for  vaginal  operations,  IV.  482 
in  abdominal  hysterectomy.  IV.  642 
iu  vaginal  hysterectomy,  IV.  655 
preparation  of,  in  obstetric  operations, 
IV.  374 

and  sterilisation  of,  I.  28-30 
required  in  vaginal  hysterectomy,  IV. 

593 
sterilisation  of,  in  puerperal  sepsis,  IV. 

288 

surgical,  for  removal  of  foreign  bodies 
in  the  air  passages,  III.  806 

sterilisation  of,  I.  72 
with    sterile    case   in    normal    labour, 

IV.  95 
Insufflations,  dry,  in  puerperal  vaginitis, 

IV.  563 
Insufflator  for  powders  to  the   nose  and 

throat,  III.  697 
Intensive  baths,  III.  126 
Inter-arytenoideus  muscles,  paralysis  of, 

III.  1844 

Interscapulo-thoracic  amputation,  I.  830 
Intertrigo.  dusting  powders  for,  IV.  529 
Intestinal  obstruction,  II.  528-540 

ainesthetics  in  operation  for,  III.  32 

cancerous,  relief  of,  I.  142 

complicating  gynaecological  surgery, 

IV.  -lies 
tract,    bacterial    decomposition    in,   1. 

450 

Intestines,  abscesses,  with  fistulas,  II.  485 
and  bladder,  fistulas  between,  II.  491 
and  female  generative  organs,   fistulae 

between,  II.  491 
anthrax  of,  I.  179 

antiseptics  in  typhoid  fever,  I.  353-356 
auto-intoxication  arising  in,  I.  387 
bi-mucous  fistula?  of,  II.  490 
cancer  of,  relief  of  obstruction   in,   I. 

140 
care  of,  after  abdominal  operations,  II. 

264 

constipation  in,  enemata  for,  II.  1." 
control  of  bowels  in  children,  I.  53 
dilatation   of   atonic  in   infantile  con- 
stipation, II.  435 
diseases  of,  II.  401 

diet  in,  II.  208 

in  cholera,  III.  425 
empty,  treatment,  in  typhoid  fever,  I. 

344 
fistula?  of,  II.  483-492 

abscess  with,  II.  485 

anastomosis  operations  in,  II.  487 


Intestines,  fistulae  of  (contd.~) — 
and  artificial  anus,  II.  488 
non-operative  treatment,  II.  484 
plastic  operations  for,  II.  486 
simple  external,  II.  483 
foreign  bodies  in,  II.  493-4'.i7 

cases    associated     with     obstructive 

symptoms.  II.  495 
causing    inflammatory   symptoms, 

II.  494 

without  definite  symptoms,  II.  493 
gunshot  wounds  of,  I.  565 
haemorrhage  from  complicating  typhoid 

fever,  I.  359 
hygiene  of,  in  constipation   in  adults, 

II.  439 

in  gynaecological  surgery,  IV.  487 
in  normal  puerperium,  IV.  266 
injury  of,  in  ovariotomy,  IV.  785 
internal  fistula?  of,  II.  490 
lavage  of,  in  constipation  in  adults,  II. 

467 

paralytic    distension    following  opera- 
tions, II.  271 

perforation  of,  II.  550-558 
after-treatment,  II.  555 
anaesthetic  in,  II.  551 
complicating  typhoid  fever,  1. 359 
incision  in,  II.  552 
location  of  the  lesion  in,  II.  552 
mortality  after  operation  for,  II.  556 
operation  for,  II.  551 
peritoneal  toilet  in,  II.  554 
suture  of,  II.  552 
preparation  of  in  abdominal  operations, 

II.  259 

tajniasis  in.  III.  617-520 
typhoid,  perforation  of,  II.  550 
Intoxications,  I.  495-502 
Intracranial  aneurysm,  I.  1304 

complications  of  ear  disease,  937-943 
disease,  headache  from,  II.  1034 
Intramuscular    injections    in  syphilis,  I. 

318 
Intraperitoneal  haemorrhage  complicating 

abdominal  operations,  II.  275 
Intratracheal  injections  in  bronchiectasis, 

I.  1046 

Intratympanic  operations,  III.  952 
Intravenous  anaesthesia,  III.  35 

complications  of  ear  disease,  III.  937-943 
injection  of  antitoxin,  dosage  of,  I.  192 
in  syphilis,  I.  320,  322 
in  tetanus,  I.  330 

Intubation  in  laryngeal  diphtheria,  I.  198 
in  stenosis  of  the  larynx,  III.  865 
instruments  for,  III.  804 
Intussusception.  II.  541-549 
acute,  11.  541 

after-treatment  of,  II.  549 
closure  of  abdominal  wound  in,  II.  546 
in  newborn  child,  IV.  371 
of  appendix,  II.  422 
steps  of  the  operation  in,  II.  543 
when  irreducible,  II.  546 


61 


A    SYSTEM   OF   TREATMENT. 


Inunctions  in  diseases  of  children.  I.  70 

in  syphilis,  I.  319 

Iodide  of  potassium.     See  Potassium. 
Iodides,  dosage  of  in  children's  diseases, 
1.67 

in  cerebro-spinal  syphilis,  II.  1065 

in  chronic  rheumatism,  I.  490 

in  inveterate  chronic  glossitis,  II.  136 
Iodine,  applications  of,  I.  35 

applied  to  the  skin  before  operations,  I. 
27 

in  chronic  rheumatism,  I.  487 

in  goitre,  II.  62 

in  syphilis,  I.  321 

ions,  III.  184 

in  rheumatism.  I.  488 

preparation  of  skin  with,  I.  74 

use  of,  in  radical  operation  for  cancer 

of  breast,  II.  967 
lodipin  in  inveterate  chronic  glossitis,  II. 

136 

lodoform  gauze,  composition  of,  I.  77 
lodo-glycerin    solution,   injection    of    in 

spina  bifida,  I.  913 

lodolysin  in  chronic  rheumatism,  I.  491 
Ionic  medication,  III.  180-185 

in  cancer,  I.  153 

in  chronic  rheumatism,  I.  488 

in  leucorrhcea,  IV.  573 

of  boils,  III.  184 

of  carbuncles,  III.  184 

of  chronic  synovitis,  III.  185 

of  lupus  erythematosus,  III.  184,  1070 

of  lupus  vulgaris,  III.  184,  1150 

of  rodent  ulcer,  III.  184,  1133 

of  trigeminal  neuralgia,  III.  184 

of  warts,  III.  184 
Ions,  conversion  of,  I.  437 

doctrine  of,  in  hydrology,  III.  114 

mineral  waters  containing,  I.  458 
Ipecacuanha  in  chronic  dysentery,  III.  435 

in  undefined  tropical  fevers,  III.  411 

in  whooping  cough,  I.  380 
Iridectomy  in  mature  cataract,  III.  624 

preliminary,  in  cataract,  III.  619 
Iris,  diseases  of,  III.  583-592 

injuries  of,  III.  591 

prolapse  of,  III.  591 

tumours  of,  III.  592 
Iritis,  acute,  III.  583 

blisters  in,  III.  586 

complicating  small-pox,  I.  309 

dionin  in,  III.  586 

general  treatment  of,  III.  583 

heat  in,  III.  585 

internal  treatment  of.  III.  587 

leeches  in,  III.  586 

lotions  in.  III.  586 

recurrent,  III.  589 

rheumatic,  III.  587 

serous,  complicating  gonorrhoea,  I.  229 

special  varieties  of,  III.  587-589 

syphilitic.  III.  588 

tuberculous,  III.  589 

vaccine  therapy  of,  III.  281 


Iron,  contra-indicated  in  gastric  derange- 
ments, I.  65 

in  atrophy  of  the  stomach,  II.  294 

in  chlorosis,  II.  21-25 

perchloride  of,  in  erysipelas,  I.  211 

peroxide    of,    hydrated,    in    arsenical 

poisoning,  I.  504 
Irritability   in   general   paralysis  of  the 

insane,  II.  1079 
Irritant  poisoning.  I.  528-530 
Irritation,  chronic,  as  a  cause  of  cancer, 
I.  118 

counter,     in     chronic     synovitis     and 

arthritis,  I.*748 
Irwln  and  Houston,  on  vaccine  therapy  in 

typhoid  fever,  I.  346 
Ischaemic   paralysis   or  Volkmann's  con- 

tracture,  I.  940 
Ischia  spa,  III.  151 
Ischio-rectal    abscess    of    the    anus,    II. 

601 

Ischl  spa,  III.  151 
Isolation  in  diphtheria,  I.  187 

in  influenza,  I.  236 
Isotonic  waters,  III.  115 
Itch,  coolie,  III.  486 

Dhobie's,  III.  478 

water,  III.  486 
Itching  or  pruritus,  III.  1097-1101 


Jaborandi,  poisoning  by,  I.  533 
Jackson  (Chevalier),  new  growths  of  the 
laryngo-pharynx,  III.  786 

of   the   larynx   (malignant),  III.    853- 
857 

of  the  nasal  cavities,  III.  692-698 

of  the  pharynx,  III.  699-700 
Jacques's     catheter     in     cancer    of    the 

stomach,  II.  306 
Jaffrey  (F.),  dislocations,  I.  713-733 

wounds  of  joints,  I.  735-736 
Janet's  method  of  urethral  irrigation,  I. 

224 

Japanese  river  fever,  III.  390 
Jaundice,  II.  670-675 

and  abdominal  operations,  II.  258 

cancer  complicating,  I.  128 

catarrhal,  II.  672,  673 

chronic  haemolytic,  II.  674 

complicating  influenza,  I.  241 
pregnancy,  IV.  53 

congenital  syphilis  and,  II.  672 

cutaneous  haemorrhage  in,  II.  671 

diet  in,  II.  671 

due  to  biliary  cancer,  I.  143 

in  newborn  child,  II.  672  ;  IV.  369 

infective,  of  intestinal  origin,  II.  672 
of  umbilical  origin,  II.  673 

mucous  haemorrhage  in,  II.  671 

physiological,  of  newborn   infants,  II. 
672 

pruritus  in,  II.  670 

special  forms  of,  II,  672 

symptomatic  treatment  of,  II.  670 


62 


A    SYSTEM   OF   TREATMENT. 


Jaw,  abnormal  development  of,  III.  1165 
ankylosis  of,  II.  105 
benign  growths  of,  II.  109 
central  myelomata  of,  II.  Ill 
cysts  of,  simple.  II.  110 
development  of,  retarded  by  incorrect 

breathing,  I.  411 
dislocation  of,  II.  104 

treatment  of  old  unreduced  cases  of, 

II.  104 

recent  cases  of,  II.  104 
epithelial  odontomes  of,  II.  112 
fibrocystic  disease  of,  II.  112 
fibromata  of,  II.  109 
fibrous  ankvl'isis  of,  II.  186 
fractures  of,  I.  563  ;  II.  99-119 
dental  displacement  in.  II.  99 
epiphora  and,  II.  100 
prevention  of  facial  deformity  in,  II. 

'.lit 

ramus  of.  II.  103 

severe  grades  of  extra-articular  adhe- 
sions in.  II.  107 
Guerin's  fracture  of,  II.  100 
inHaiumatory  diseases  of,  II.  107 
lower,  fracture  of,  II.  100 

with  and  without  displacement,  II. 

101 

malignant  disease  of,  II.  113 
restoration  of  continuity  of,  II.  114 
malignant  disease  of,  II.  112 
mortality  of  operations  on,  II.  117 
morbid  growths  of,  II.  110 
necrosis  of,  II.  108 
curative  treatment  of,  II.  108 
prophylactic  treatment  of,  II.  108 
operations  on,  and  anaesthetics,  III.  26 
osteoma  of,  II.  109 
specific  infective  diseases  of,  II.  109 
upper,  fracture  of,  II.  99 
malignant  disease  of,  II.  115 
control  of  haemorrhage  in,  II.  116 
diagnostic  operations  in,  II.  115 
limitations  of  operation  in,  II.  115 
method  of  anaesthesia  in,  II.  117 
partial  or  modified  operation  in,  II. 

116 

removal  of  lymph  glands  in  II.  116 
results  of  operations  for,  II.  117 
routine  operation  in,  II.  118 
treatment,  other  than  operative,  II. 

118 
separation  from  skull  in  fractures,  II. 

100 
Jejunostomy  for  cancer  of  the  stomach, 

II.  305 

for  hour-glass  stomach,  II.  334 
in  intestinal  cancer,  I.  140 
Jejunum,  perforation  of,  II.  557 
Jez  method  in  typhoid  fever,  I.  317 
Jigger   or    sand    flea   (dermatophiliasis). 

III.' 481 

Johannisbad  spa.  III.  151 
Joints,     adhesions     in.     anaesthetics     in 
operations  for.  III.  32 


Joints  (eontd.') — 

care  of  in  rheumatism  in  childhood,  I. 

279 

Charcot's  disease  of,  I.  785 
chronic  rheumatism  of,  I.  484 
condition  of  in  acute  rheumatism,   I. 

274 
diseases  of,  complicating  typhoid  fever, 

1.363 

electro-therapeutics  in,  I.  746-748 
nervous  mimicry  of,  I.  786 
non-traumatic,  massage  in,  III.  208 
functional     derangements    of,    Zander 

treatment  in,  III.  373 
gouty  enlargement  of,  I.  436 

local  treatment  of,  I.  438 
gunshot  wounds  of,  I.  562,  735 
inflammation  of.     See  Arthritis, 
mal-positions  of,  in  arthritis  deformans, 

I.  397 

pain  in,  in  fracture,  I.  577 
sprained,  I.  739 
stiff,   following  fractures,   massage   in, 

III.  207 

stiffness  in,  in  fractures,  I.  577 
surgical  diseases  of,  I.  741-788 
swelling  of,  in   gout  and  gouty  condi- 
tions, I.  438 

syphilitic,  disease  of,  I.  784 
tuberculous,  I.  750-752 
Bier's  treatment  in,  I.  751 
general  treatment  of,  I.  750 
operative  treatment  of,  I.  752 
tuberculin  in,  I.  750 
vaccine  therapy  in,  I.  750 
wounds  of,  I.  734-736 
Jones  (Bence),  protein  in  urine,  II.  749 
Jones   (H.    Lewis),    electro-therapeutics, 

III,  103-110 

ionic  medication,  III.  180-185 
Jones    (Eobert),    surgical    treatment    of 
cerebral  palsies  of  infancy,  II.   1157- 
llt>4 

elbow  halter  of,  I.  777 
Jordan  (Furneaux),  method  of  disarticu- 

lation  modified,  I.  868 
Jothion  in  chronic  rheumatism,  I.  488 
Jumping  exercises  in  gymnastics,  III.  226 
Junker's  apparatus  for  anaesthetics,  III.  14 
inhaler  for  administration    of    chloro- 
form, III.  16 

metal  tube  for  use  with,  III.  17 
Junket,  preparation  of.  I.  4i' 


Kala  azar,  III.  391 

Kangri  cancer  of  Kashmir,  I.  117 

Kaolin  in  leucorrhoea,  IV.  573 

insufflations  in  leucorrhoea,  IV.  572 
Kaposi's  disease,  III.  1057 
Karlsbad  spa.  III.  151 
Keating-Hart  on   fulguration   in  cancer, 

I.  i:.4 
Keith  (George  and  Skene),  on  treatment 

of  cancer,  I.  149 


63 


A    SYSTEM  OF   TREATMENT. 


Kelly  (A.  Brown),  acute  catarrhal  pharyn- 
gitis, III.  766-767 

acute  membranous  angina,  III.  771 
acute    septic    inflammation     of      the 

pharynx  and  larynx,  III.  772-773 
chronic  catarrhal  pharyngitis,  III.  768- 

769 

haemorrhage,  pharyngeal,  III.  776-777 
herpes  of  the  pharynx,  III.  778 
pemphigus  of  the  pharynx,  III.  788 
retro-pharyngeal  abscess,  III.  789-790 
ulcerative  pharyngitis,  III.  795-796 
Keloid  in  wounds,  I.  556 
of  the  auricle,  III.  879 
Ker   (Claude),   on   stimulants  in  typhus 

fever,  I.  367 
on  treatment  of  lobular  pneumonia,  I. 

245 
Keratitis,  interstitial,  of  the  cornea,  III. 

568 

sclerosing,  of  the  cornea,  III.  570 
tuberculous,  of  the  cornea,  III.  569 
vascular,  of  the  cornea,  III.  570 
Keratosis  obturans  of  the  meatus,  III.  885 
of  the  pharynx,  III.  779 
pharyngo,  of  lingual  tonsil,  III.  762 
Kerion.  Rontgen  rays  in,  III.  1129 
Kerr  (J.  M.  Munro),  Caesarean  section  and 

Caesarean  hysterectomy,  IV.  382-402 
Kidney  belt  for  movable  kidney,  II.  788 
Kidneys,   aberrant    vessels    of,   hydrone- 

phrosis  with.  II.  773 
amyloid  disease  of,  II.  839 
bilateral  calculi  of,  II.  765 
calculus  in  solitary,  II.  766 
decapsulation  of,   in  chronic    Bright's 

disease,  II.  799 
in  eclampsia,  IV.  37 
diseases  of,  II.  730 
anaesthetics  in,  III.  24 
associated    with     vascular     disease, 
cerebral    thrombosis    due    to,    II. 
1178 

climate  for,  III.  101 
complicated  by  cancer,  I.  128 
diphtheria,  I.  201 
headache  from,  II.  1034 
effect  of  protein  on,  II.  204 
elimination  of  infection  by,  I.  10 
embolism  of,  I.  1308 
failure  of,  in  poisoning,  I.  530,  532 
fistulae  of,  II.  767. 

granular,  water  allowance  in,  II.  206 
growths  of,  dangers  of  nephrectomy  in, 

II.  833 

results  of,  nephrectomy  for,  II.  833 
hydronephrosis  of,  II.  770-779 
injuries  to,  II.  250 

with  external  wound,  II.  783-784 

operative  treatment,  II.  783 
without  external  wound,  II.  780-782 
operations  for,  II.  780 
results  of  operation,  II.  781-784 
movable,  II.  785-791 
corset  for,  II.  789 


Kidneys,  movable  (conttl.) — 

hydronephrosis  with.  II.  772 
operative  treatment,  II.  789 
palliative  treatment,  II.  786 
results  of  operative  treatment,  II. 

790 

selection  of  cases  of,  II.  785 
truss  for,  II.  787 

nephritis  of,  non-tuberculous,  II.  824 
of  foetus,  congenital  cystic  disease  of, 

complicating  labour,  IV.  180 
perinephritic  abscess  of,  II.  801 
secretion  of  in  diabetes  insipidus,  I. 

428 

stone  in.     See  Calculus,  renal, 
surgery  of,  in  vesical  cancer,  I.  143 
tuberculosis  of,  II.  819-829 
after-results,  of  nephrectomy  for,  II. 

828 

bilateral,  II.  823 
nephrotomy  for,  II.  828 
partial  nephrectomy  for,  II.  822 
primary  results  of  nephrectomy  for, 

II.  827 

tuberculin  treatment  of,  II.  820 
tumours  of,  in  adults,  II.  830-835 

operation  for,  II.  831 
in  children,  II.  836 

statistics  of,  II.  836 
Kilian's  bronchoscopy,  III.  806 

operation    for    malformation     of     the 

nasal  septum.  III.  6S2 
Kirstenrs  lamp.  III.  811 
Kissengen  spa,  III.  151 
Kitasato's  bacillus  in  tetanus,  I.  329 
Klebs-Loffler    bacillus    in   diphtheria,    I. 

188 

Knee,  congenital  dislocation  of,  I.  949 
contraction  of,  I.  950 
dislocations  of,  I.  728 
hot-air  apparatus  for,  III.  325 
leather  splint  for,  I.  766 
Knee-bending  exercise  for  flat  foot,  III. 

236 

Knee-joint,  disarticulation  at,  I.  859-861 
by  an  anterior  elliptical  incision,  I. 

861 

indications  for,  I.  859 
hot-air  chamber,  in  hyperaeuiic  treat- 
ment, III.  64 

Miller's  disarticulation  at,  I   861 
tuberculosis  of,  I.  765-772 
amputation  in,  I.  771 
caseation  and  suppuration  in,  I.  768 
deformity  after  excision,  I.  771 
excision  and  erasion  in,  I.  769 
flexion  deformity  of,  I.  767 
rest  and  fixation  in,  I.  7<!.~> 
synovial  effusion  in,  I.  767 
weight  extension  in,  I.  767 
Kneeling  in  physical  exercises,  III.  L'29 
Knock-knee  or  genii  valgum,  I.  i»5!> 

physical  exercises  for,  III.  235 
Koch's  new  tuberculin.  III.  293 
old  tuberculin,  III.  293 


64 


A    SYSTEM  OF    TREATMENT. 


Kocher's  gastro-duodenostomy  for  pyloric 
stenosis,  II.  316 

reduction  of  dislocations,  I.  716 
Koenig.    on   infiltrating    tuberculosis,   I. 
890 

on  mortality  of  cancer  of  jaw,  II.  118 
Koenig' s  long  flexible  silver  tracheotomy 

tube,  II.  74 
Kb'rners  flap  in  operation  for  diseases  of 

mast  process,  III.  924 
Kraske's  method  in  erysipelas,  I.  210 
Kraurosis  of  the  vulva,  IV.  508 
Krause's  operation  for  prurititis  ani,  II. 

597 

Kreuznach  spa,  III.  151 
Kronig  on  pubiotomy,  IV.  448 
Kronlein's  suggestive  anaesthesia,  II.  117. 
Kuhn's  mask,  I.  1148 
Kiister's  post-aural  operation  in  diseases 

of  mastoid  process,  III.  922,  923 
Kyphosis,  physical  exercises  for,  III.  236 
Kyphotic  pelvis  complicating  labour,  IV. 

173 


Labia,  abscess  of,  complicating  gonorrhoea, 

I.  229 

Labial  hernia,  IV.  512 
Labour,  abnormalities  of,  excluding  mal- 

presentations,  IV.  157 
abnormalities  of  maternal  soft  parts  in, 

IV.  157-160 

air  embolism  in,  IV.  161-162 
anaesthetics  in,  IV.  376-381 
atresia  of  the  cervix  in,  IV.  158 
carcinoma  of  cervix  in,  IV.  160 
complications  of,  excluding  malpresen- 

tations,  IV.  157- 

contracted  pelvis  and,  IV.  163-175 
diagnosis  of,  IV.  103 
diet  in  treatment  of  contracted  pelvis, 

IV.  174 

exhaustion  of  uterus  in,  IV.  250-251 
exostoses  of  pelvic  bones  and,  IV.  174 
false,  IV.  103 
fibrinous  polypus  of  placenta  in,  IV. 

228 

forceps  in,  dangers  of,  IV.  430 
to    hasten    delivery  in   interests  of 

child,  IV.  421 
to   hasten  delivery   in    interests    of 

mother,  IV.  420 
forcible  methods  of  delivery  in,  dangers 

of,  IV.  444 

by  dilatation  of  cervix,  IV.  442 
funic  souffle  in,  IV.  104 
haemorrhage,  accidental  after,  IV.  28, 

29 

from  shortness  of  cord  after,  IV.  29 
concealed,  after  and  before,  IV.  27,  28 
external,  after,  before  and  during,  IV. 

26-28 

mixed,  after,  IV.  28 
post-partum,  in,  IV.  29,  214-223 
severe,  mixed,  before,  IV.  28 

S.T.  I 


Labour  (contd.) — 
hypodermic  medication  in,  IV.  378 
induction  of.  IV.  433-437 
"intra-spinal  injection  in,  IV.  379 
inversion  of  uterus  in,  IV.  182-187 
ky photic  pelvis  and.  IV.  173 
lacerations  of  genital  tract  in,  IV.  188- 

213 

malacosteon  pelvis  and,  IV.  172 
malposition   of  cervical  canal   in,  IV. 

157 
management  of,  obstetrical  bag  in,  IV. 

93 
normal,  auscultation  in,  IV.  103 

dilatation  of  os  in,  IV.  103 

management  of,  IV.  91-127 

palpation  in,  IV.  97,  98 

show  in,  IV.  103 

sterile  instruments  in,  IV.  95 

uterine  souffle  in,  IV.  104 
oblique  pelves  and,  IV.  173 
obstruction  of,   by  cystic  diseases   of 
foetus,  IV.  180 

by  deformity  of  the  foetus,  IV.  176- 
181 

by  diseases  of  the  foetus,  IV.  176-181 

local    enlargement    of    tetus,    IV. 
179-181 

laceration  of  perineum  in,  IV.  204 
of  vagina  in,  IV.  201,  204 
of  vulva  in,  IV.  204 
osteomalacic  pelvis  and,  IV.  172 
ovarian     tumours     complicating,     IV. 

773-774 

pains  of,  IV.  103 

paralysis  associated  with,  IV.  280 
placental  polypus  in,  IV.  228 
post-partum    haemorrhage   in,   IV.   29, 

214-223 

precipitate,  IV.  224 

premature   induction  of,  dilatation  of 
cervix  in,  IV.  439 

foetal  indications  for,  IV.  434 

for  habitual  death  of  foetus,  IV.  436 

for  large  foetus,  IV.  436 

in  contracted  pelvis,  IV.  434 

in  diseases  of  pregnancy,  IV.  434 

in  prolongation   of    pregnancy,   IV. 
436 

insertion  of  gum-elastic   bougie  in, 
IV.  437 

maternal  indications  for,  IV.  434 

methods,  IV.  437-445 

rupture  of  membranes  in,  IV.  437 
presentations  in,  breech,  IV.  128 

brow,  IV.  137-139 

deformity  following,  IV.  143 

face,  IV.  140-143 

impacted,  IV.  135 

neglected,  IV.  152 

occipito- posterior,  IV.  144-146 

prolapse  of  arm  in,  IV.  151 

Schatz's  method  in,  IV.  141 

special  management  of,  IV.  128-156 

transverse,  IV.  150-153 

5 


A    SYSTEM  OF  TREATMENT. 


Labour,  presentations  in  (cowtd.) — 
twins,  IV.  154-156 
vaginal  examination  in,  IV.  141 
prolapse  of  the  cord  in,  IV.  147-149 
leg  in,  IV.  149 
limbs  in,  IV.  149 

pseudo-osteomalacic  pelvis  and,  IV.  172 
pubiotomy  in,  IV.  446-450 
rarer  forms  of  contracted  pelvis  in,  IV. 

172-175 
retention  of  placenta  complicating,  IV. 

225-237 
rigidity  of  cervix   in,   functional,   IV. 

158 

organic,  IV.  159 
Roberta's  pelvis  and,  IV.  173 
rupture  of  uterus  in,  IV.  238-247 
incomplete,  involving   perineal  coat 

only,  IV.  242 

limited  to  lower  segment,  IV.  240-241 
severe  lacerations  of  cervix  in,  IV.  189 
spondylolisthetic  pelvis  and,  IV.  173 
stages  of,  first,  breech  presentation  in, 

IV.  129 

management  of,  IV.  109 
second,  breech  presentation  in,  IV. 

130 

delivery  of  after-coming  head  in 
breech  presentation,  IV.  132, 
133 

episiotomy  in,  IV.  115 
management  of,  IV.  110 
nuchal  position  of  the  arm  in,  IV. 

132 

rupture  of  membranes  in,  IV.  112 
support    of  the  perineum  in,  IV. 

113 

third,  IV.  117 
binder  in,  IV.  125 
change  of  shape  of  uterus  in,  IV. 

120 

control  of  uterus  in,  IV.  118 
examination  of   afterbirth  in,  IV. 

123 

expression  of  placenta  in,  IV.  121 
expulsion  of  placenta  in,  IV.  119 
failure  of  cord  to  pull  up  with 

uterus  in,  IV.  120 
increased  mobility  of    uterus   in, 

IV.  120 

lengthening  of  cord  in,  IV.  119 
ligature  of  cord  in,  IV.  117 
perineum  in,  IV.  126 
prominence  of  the  hypogastrium  in, 

IV.  120 

retention  of  placenta  in,  IV.  229 
rising  of  the  fundus  in,  IV.  120 
succenturiate  placenta  in,  IV.  124 
vulval  pad  in,  IV.  125 
spondylotomy  in,  IV.  451 
sterilised  rubber  gloves  in,  IV.  288 
symphysiotomy  in,  IV.  452-460 
tonic  contraction  of  uterus  in,  IV.  248- 

249 
transverse  presentation  in,  IV.  152 


Labour  (contd.} — 

turning  in,  IV.  461-473 

unavailing  at   term,    in    extra-uterine 

pregnancy,  IV.  87 
uterine  inertia  in,  IV.  252-255 
vaginal  examination  in,  IV.  104 
version  in,  IV.  461-473 
Laburnum,  poisoning  by,  I.  533 
Labyrinth,  anaemia  of,  III.  967 
concussion  of,  III.  968 
destruction     of,     paroxysmal     vertigo 

associated  with,  III.  961 
diseases  of,  acute,  III.  958-966 

chronic,  III.  967-976 
hyperaemia  of,  III.  967 
hypersesthesia  of,  III.  967 
hysterical  deafness  and,  III.  968 
injuries  of,  III.  969 
Menier's  disease  of,  III.  970 
necrosis  of,  III.  965-966 
paroxysmal     vertigo      of      vasomotor 

origin,  III.  958-960 
suppuration  of,  III.  958-966 
tinnitis  of,  III.  971-973 
vertigo  of,  paroxysmal,  and  middle  ear 

suppuration,  III.  960-961 
Labyrlnthitis,  infective,  acute.  III.  961- 

962 
vestibulotomy,  double  in,  III.  962 

inferior  in,  III.  962,  963 
Lack  (H.  Lambert),  epistaxis,  III.  664-666 
neuroses  of  the  pharynx,  III.  782-783 
rhinitis,  acute  and  chronic.  III.  701-712 
Lactic  acid  in  leucorrhoea,  IV.  571 

ferment  preparations  in  leucorrhcea,  IV. 

571 
Lacrymal  gland,  blocking  of    excretory 

passages  of,  III.  556 
diseases  and  aflEections  of,  III.  556-558 
lacrymation  and,  III.  556 
Lacrymation  and  lacrymal  gland.  III.  556 
Lactation,  insanity  of,  IV.  279 

in  secondary  amenorrhoea,  IV.  747 
Lactose,  top  milk  diluted  by,  in  infant 

feeding,  II.  224 

use  of  in  prolonged  pyrexia,  I.  158 
Lacto-serum  injections  in  arterio-sclerosis, 

I.  1295 

Lake-Barwell  epiglottis  punch,  III.  875 
Lake    (Eichard),    chronic    diseases    and 
affections  of  the  labyrinth,  III.  967- 
976 

nerve  deafness  or  deafness  due  to  dis- 
turbance of  cochlea  division  of  eighth 
nerve,  III.  977-978 

polyneuritis  of  the  auditory  nerve  and 
affections  simulating  this  condition, 
III.  977 

syphilis  of  the  internal  ear,  III.  -978 
Lake's  laryngeal  punch  forceps,  III.  874 
Lamalou  spa,  III.  152 
Lamb,  chemical  composition  of.  II.  193 
Lamblia  intestinalis  in  chronic  dysentery, 

III.  436 
Lamellar  cataract,  III.  608 


66 


A    SYSTEM  OF  TREATMENT. 


Laminectomy  in  gunshot  injuries,  I.  5f>4 

in  injuries  of  the  spine,  I.  906 
Landry's  paralysis,  II.  1080 
Lane  (J.  Ernest),  sonorrhoea.  I.  223-230 

impotence.  I.  231-232  ;  II.  911-912 

soft  chancre,  I.  315 

syphilis,  I.  316-324 

Lane  (W.  Arhuthnot),  the  operative  treat- 
ment of  fractures,  I.  634-693 

on  care  of  the  feet  in  children,  I.  57 

on  care  of  nasal  passages  in  children,  I. 
49 

on  spinal  deformity  in  children,  I.  56 
Lane's  continuous  subcutaneous  infusion 

apparatus,  I.  99 

Lange's  method  in  sciatica,  II.  1026 
Laparotomy,  removal  of  appendix  during, 

II.  410 
Lardaceous  disease  (albuminoid  or  amyloid 

degeneration),  I.  462 

Laryngectomy,  for   new  growths  of   the 
larynx,  III.  856 

partial,  for  new  growths  of  the  larynx, 

III.  855 

Laryngismus  stridulus.  III.  827 
Laryngitis.  III.  831-837 

acute,  III.  831 

chronic,  III.  834 

complicating  measles,  I.  245,  247 

stridulosa,  III.  828 
Laryngo-pharynz,  new  growths  on,  III. 

78(5 

Laryngoscope,  Bruning's  direct,  III.  849 
Laryngotomy  in   epithelioma  of  tongue, 

II.  140,  143 

in  sarcoma  of  the  tongue,  II.  145 
Larynx,  anaemia  of,  III.  822 

cancer  of,  relief  of  obstruction  in,  1. 142 

diphtheria  of,  I.  194-199 

diseases  of,  III.  803-872 

fractures  of,  III.  825 

growths  of  (benign),  III.  846-852 
malignant,  III.  853-857 
extrinsic  cases,  III.  854 
intrinsic  cases,  III.  853 
laryngectomy  for,  III.  855,  856 
palliative  treatment  of,  III.  856 
thyrotomy  in,  III.  854 

haemorrhage  from,  III.  824 

hyperaemia  of,  III.  822 

hyperaesthesia  of,  III.  845 

ictus  of,  III.  841 

leprosy  of,  III.  780 

lupus  of,  III.  838-839 

multiple   papillomata  of,   in   children, 

III.  851 

muscles  of,  intrinsic,  paralysis  of,  III. 

841-844 

nervous  cough  of,  III.  840 
neuralgia  of,  III.  845 
neurosis  of,  III.  840-845 

motor,  III.  840 

sensory,  III.  844 
oedema  of,  III.  858-860 

acute  inflammatory,  III.  858 


Larynx,  oedema  of  (contd.) — 
acute  passive,  III.  860 
non-infective  inflammatory,  III.  860 
secondary  inflammatory,  III.  859 
operations  on,  III.  846 
pachydermia  of,  III.  846,  850 
perichondritis  of,  III.  861-862 
phonetic  spasm  of,  III.  841 
septic  inflammation  of,  III.  772 
singers'  nodules  of,  III.  851 
spasm  of,  in  children,  III.  827-830 
spasmodic  affections  of,  III.  840 
stenosis  of,  cicatricial,  III.  863-867 
fixed  dilatation  in,  III.  864 
intermittent  dilatation  in,  III.  865 
intubation  in,  III.  865 
tracheo-laryngotomy  in,  III.  866 
syphilis  of,  III.  868-869 
tuberculosis  of,  III.  870-875 

curative  local  treatment  of,  III.  873 
general  treatment  of,  III.  871 
indications    for    treatment    in,    III. 

870 
injection  of  alcohol  for  relief  of  pain 

in,  1. 135 

palliative  local  treatment  of,  III,  872 
ulceration    of,    complicating    typhoid 

fever,  I.  361 
vertigo  of,  III.  841 
wounds  of,  III.  825 
Larva  migrans,  III.  482 
Lassitude    in    sanatorium    treatment    of 

pulmonary  tuberculosis,  I.  1138 
Lasts,  for  weak  foot,  I.  967 
Latham  (Arthur),  acute  endocarditis,  I. 

1190-1193 
bacilluria,  II.  751 
bronchitis,  I.  1049-1058 
congenital  affections  of  the  heart,  1. 1254 
general  principles    of    serum   therapy 

and  vaccine  therapy,  III.  258-270 
pulmonary  tuberculosis,  I.  1117-1126 
rheumatic  fever  (acute),  I:  268-275 
serum  therapy,  summary  of  doses  in, 

III.  301-302 

tuberculosis  (acute),  I.  332-334 
tuberculosis,  tuberculin  therapy  of,  III. 

291-298 
tul)erculous  disease  of  lymphatic  glands, 

I.  1344-1347 

tuberculous  peritonitis,  II.  645-647 
tumours  of  the  lung,  I.  1174 
vaccine  therapy,  summary  of  doses  in, 

III.  301-302 
Latham  (P.  W.),  on  treatment  of  acute 

rheumatism,  I.  268 

on  the  treatment  of  rheumatoid  arth- 
ritis   by    counter-irritation    of    the 
spine,  I.  405-407 
Laurvek  spa,  III.  152 
Lavage,  gastric,  in  atony,  II.  288 
in  cancer  of  stomach,  II.  296 
in  chronic  dilatation,  II.  312 
in  chronic  gastritis,  II.  349,  353 
in  hypersecretion,  II.  367 

67  5—2 


A    SYSTEM  OF  TREATMENT. 


Lavage,  gastric  (contd.') — 

in  infantile  hypertrophic  stenosis  oi 

the  pylorus,  II.  338 
in  secretory  disorders  of  the  stomach 

II.  361 

intestinal,  in  constipation,  II.  467 
Lavey  spa,  III.  152 

Lawson  (Arnold),  cataract,  III.  607-641 
diseases  and  affections  of  the  iris  and 

ciliary  body,  III.  583-596 
sympathetic  ophthalmitis,  III.  598-601 
Lawson  (David),  sanatorium  treatment  of 

pulmonary  tuberculosis,  I.  1127-1158 
Lazarus-Barlow's  solution  in  haemorrhage, 

I.  1267 

Lead  colic,  I.  512 
Lead  in  pruritus,  III.  1099 
lotion  in  erysipelas,  I.  210 
salts  of,  poisoning,  I.  529 
unsuitable  remedy  for  children,  I.  67 
Lead  neuritis,  II.  1137,  1139 
Lead  poisoning,  I.  512-515 

dropped-wrist,  due  to,  I.  991 
paralysis  in,  I.  513 
prevention  of,  I.  514 
saturnine  encephalopathy  in,  I.  514 
Leamington  spa,  III.  152 
Leather  goods,  disinfection  of,  I.  162 
Lednc's  ionisation  in  rheumatism,  I.  488 
Leeches,  application  of,  I.  35 

in  iritis,  III.  586 

Leg,  amputations  through,  I.  850-859 
bowing  of  in  rickets,  I.  481 
constant  pain  in,  hypnotism  in  case  of, 

III.  172 

elephantiasis  of,  III.  516 
exercises  in  defective  embolism,  III.  255 
protection  of,  in  children,  I.  50 

See  also  Fractures. 
Legg    (T.    P.),    foreign     bodies    in    the 

oesophagus,  II.  184-189 
goitre,  II.  62-71 
inflammation  of  parotid  gland,  II.  157- 

163 
injuries  and  diseases  of  neck,  II.  164- 

170 

malignant  disease  of  thyroid,  II.  73-74 
simple  stricture  of  cssophagus,  II.  171- 

183 
surgical     treatment    of    inflammatory 

affections  of  thyroid,  II.  53 
surgical    treatment    of    exophthalmic 

goitre,  II.  58-61 
Leitch    (A.),    on    vaccine    treatment    of 

cancer,  I.  152 
Letter's  cold  coil  apparatus,  III.  919 

tubes  in  sprains,  1.  738 
Lembert's  suture,  II.  282 
Lemonade,  preparation  of,  I.  42 
Lenhartz  diet,  II.  210 
Lenk  spa,  III.  152 
Lens.     See  Crystalline  lens. 
Lentigo  (freckles),  III.  1058 
Leontiasis  ossea,  II.  1236 
Leopold  on  pubiotomy,  IV.  449 


Lepine  (R.),  on  pregnancy  in  diabetes,  I . 

425 

Leprosy,  III.  447-453 
general  treatment  of,  III.  448 
local  treatment  of,  III.  450 
medicinal  treatment  of,  III.  449 
Nastin  treatment  of,  III.  452 
of  the  larynx,  III.  780 
of  the  nose,  III.  780 
of  the  pharynx,  III.  780 
prophylaxis  of,  III.  447 
serum  treatment  of,  III.  451 
surgical  treatment  of,  III.  450 
Leptothrix,  III.  1058 
Leube  (V.)  diet,  II.  210 
Lencocytosis,  artificial,  in  peritonitis,  II. 

637 
promotion  of,  in  infective  endocarditis, 

1.204 

Leucomata  of  the  tongue,  II.  137 
Leucoplakia,  preceding  carcinoma,  I.  117 
Leucorrhoaa,  IV.  555-574 
after  curettage,  IV.  627 
as  an  increase  of  altered  secretions,  IV. 

558 
as    an    increase    of    the    physiological 

secretions,  IV.  556 

as  a  simple  increase  of  normal  secre- 
tions, IV.  557 

due  to  general  diseases,  IV.  557 
due    to    pathological  changes    in    the 

mucosa,  IV.  559 

from  affections  of  cervix,  IV.  566 
from  affections    of    corpus  uteri,   IV. 

568 

from  Fallopian  tubes,  IV.  571 
from  operations,  IV.  570 
ionic  medication  in,  IV.  573 
kaolin  in,  IV.  572 
lactic  acid  in,  IV.  571 
lactic     ferment    preparations    in,    IV. 

571 

milk,  IV.  559 

normal  secretions  in,  IV.  556 
of  menopause,  IV.  557 
of  pregnancy,  IV.  557 
post-menstrual,  IV.  557 
post-sexual,  IV.  557 
replacing  menstruation,  IV.  557 
uterine,  IV.  565 

spa  treatment  in,  IV.  571 
vaccine  treatment  in,  IV.  572 
vaginal,  IV.  561 

due  to  tumours,  IV.  557 
vulvar,  IV.  559 
yeast  in,  IV.  572 
Leukaemia,  II.  38-42 
general  treatment,  II.  38 
lymphatic,  II.  41 
medicines  in,  II.  39 
pseudo-,  II.  42 
spleno-medullary,  II.  38 
complicating  pregnancy,  IV.  55 
X-rays  in,  III.  363 
X-rays  application  in,  II.  39 


68 


A    SYSTEM  OF   TREATMENT. 


Leukoplakia  buccalis,  II.  126 

of  the  tongue,  II.  137 
Levico  spa,  III.  152 
Lichen  planus,  III.  1061-1064 
chronic,  X-rays  in,  III.  351 
general  treatment,  III.  1061 
local  treatment,  III.  1063 
prognosis  in.  III.  1061 
Lichen  scrofulosorum,  III.  1151 

urticatis.  III.  1154-1156 
Lichenification,  III.  1059-1060 
general  treatment  of,  III.  lo.v.i 
local  treatment  of,  III.  1059 
Rontgen  rays  in,  III.  1060 
Liebeault  and  mesmerism,  III.  161 

method  of  hypnotism,  III.  164 
Ligamentum  patella,  rupture  of,  II.  1328 
Ligation  of  arteries  in  haemorrhage,  1. 559 
Ligatures,  catgut  and  silk,  sterilisation  of, 

I.  72 

in  ovariotomy,  IV.  776 
material  for  gynaecological  operations, 

IV.  482 
Light,  arc,  III.  186 

concentrated,  III.  199 
bath,  III.  187 

and  projector,  III.  188 
blue  incandescent  lamp  in,  III.  193 
blue,  III.  187 
cabinet,  III.  187 

concentrated  incandescent,  III.  196 
energy,  concentrated,  treatment  by,  III. 

196 

exposure  of  the  body  to,  IIP.  187 
incandescent,  III.  186 

red,  III.  187 

incandescent  lamp  in,  III.  193 
therapeutic  effect  of,  III.  189 
treatment  by  various  forms   of,  III. 

186 

general  exposure  to,  III.  187 
in  gynaecology,  III.  201 
in  pulmonary  tuberculosis,  III.  201 
in  small-pox.  I.  307 
local,  treatment  by,  III.  194 
precautions  in  giving.  III.  189 
Lillingston  (Claude)  and  8.  Yere  Pearson, 
the    treatment    of    pulmonary    tuber- 
culosis  by   the   induction   of   an   arti- 
ficial pneumothorax.  1. 1164 
Limbs,  diathetic  neuralgia  of,  II.  1024 
extremities,  application  of  vibration  to, 

III.  220 

foetal  prolapse  of,  in  labour.  IV.  149 
involuntary   movements   of,    in    hemi- 

plegia,  II.  1188 

lower  and  upper,  varix  of,  I.  1311-1320 
lower,  acquired  deformities  of,  I.  958- 

970 

congenital  deformities  of,  I.  943-958 
in    cerebral    palsies   of  infancy,   II. 

1159 
neuralgia,  diathetic  affecting,  II.  1122 

toxic,  affecting,  II.  1122 
toxic  neuralgia  of,  II.  1024 


Limbs  (contd.) — 

upper,  deformities  of,  I.  935-943 
in  cerebral  palsies  of  infancy,  II.  1162 
paralytic  deformities  of,  I.  990 
spastic  hemiplegia  of,  II.  1064 

See  alao  Arm  and  Leg. 
Limp,  intermittent,  II.  1234-1236 
Linen,  small,  disinfection  of,  I.  161 
Lingual  tonsil,  benign  tumours  of,  III.  762 
diseases  of,  III.  760-763 
chronic  abscess  of,  III.  762 
malignant  diseases  of,  III.  762 
tonsillotome,  III.  761 
tonsillitis,  acute,  III.  760 

chronic,  III.  761. 

Liniments  in  arthritis  deformans,  I.  396 
in  chronic  rheumatism,  I.  487 
in  joint  affections,  I.  748 
salicylate,  in  muscular  rheumatism,  I. 

493 

Linseed  poultices,  I.  33 
Lint,  value  of,  I.  79 

Lipomata,  diffuse,  thyroid  extract  in,  1. 108 
length  of  incision  required  in,  I.  107 
of  muscle,  II.  1325 
of  the  scalp,  I.  893 
of  the  vulva,  IV.  511 
surgical  treatment  of,  I.  106 
Lipcmatosis,  symmetrical,  I.  108 
Lips,  acquired  deformities  of,  II.  96 
carcinoma  of,  I.  124 
diseases  of,  II.  85-98 
epithelioma  of,  II.  98 
inflammation  of,  II.  96 
new  growths  of,  II.  97 
wounds  of,  II.  96 
Lipuria,  II.  737 
Lisdoonvarna  spa,  III.  152 
Lisfranc's  amputation  of  the  foot,  I.  836 
Cooper's  modification  of,  I.  840 
Hey's  modification  of,  I.  840 
Skey's  modification  of,  I.  840 
disarticulation  of  the  metatarsus,  I.  837- 

839 

Lister's  (Lord)  amputation,  I.  852 
head  and  neck  bandage,  I.  87 
methods  of,  I.  80 

strong  solution,  preparation  of,  I.  73-81 
transcondyloid  amputation,  I.  862 
Listen's  splint  for  fracture  of  the  femur, 

I.  till-617 

in  hip  disease,  I.  754,  762 
Lithium,  ionisation  with,  I.  488 
Litholapaxy,  in vesical  calculus,  II.  854, 855 
Lithotomy,  median  perineal,    for  vesical 

calculus,  II.  856 

supra-pubic  for  vesical  calculus,  II.  856 
vaginal,  IV.  877 
Lithuria,  II.  738 
Little's  palsy,  I.  886 
Liver,  abscess  of,  intra-hepatic,  II.  648 
needle  in  search  of  pus  in,  II.  650 
operations  for,  II.  652 

by  abdominal  incision,  II.  654 
when  pus  is  supra-hepatic,  II.  652 


69 


A    SYSTEM   OF  TREATMENT. 


Liver,  abscess  of  (contd.} — 

pulmonary  complications  of,  II.  655 

pus  in, II.  649 

sub-hepatic,  II.  649 

supra-hepatic,  II.  648 

surgical  aspects,  II.  648 

symptoms  which  suggest  operation  in, 

II.  649 
trans-thoracic  operation  by  incision, 

II.  654 
trans-thoracic    operation    by    trocar 

and  cannula,  II.  652 
acute  yellow  atrophy  of,  II.  657-658 
amyloid,  II.  675 

aneurysm  of  hepatic  artery  of,  II.  667 
anomalies  of,  II.  659 
cirrhosis  of,  II.  631,  660-665 
common,  II.  660-663 
complicating  cancer  of  the  breast,  II. 

966 

haemorrhage  in,  II.  329 
infantile,  III.  439 
portal,  II.  660-663 
early  stages  of,  II.  660 
hsemorrhagic  tendencies  in,  II.  663 
late  stages  of,  II.  662 
prophylactic  treatment  of,  II.  660 
degeneration  of,  II  668 
diseases  of,  II.  648 

mineral   waters  and    baths  in,   III. 

139 
enlargement  of   complicating  typhoid 

fever,  I.  360 

gunshot  wound  of,  II.  251 
fatty,  II.  668 

functional  derangement  of,  II.  668 
hepatoptosis  of,  II.  659 
hydatid  cysts  of,  II.  669 
enucleation  in,  II.  669 
incision  and  drainage  in,  II.  669 
injuries  of,  II.  250 
lardaceous,  II.  675 
linguiform  of,  II.  659 
obstruction  of  veins  of,  II.  667 
partial  hepatoptosis  of,  II.  659 
Riedel's  lobe  of,  II.  659 
secondary  malignant  growths  of,  II.  679 
suppurative  pylephlebitis  of,  II.  666 
syphilitic  cirrhosis  of,  II.  665 
tear  of,  II.  250 
torpor  of,  in  gout  and  gouty  conditions, 

1.442 

tropical,  II.  676-678 
and  malaria,  II.  676 
dyspepsia  and,  II.  678 
excessive  heat  and,  II.  677 
over-eating  and  over-drinking,  II.  677 
tumours  of,  II.  679 
vascular  diseases  of,  II.  666 
wandering,  II.  659 
Llandrindod  spa,  III.  152 
Llangammarch  spa,  III.  152 
Llanwrytd  spa,  III,  152 
Llewelyn  (L.  Jones),  arthritis  deformans, 
I.  391-399 


Llewelyn,  (L.  Jones)  (contd,.') — 

osteo-arthritis,  I.  400-403 

spondylitis  deformans,  I.  404 
Lochia   in  normal   puerperium,   IV.  257, 

262 

Lockyer  (Cuthbert)  inversion  of  uterus  in 
labour,  IV.  182-187 

lacerations    of    the    genital    tract    in 
labour,  IV.  188-213 

post-partum   haemorrhage,  IV.  214-223 

retained  placenta,  IV.  225-237 

rupture  of  the  uterus,  IV.  238-247 
Locomotor  ataxy,  II.  1085-1092 
Loeche-les-Bains  spa,  III.  152 
Longhurst's  combined    chloroform    tube 

and  tongue  depressor,  III.  29 
Lordosis,  physical  exercises  for,  III.  239 
Loreta's  operation,  II.  317 

stretching    operation   in   hypertrophic 

stenosis  of  the  pylorus,  II.  339,  342 
Lotheissen's  operation  for  femoral  hernia, 

II.,  511 
Lotions  after  cataract  extraction,  III.  633 

boiled  water  in  preparation  of,  I.  73 

evaporating,  I.  36 

in  acute  gout,  I.  433 

in  herpes  zoster,  II.  1096 

in  iritis,  III.  586 

for  pruritus,  IV.  530 
•  for  vulvitis,  IV.  530 
Love  (James  Kerr),  deaf  mutism,  III. 

979-981 

Low  (G.  C.),  acute  dysentery,  III.  428- 
432 

Bilharzia  disease,  III.  498-500 

cholera,  III.  423-427 

diseases  of  obscure  origin,  III.  465-469 

epidemic  gangrenous  proctitis,  III.  437 

filariasis,  III.  503 

hill  diarrhoea,  III.  438 

infantile  biliary  cirrhosis,  III.  439 

ponos,  III.  440-441 

tropical  liver,  II.  676-678 
Luc's  nasal  biting  forceps,  III.  693 
Lucae's    pressure    probe    in    massage  of 

tympanic  membrane,  III.  952 
Lucan  spa,  III.  152 
Lucca  spa,  III.  152 
Luchon  spa,  III.  152 
Ludwig's  angina,  treatment  of,  I.  183 
Luff  (Arthur  P.),  gout  and  gouty  con- 
ditions, I.  432-461 
Lumbago,  mineral  waters  and  baths  in, 

III.  142 
Lumbar  puncture,  II.  1025-1026 

in  cerebral  concussion,  I.  879 

in  eclampsia,  IV.  38 

in  hydrocephalus,  II.  1191 

in  meningitis,  I.  251 

in  tuberculous  meningitis,  I.  249 

methods  of,  I.  251-252 
Lunacy  in  pellagra,  I.  523 

See  also  Insanity  and  Mental  diseases. 
Lungs,  abscess  of,  I.  1059 

following  pneumonia,  I.  1060 


70 


A    SYSTEM  OF   TREATMENT. 


Lungs,  abscess  of  (contd.) — 

surgical  treatment  of,  I.  1060-1062 
actinomycosis  of,  surgical  treatment  of, 

I.  1175 

aspergillosis  of,  I.  1116 
atelectasis  and  collapse  of,  I.  1063-1065 
collapse  of,  I.  1065 
congestion  of,  acute,  I.  1076 

chronic,  I.  1077 

hypostatic,  I.  1079 

and  oadema  of,  I.  1076-1081 
decortication  of,  in  empyema,  I.  1108 
diseases  of,  I.  1059-1175 

breathing  exercises  in,  III.  249 

complicating  gynaecological  surgery, 
IV.  494 

physical  exercises  in,  III.  249 
effect  of  ammonia  on,  I.  527 
embolism  of,   after   abdominal    opera- 
tions, II.  275 

complicating   the    puerperium,    IV. 

324-325 

expansion  of,  correct  breathing  neces- 
sary for,  I.  49 

in  generalised  empyema,  I.  1104 
gangrene  of,  I.  1090 
hernia  of,  I.  1027 
hydatid  cyst  of,  I.  1175 
hypcracute    or   fulminating   forms    of 

oedema  of,  I.  1080 
injuries  to,  I.  1028 
oedema  of,  I.  1081 

and  congestion  of,  1. 1076-1081 
operation    when  hepatic    abscess    has 

burst  through,  II.  655 
tuberculosis  of,  I.  1117-1126 

See  also  Tuberculosis,  Pulmonary, 
tumours  of,  I.  1174 

surgical  treatment  of,  I.  1175 
want  of  expansion  of,  in  empyema,  I. 

1107 
Lupus,  III.  1146 

cauterisation  in,  III.  1149 

crusted  and  ulcerated,  X-rays  in,  III.  352 

erasion  in,  III.  1149 

excision  in,  III.  1146 

Finsen  light  in,  III.  1147 

frequent  source  of  carcinoma,  I.  117 

ionisation  in,  III.  184,  1150 

of  the  auricle,  III.  881 

of  the  larynx,  III.  838-839 

of  the  nares,  III.  687 

of  the  naso-pharynx,  III.  742 

of  the  pharynx,  III.  781 

of  the  tonsil,  III.  757 

of  the  vulva,  IV.  508 

pyrogallic  acid  in,  III.  1150 

radium  in,  III.  1150 

Rontgen  rays  in,  III.  352,  1148 

salicyclic  acid  in,  III.  1150 

scarification  in,  III.  1141) 

silver  nitrate  in,  III.  1150 

vaccine  therapy  of,  III.  1150 

verrucosus,  X-rays  in,  III.  352 

Vienna  paste  in,  III.  1150 


Lupus  erythematosus,  III.  1065-1072 
direct  causes,  III.  1066 
Finsen  light  in,  III.  1071 
general  treatment,  III.  1066 
•  ionic  medication  of,  III.  184 
ionisation  in,  III.  1070 
local  treatment,  III.  1067 
predisposing  causes,  III.  1065 
radium  in,  III.  1071 
solid  carbon  dioxide  in,  III.  1071 
Luxeuil-les-Bains  spa,  III.  153 
Luy's  method  of  hypnotism,  III.  165 
Lying-in,  length  of  in  normal  puerperium, 

IV.  270 

Lymph,  flow  of,  increase  of,  I.  438 
Lymphadenoma,  I.  1341-1343 
Lymphangiectasis,  cavernous,  of  the  lym- 
phatic vessels,  I.  1351 
cystic,  of  lymphatic  vessels,  I.  1351 
rllarial,  III.  516 

simple,  of  lymphatic  vessels,  I.  1351 
Lymphangioma  of  neck,  II.  169 

proper  of  lymphatic  vessels,  I.  1352 
Lymphangiomatous  tumours  of  the  scalp, 

I.  893 
Lymphangioplasty    in    brawny    arm    of 

cancer,  I.  144 

Lymphangitis,  acute,  complicating  gonor- 
rhoea, I.  226 
filarial,  III.  503 
of  lymphatic  vessels,  I.  1352 
Lymphatic  glands,  carcinoma  of,  1. 124, 125 
diseases  of,  I.  1339-1344 

secondary  to  infective  processes,  I. 

1339 
removal  of  in  malignant  disease  of 

upper  jaw,  II.  116 
sarcomatous  secondary  deposits  of,  I. 

135 

tuberculous  disease  of,  I.  1344 
general  measures  in,  I.  1345 
tuberculin  in,  I.  1346 
varicose,  III.  516 
leukaemia,  II.  41 
system,  anatomy   of,    and   permeation 

theory,  I.  126 
vessels,  I.  1351-1352 
cavernous  lymphangiectasis  of,  1. 1351 
cystic  hygroma  of,  I.  1351 
cystic  lymphangiectasis  of,  I.  1351 
diseases  of,  I.  1339-1340 
lymphangioma  proper  of,  I.  1352 
lymphangitis  of,  I.  1352 
simple  lymphangiectasis  of,  1. 1351 
Lymphorrhoea    of    lymphatic    vessels,  I. 

1351 
Lymphosarcoma  of  glands,  I.  1350 


McBurney's  incision  in  appendicitis,  II. 
411 

MacCormac  (Sir  W.)  on  cancerous  secon- 
dary growths,  I.  125 

Macdonald  (Sydney  G.),  calculus  of  the 
bladder,  II.  852-857 


71 


A    SYSTEM   OF  TREATMENT. 


Macdonald  (Sidney  G.)  (contd)— 
cystitis,  II.  858-860 
diverticula  and  sacculi  of  the  bladder, 

II.  864-865 

ectopia  vesicae,  II.  866-869 
injuries  of  the  bladder,  II.  868-869 
tuberculous  cystitis,  II.  861-863 
tumours  of  the  bladder,  II.  870-873 

McEwen's  operation  for  inguinal  hernia, 
II.  507 

Maclntyre's  splint  in  fractures  of  the 
femur,  I.  618 

Mackenzie  (Hector),  pleurisy  and  effusion 
(sero-fibrinous),  I.  1093-1098 

Mackenzie  (James),  general  treatment  of 
diseases  and  affections  of  the  heart,  I. 
1194-1254 

Mackenzie's  laryngeal  forceps,  III. 
847 

McKenzie's  pillar  separator  in  operations 
on  tonsil,  III.  752 

Mackintosh  sheets,  use  of,  I.  30,  31 

Mackintoshes,  arrangement  of  before 
operation,  I.  84 

MacLeod   (J.  M.  H.),  acne  vulgaris,  III. 

982-990 

alopecia,  III.  992-1004 
boils  or  furuncles,  III.  1006-1111 
carbuncles,  III.  1012-1014 
chromidrosis  or  coloured  sweating,  III. 

1021 

comedones,  III.  1022-1023 
granulosis  rubra  nasi,  III.  1041 
hyperidrosis  or  excessive  sweating,  III. 

1044-1045 

hypertrichosis,  III.  1046-1052 
impetigo,  III.  1054-1056 
leptothrix,  III.  1058 
lichenification,  III.  1059-1060 
lichen  planus,  III,  1061-1064 
lupus  erythematosus,  III.  1065-1072 
parapsoriasis,  III.  1085 
pityriasis  rosea,  III.  1090-1091 
pruritus  or  itching,  III.  1097-1101 
pruritus  ani,  III.  1102-1105 
pruritus  vulvae,  III.  1106-1108 
psoriasis,  III.  1109-1123 
sporotrichosis,  III.  1143 
tropical  skin  diseases,  III.  470-486 
verruga  Peruviana,  III.  459-460 

Macnamara  (E.  D.),  cocainism,  I.  505 
dementia  praecox,  II.  1305 
exhaustion  psychoses,  II.  1299-1300 
idiocy  and  feeble-mindedness,  II.  1318- 

1320 

insomnia,  II.  982-992,  1014-1024 
mania,  II.  1284-1289 
masturbation,  II.  1316-1317 
melancholia,  II.  1290-1298 
mental  aspects  of  epilepsy,   II.    1310- 

1312 
mental   aspects  of  hysteria,   II.   1306- 

1308 

mental  diseases,  II.  1274-1283 
morphinism,  I.  516-520 


Macnamara  (E.  D.)  (contd.*) — 

obsessive    and    imperative     ideas,    II. 
1313-1314 

paranoia,  II.  1309 

perversions,  II.  1315 

psychoses   associated  with  changes   in 
thyroid  gland,  II.  1301-1302 

toxic  psychoses,  II.  1303-1304 
Macrodactyly,  I.  943 
Maddox  (E.  E.),  diseases  and  affections  of 

the  ocular  muscles,  III.  646-655 
Madeling's  deformity  of  the  wrist.  I.  939 
Madura  foot,  III.  485 
Maggots  in  the  nose,  III.  669 
Magnesium  in  arsenical  poisoning,  I.  504 

peroxide,  in  hyperchlorhydria,  I.  442 

sulphate  of,  in  constipation  in  adults, 

II.  449 

in  lead  poisoning,  I.  514 
in  tetanus  in  puerperium,  IV.  326 
Mail-carts  for  young  children,  use  of,  I. 

52 

Maize  diet,  cause  of  pellagra,  I.  521 
Malacosteon  pelvis  complicating  labour, 

IV.  172 

'•  Maladie  de  Woillez,"  I.  1076 
Malaria,  III.  392-398 

after-treatment  of,  III.  397 

coma  in,  II.  985 

complicating  pregnancy,  IV.  48 

intramuscular  injections  in,  III.  395 

medicinal  prophylaxis  of,  III.  392 

mineral  waters  and  baths  in.  III.  143 

neuritis  in,  II.  1131 

prevention  of,  III.  380 

prophylaxis  of,  III.  392 

quinine  in,  III.  392-394 

rectal  administration  of  quinine  in,  III. 
396 

spleen  in,  II.  81 

treatment  of  an  attack  of,  III.  394 

tropical  liver  and,  II.  676 
Male  fern  in  bilharzia  disease,  III.  499 
Malformations  of  the  anus,  II.  613 

of  the  colon,  II.  582-587 

of  the  external  ear,  III.  876 

of  the  meatus,  III.  882 

of  the  nails,  III.  1082 

of  the  nasal  septum,  III.  678 

of  the  nose,  III.  671-677 

external  and  internal,  III.  672-673 

of  the  oesophagus,  II.  189 

of  the  teeth,  III.  1165 

of  the  tympanic  membrane,  III.  891 

of  the  uterus,  IV.  711-717 

of  the  vagina,  IV.  541-544 

of  the  vulva,  IV.  513-514 
Malignant  cyst  of  the  neck,  II.  169 

degeneration  of  simple  tumours,  I.  119 

disease,  aetiology  of,  I.  116-119 
and  cholelithiasis,  II.  695 
of  the  appendix,  II.  411 
of  the  auricle,  III.  878 
of  the  breast,  II.  963-975 
of  the  lingual  tonsil,  III.  762 


72 


A    SYSTEM  OF   TREATMENT. 


Malignant  disease  (contd.) — 

of  the  nasopharynx,  III,  700 
of  the  penis,  II.  877-878 
of  the  uvula,  III.  746 
of  the  vulva,  IV.  51 5-5]  6 
X-rays  in,  III.  362 

See    also    Cancer,     Sarcoma    and 

Tumours. 

epulis  of  the  jaw,  II.  110 
growths,   fistula;   of   uterus    from,    IV. 

668 

in  the  lower  pharynx,  III.  786 
of  the  maxillary  antrum,  III.  fi'.'i;  - 
of  the  meatus,  III.  883 
of  muscle,  II.  1325 
of  the  nasal  cavities,  III.  694 
of  the  oro-pharynx,  III.  785 
of  the  rectum,  II.  625 
ovarian  tumours,  IV.  770 
stricture  of  the  oesophagus,  II.  175 
tumours,  Coley's  fluid  in,  III.  292 

of  the  tonsil,  III.  758 
Malignant  pustule,  I.  179 
Malingering  in  spinal  injuries,  I.  901 
Mallet  finger,  I.  943 
Malleus  incus,  removal  of,  III.  913-915 
Malta  fever,  III.  399-400 
Mammary  artery,  internal,  wounds  of,  I 

1025 

Manganese  in  chlorosis,  II.  27 
Mania,  II.  1284-1289 

acute,  in  epilepsy,  II.  1005 
delirious,  acute,  II.  1289 
medicinal  treatment  of,  II.  1287 
puerperal,   hypnotism   in  case  of,  III. 

173 

Manometer,  Leonard  Hill's,  I.  1281 
Marasmus,  I.  463 
dietetic  treatment  of,  I.  466 
drugs  in,  I.  466 
following  measles,  I.  247 
in  spina  bifida,  I.  915 
in  newborn  child,  IV.  370 
prophylaxis  of,  I.  463 
sea  water,  injections  in,  I.  467 
Marching,  equipment  for,  I.  536 
Margate,  climate  of,  III.  84 
Marienbad  spa,  III.  153 
Marine  baths,  III.  129 
Marriage  and  chlorosis,  II.  31 
and  epilepsy,  II.  1002 
and  female  sterility,  IV.  843 
Martigny  spa,  III.  153 
Martin's   rubber    bandage  for  ulcers,   I. 

371,  372 

splint  for  fracture  of  the  jaws,  II.  114 
mercurial  instrument  for  test  of  blood 

pressure,  I.  1281 

Masks,  use  of,  in  surgical  operations,  I.  81 
Mason's  gag  in  anaesthetics,  III.  2 
Massage,  III.  203-212 

abdominal  in    membranous  colitis,   II. 

565 

after  abdominal  operations,  II.  268 
callus  formation  and,  I.  579 


(contd.*)— 
effleurage  in,  III.  203 
friction  and,  III.  204 
in  acute  anterior  poliomyelitis,  II.  1056 
in  acute  gout,  contra-indicated,  I.  438 
in  adhesions  of  the  colon,  II.  559 
in  alopecia  areata,  III.  996 
in  arthritis  deformans,  I.  398 
in  atony  of  the  stomach,  II.  287 
in  chorea,  II.  1263 
in  constipation,  II.  463 
in  facial  paralysis,  II.  996,  1094 
in  flat  foot,  I.  969 
in  fracture  of  head  of  radius,  I.  599 
in  non-traumatic  joint   affections,  III. 

208 

in  paraplegia,  II.  1198 
in  diseases  of  the  heart,  I.  1210 
in  fractures,  I.  577-579 
in  orthopaedic  cases,  III.  233 
in  osteo-arthritis,  I.  402 
in  pulmonary  tuberculosis,  I.  1139 
in  Raynaud's  disease,  I.  218 
in  rheumatism  (chronic),  I.  488 

(muscular),  I.  494 
in  sprains,  I.  737,  740 
in  tabes  dorsalis,  II.  1091 
in  varix  of  lower  extremities,  I.  1312 
of  the  breasts  for  painful  engorgement, 

IV.  332 

of  the  neck,  III.  209 
of  the  tympanic  membrane,  III.  952 
of  the  tympanic  ossicles,  III.  952 
of  the  uterus,  in  retroversion,  IV.  673 
petrissage  and,  III.  204 
tapotement  and,.  III.  204 
therapeutical  indications  of,  III.  206 
vibration,  III.  204 

vibratory,  in  chronic  rhinitis,  III.  709 
Mastitis  at  puberty,  II.  960 
chronic  interstitial,  II.  961 

lobar.  II.  961 

lobular,  II.  961 
in  infants,  II.  960 
in  newborn  child,  IV.  371 
in  the  puerperium,  IV.  334-335 
Mastoid  abscess,  Bezold's,  III.  932 

antrum,  opening  of,  Schwartze  s  opera- 
tion, III.  898 

cells,  inflammation  of,  acute  primary, 
III.  919 

suppuration  of,  in  acute  inflammation 

of  middle  ear,  III.  897 
operation,  III.  920-921 

instruments  for,  III.  921 

preparation  of  patient,  III.  920 
periostitis.  III.  919 
process,  diseases  of,  III.  919-932 

after-treatment   of  operation    cases, 
III.  927 

Ballance's  operation  in,  III.  929 

Bergmann's  post-aural  operation  in, 
III.  922,  933 

Kuster's  post-aural  operation  in,  III. 
922,  923 


73 


A    SYSTEM  OF  TREATMENT. 


Mastoid  process  (contd.~) — - 

Schwartze's   post-aural  operation  in, 

III.  922,  923 
Stacke's  post-aural  operation  in,  III. 

922,  923,  926 

Mastoiditis,  diabetic,  III.  932 
influenzal,  III.  932 
latent,  III.  933 
Masturbation,  II.  1316,  1317 

in  epilepsy,  II.  992 
Matas  (Rudolf),  on  haemorrhage,  I.  1266, 

1270 
Matas's    operation    in    traumatic    aneu- 

rysms,  I.  560 

Metatarsals,  fracture  of,  I.  633 
Matico,  infusion  in  epidemic  gangrenous 

proctitis,  III.  437 
in  haemorrhage,  I.  1261 
Matlock  Bath,  III.  153 
Maxillary  alveolus,  dentigerous  cyst  of, 

III.  719 

antrum,  malignant  growths  of,  pallia- 
tive treatment,  III.  697 
sinus,  III.  721-727 

suppuration  of,  III.  721 
Mayer's  tonsil  enucleator,  III.  753 
Mayo's  operation  for  umbilical  hernia,  II 

513 

scissors,  IV.  476,  477 
Meals,  arrangement  and  composition  of, 

for  diabetes,  I.  414,  419 
in  obesity,  I.  471 

daily  number  of,  for  children,  I.  62 
hypersecretion  and,  II.  209 
nature  of,  and  gout,  I.  449,  455 
Mealies,  chemical  composition  of,  II.  195 
Measles,  I.  243-247 
acute  inflammation  of  middle  ear  in,  III. 

902 

bronchitis  and,  I.  245 
cancrum  oris  complicating,  I.  247 
care  of  eyes  in,  I.  246 
croup  and,  I.  245 
diarrhoea  and,  I.  246 
diet  in,  I.  244 
fever  and,  I.  244 
glandular  affections  in,  I.  246 
.    laryngitis  complicating,  I.  245,  247 
lobular  pneumonia  in,  I.  245 
marasmus  following,  I.  247 
otorrhoea  in,  I.  246 
quinine  in  convalescence  from,  I.  65 
stomatitis  and,  I.  246 
Meat  broths  in  typhoid  fever,  I.  342 
diet  in  gout,  I.  452 
in  sprue,  III.  443 

dietary  for  children,  directions  for,  I.  59 
extracts  in  typhoid  fever,  I.  342 
Meatus,  congenital  atresia  and  webs  of, 

111.  882 

cutaneous  diseases  of,  III.  884 
diphtheria  of,  III.  883 
diseases  of,  III.  883 
eczema  of,  III.  886 
exostoses  of,  III.  883 


Meatus  (contd.) — 

fibroid  polypi  of,  III.  882 
foreign  bodies  in,  III.  888 
granulations  of,  III.  882 
hypersecretion  of  cerumen  in,  III.  884 
herpes  of,  III.  885 
inflammations  of,  III.  885 
keratosis  obturans  of,  III.  885 
malformations  of,  III.  882 
malignant  growths  of,  III.  883 
neuroses  of,  III.  884 
new  growths  of,  III.  882 
otalgia  of,  III.  884 
otomycosis  of,  III.  886 
otitis  externa,  circumscripta  of,  III.  885 
croupous,  III.  884 
diffusa  of,  III.  886 
haemorrhagic,  III.  886 
papillomata  of,  III.  883 
secretion  of,  deficient,  III.  885 
stenosis  of,  III.  882 
syphilis  of,  III.  883 
vascular  caruncle  of,  IV.  512 
Medical  sciences,  advance  of,  influence  of, 

in  treatment,  I.  1 
Medicines.    See  Drugs. 
Mechanical  supports  for  varix  of   lower 

extremities,  I.  1313 
vibration,  III.  213-221 
Meckel's  diverticulum,  II.  277 
Mediastino-pericarditis,  chronic  and  ad- 
herent pericardium,  I.  1186 
Mediastinum,       caseating       tuberculous 

glands  in,  I.  1176 
inflammation  of,  surgical  treatment  of, 

I.  1176 

injuries  of,  I.  1031 
new  growth  in,  I.  1178 
Mediterranean  fever,  III.  399 
Melaena  in  newborn  child,  IV.  370 
Melancholia,  II.  1290-1298 
acute  stage  of,  II.  1291 
electricity  in,  II.  1294 
feeding  in,  II.  1292 
opium  in,  1297 
psychotherapy  in,  II.  1295 
hypnotism  in  case  of,  III.  171 
with  delusions,  hypnotism  in  case  of, 

III.  173 

Melanoderma,  III.  1073 
Melanuria,  II.  741 

Membrana  flaccida  shrapnelli,  perforation 
of,  in  epitympanic  suppuration,  III. 
912 

Membranes,  perforation  of,  in  accidental 
haemorrhage  during  pregnancy,   IV. 
25 
rupture   of,  in  inducing  abortion,  IV. 

436 

in  second  stage  of  labour,  IV.  112 
Menier's  disease  of  the  labyrinth,  III.  970 
Meningeal  artery,  middle,    haemorrhage 

from,  I.  1275 

Meninges  cerebral,  direct  drainage  from, 
in  purulent  meningitis,  I.  252 


74 


A    SYSTEM  OF   TREATMENT. 


Meningitis,  cerebro-spinal,  I.  250 

complicating  pregnancy,  IV.  49 
chronic  basilar,  I.  253 
complicating  diseases   of  the  ear,  III. 
937-939 

influenza,  I.  241 

typhoid  fever,  I.  362 
forms  of  infection  in,  I.  251 
meningococcus,  I.  250 
palliative  measures  and  general  points 

in  treatment  in,  I.  253 
pneumococcus,  I.  250 
purulent,  drainage  by  limber  puncture, 
I.  251 

specific   treatment  of   the    infective 

process  in,  I,  249 
spinal  gummatous,  II.  1068 
streptococcus,  I.  250 
tuberculous,  drainage  in,  I.  249 

non-specific  measures  in,  I.  248 

specific  measures  in,  I.  249 
Meningocele    concealed    in    lipoma,    I. 

107 

cranial,  II.  1194 
in  spina  bifida,  I.  914 
of  newborn  child,  IV.  357 
Meningococcus  infection,  Flexner's  anti- 
meningitis  serum  in,  III.  282 

serum  therapy  of,  III.  282-283 
meningitis,  I.  250 
Meningo  encephalitis.  I.  885 
Menopause,  dyspepsia  in,  IV.  501 
effect  on  metabolism.  I.  389 
flushes  of  heat  in,  IV.  502 
insomnia  in,  IV.  502 
leucorrhoea  in,  IV.  557 
management  of,  IV.  501-503 
menorrhagia  in,  IV.  503 
mental  irritability  in,  IV.  502 
metorrhagia  in,  IV.  503 
nervous  depression  in,  IV.  502 
neurasthenia  in,  IV.  503 
overstrain  in,  IV.  503 
polysarcia  abdominalis  in,  IV.  501 
tachycardia  in,  IV.  502 
Menorrhagia,  IV.  751-764 
curettage  in,  IV.  758 
douches  in,  IV.  756 
drugs  in,  IV.  754 
electrical  treatment  of,  IV.  762 
ergot  in,  IV.  754 
general  treatment,  IV.  752 
.  hydrastis  canadensis  in,  IV.  755 
hysterectomy  in,  IV.  763 
in  the  menopause,  IV.  503 
in  puberty,  IV.  501 
intra-uterine  applications  in,  IV.  758 
obphorectomy  in,  IV.  763 
plugging  in,  IV.  757 
steaming  the  uterus  in,  IV.  760 
Menorrhoea,  crypto-,  IV.  732 
Menstruation,  disorders  of,  IV.  725-764 
establishment  of,  IV.  499 
hidden,  IV.  732 
leucorrhoea  replacing,  IV.  557 


Menstruation  (contd.} — 
operations  during,  III.  24 
scanty,  IV.  725,  734 
Mental  aspects  of  epilepsy,  II.  1310-1312 

of  hysteria,  II.  1306-1308 
cough    in    pulmonary    tuberculosis,    I. 

1144 

diseases,  II.  1274-1283 
certification  in,  II.  1278 
general  considerations  of,  II.  1274 
in  pregnant  women,  IV.  46-58 
prophylaxis  of,  II.  1279 
See  also  Insanity,  &c. 
irritability  in  the  menopause,  IV.  502 
torticollis,  II.  1052 
Mercurial  inunctions,  I.  70 

in  disseminated  sclerosis,  II.  1072 
in  syphilis,  I.  319 
ointment  in  goitre,  II.  63 
poisoning,  treatment  of,  I.  530 
purgatives  in  constipation  in  adults,  IIt 

450 

stomatitis,  II.  125 
Mercury,   biniodide  of,  in   treatment  of 

actinomycosis,  I.  177 
effect  of,  on  children,  I.  68 
in  arterio-sclerosis,  I.  1292 
in  cerebro-spinal  syphilis,  II.  1065 
in  syphilitic  affections  of  the  vulva, 

520 

ulcers  of  tongue,  II.  135 
in  tabes  dorsalis,  II.  1086 
in    undefined    tropical    fevers,    III. 

410 

percentage  of  in  cyanide  gauze,  I.  76 
perchloride  of,  as  disinfectant,  I.  339 
in  lotions,  I.  73 
strength  of  solution,  I.  81 
in  typhoid  fever,  I.  353 
in  trypanosomiasis,  III.  421 
treatment  of  syphilis  by,  I.  317 
Mesenteric  arteries,  embolism  of,  I.  1307 
Mesentery,  injuries  to,  II.  252 
Mesmer's  method  of  inducing  hypnotism, 

III.  163 
Mesocolon,   operation  for  shortening,  in 

volvulus  of  colon,  II.  592 
Mesometrium,  cyst  of,  IV.  769 
Mesosalpinx,  cyst  of,  IV.  768 
Mesotan  liniment  in  rheumatism,  I.  487 
Metabolism,  defective,  exercises  in  diseases 

associated  with,  III.  254 
disorders  of,  in  constitutional  diseases, 

I.  386-390 

influence  of  climate  on,  I.  460 
Metacarpal  bones,  fractures  of,  I.  604 

bone,  excision  of  head  of,  I.  810 
Metacarpo-phalangeal  joints,  amputation 

and  disarticulation  at,  I.  807-811 
Metal  splints  for  fractures,  I.  574 

suspension  splint  for  the  ankle,  I.  773 
Metallic    poisoning    due    to    poisonous 

metals  in  tinned  foods,  I.  510 
Metals,  poisonous,  in  tinned  foods,  poison- 
ing due  to,  I.  510 


75 


A    SYSTEM  OF  TREATMENT. 


Metastasis    of     carcinoma,     permeation 

theory  of,  I.  124,  126 
Metatarsalgia,     Morton's    neuralgia,     I. 

964 
Metatarsus,  amputation  of.  I.  830 

disease  of,  I.  773 

Lisfranc's  disarticulation  of,  I.  837-839 
MetchnikofFs    curdled   milk   in   achylia, 
II.  295 

sour  milk  in  cancer  of  the  stomach,  II. 

298 

Methyl,  bichlorinated  chlorate   as  anaes- 
thetic, III.  13 

Methylene  blue  in  bilharzia  disease,  III. 
499 

in  chronic  dysentery,  III.  436 
Metritis,  sterility  and,  IV.  845 
Metrorrhagia,  IV.  751-764 

curettage  in,  IV.  758 

douches  in,  IV.  756 
.    drugs  in,  IV.  754 

electrical  treatment  of,  IV.  762 

ergot  in,  IV.  754" 
•   general  treatment,  IV.  752 

hydrastis  canadensis  in,  IV.  755 

hysterectomy  in,  IV.  763 

in  the  menopause,  IV.  503 

intra-uterine  applications  in,  IV.  758 

oophorectomy  in,  IV.  763 

plugging  in,  IV.  757 

steaming  the  uterus  in,  IV.  760 
Micrococcns  catarrhalis  infections,  vaccine 
therapy  of,  III.  283 

melitensis  in  goat's  milk,  III.  384 

neoformans  vaccine  in  cancer,  1.  152 

vaccine  therapy  of,  III.  299 
Micro-organisms,    virulent,   conservative 

factors  of  resistance  to,  I.  10,  11 
Micturition,  frequency  of,  in  pendulous 
belly  during  pregnancy,  IV.  61 

obstruction  of,  due  to  premature  en- 
largement of  the  prostate,  II.  930 

precipitate,  in  myelitis,  II.  1218 
Mid-tarsal  joint,  Chopart's  disarticulation 

at,  I.  840 
Middledorf  s  triangle,  use  of,  in  fractures, 

1.591 
Migraine,  II.  1027-1035 

drugs  in,  II.  1029 

exciting  causes  of  attack,  II.  1027 

fatigue  in,  II.  1027 

functional  troubles  of  the  eyes  in,  III. 
545 

ophthalmoplegic,  II.  1033 

surgical  procedures  for,  II.  1031 

treatment  of  attacks  of,  II.  1031 

between  attacks,  II.  1029 
Miliary  or  generalised  tuberculosis,  I.  332 
Milium,  III.  1073 

Milligan  (William),  cholesteatoma,   III. 
934 

chronic    suppurative  inflammation    of 
the  middle  ear,  III.  904-918 

diseases  of   the  mastoid   process,   III. 
919-933 


Milligan  (William)  (contd.*)— 

tuberculous  disease  of  the  middle  ear 

and     its     accessory      cavities,    III. 

935-936 
Milligan's  flap  in  operation  for  diseases 

of  mastoid  process,  III.  924,  952 
intra-tympanic  syringe,  III.  906 
Milk,  boiled,  in  the  tropics,  III.  384 
carrier  of  typhoid,  I.  337 
citrated,  in  infant  feeding,  II.  225 
composition   of,  in  infant  feeding,  II. 

221 

condensed    chemical    composition    of, 
II.  194 

in  infant  feeding,  II.  227 
cow's,  in  infant  feeding,  II.  219 
diet,  additions  to  in  fevers,  I.  158 

for  infants,  I.  59 

in  arthritis  deformans.  I.  393 

in  chronic  dysentery,  III.  434 

in  gastric  cancer,  II.  297 
neurasthenia,  II.  355 
ulcer,  II.  210 

in  gout,  I.  452 

in  pellagra,  I.  522 

in  scurvy,  I.  475 

in  sprue,  III.  442 

in  typhoid  fever,  I.  340 
diluted  by  adding  fat  in  infant  feeding, 
II.  223 

by  adding  sugar  in  infant  feeding, 
II.  223 

in  infant  feeding,  II.  222 
disordered  digestion,  due  to,  I.  61 
dried,  II.  228 

in  infant  feeding,  II.  228 
effects  upon  digestion  of  young  children, 

I.  60 

foods  in  marasmus,  I.  466 
human,  best  for  infants,  II.  215-218 
in  food  fever,  II.  237 
in  hill  diarrhosa,  III.  438 
in  pneumonia,  I.  258 
Metchnikoff's  sour,  in   cancer  of   the 

stomach,  II.  298 
Pasteurisation  of,  II.  220 
peptonised.  preparation  of,  I.  42 
predigested,  in  infant  feeding,  II.  226 
soured,  in  achylia,  II.  295 

in  sprue,  III.  445 
sterilisation  of,   in  infant  feeding,  II. 

220 ;  IV.  345 
various  forms  of,  in  infant  feeding,  II. 

221 

whole,  in  infant  feeding,  II.  221 
Miller's  disarticulation  at  the  knee  by  a 

circular  incision,  I.  861 
Milne  (Eobert),  on  inunction  of  eucalyptus 

oil  in  scarlet  fever,  I.  288 
Mimicry,  nervous,  of  joint  disease,  I.  787- 

788 

Mind,  effect  on  temperature  by,  I.  1141 
Mineral  acids,  poisoning  by,  treatment  of, 

I.  526 
springs,  general  characters  of,  III.  114 


76 


A    SYSTEM   OF  TREATMENT. 


Mineral  (contd.~) — 
waters,  classification  of,  in  treatment  of 

gout,  I.  460 

in  acute  gastritis,  II.  351 
in  arthritis  deformans,  I.  398 
in  atony  of  stomach,  II.  289 
in  chronic  rheumatism,  I.  491 
in  gout,  I.  457 
in  obesity,  I.  470,  471 
thermal,  III.  116 
tonicity  of,  III.  115 
uses  of,  III.  116 

Mineralisation  of  springs,  III.  114 
Miner's  dermatitis,  III.  1030 

nystagmus,  II.  1140 
Missiles,  lodged,  I.  558 
Modern  life,  effect  upon  the  nervous 

system,  I.  8 

Moebius's  anti-thyroid  serum  in  exophthal- 
mic goitre,  II.  56 
Moffat  spa,  III.  153 
Molar  roots,  upper,   extraction   of,    III. 

1183 
Molars,  lower,  extraction  of,  III.  1185 

third,  extraction  of,  III.  1186 
upper,  first  and   second  extraction  of. 

III.  1182 

third,  extraction  of,  III.  1183 
Moles,  III.  1077-1081 
blood  or  carneous,  IV.  59 
carneous,  complicating  pregnancy,  IV. 

59 

hydatidiform.  IV.  59 
pigmented,  III.  1080 
vesicular,  IV.  59 
Mollities  ossiuin  complicating  pregnancy, 

IV.  58 

Molluscum  contagiosum,  III.  1073 
fibrosum,  III.  1074 

severest  forms  of,  I.  112 
Monilithrix,  III.  1075 
Monsarrat  (K.  W.),  injuries  and  diseases 

of  the  head,  I.  872-887 
Monsummano  spa,  III.  153 
Mont  Dore  spa,  III.  153 
Montecantini  spa,  III.  153 
Moore  on  moist  applications    in  small- 
pox, I.  306 

Mooren's  ulcer  of  the  cornea,  III.  566 
Morcellement  in  chronic  injections  of  the 

tonsil,  III.  751 

Morgagni  on  aortic  aneurysm,  I.  1 297 
Morgan  and  Harvey  on  bacillus  typhosus, 

1.336 
Morphia,  hypodermic  injection  of,  I.  134 

before  operation,  I.  84 
in     accidental      hemorrhage     during 

pregnancy,  IV.  26 
in  constipation  in  adults,  II.  446 
in  eclampsia,  IV.  36 
in  malignant  disease  of  the  thyroid,  I. 

74 

in  peritonitis,  II.  638 
injection  of,  in  morphinism,  I.  519 
poisoning  by,  coma  in,  II,  984 


Morphia  (contd.*) — 

prevention  of  shock  by,  I.  96 

use  of,  in  blackwater  fever,  III.  388 
Morphine  and  scopolamine,  injection  of, 
in  labour,  IV.  378 

in  asthma,  I.  1038 

poisoning  by,  I.  531 
Morphinism,  I.  516-520 

hyoscine  in,  I.  517 

psychotherapy  in,  I.  519 
Morphoea,  III.  1075 

Mortality  after  operation  for  perforation 
of  the  intestine,  II.  556 

from  gastric  cancer,  II.  302 

in  abdominal  injuries,  II.  243 

of  nephrectomy,  II.  827 

of  operations  on  jaws,  II.  117 

of  scarlet  fever,  I.  287 

of  typhoid  fever,  I.  335 
Morton's  fluid.     See  lodo-glycerin. 

neuralgia,  I.  964 
Motion,  disorders  of,  II.  1257 
Moullin  (Mansell)  on  sprains,  I.  738 
Moure's  operation  on  the  nasal  septum, 

III.  681 

Mouth -breathing  in  anaemia,  II.  14 
in  children,  prevention  of,  I.  49 

care  of,  after  abdominal  operations,  II. 

264 
in  children,  I.  49 

diseases  of,  II.  120-129 

dry,  in  inflammation  of  parotid  glands, 

II.  163 
xerostomia,  II.  130 

epithelioma  of  tongue  invading  floor  of, 

II.  143 

floor  of,  cysts  of,  II.  145 

ranula  cyst  of,  II.  145 
hygiene  of,  III.  1170 

in  sprue,  III.  445 

in  syphilis,  I.  318 

in  typhoid  fever,  I.  356 
operation  on,  and  anaesthetics,  III.  26 
-prop,  wooden,  in  anaesthetics,  III.  1 
sepsis  of,  II.  127 
voice  production  and,  III.  336 
washes,  II.  121,  135 

antiseptic,  I.  259 

in  scarlet  fever,  I.  285 

in  syphilis,  I.  324' 
Movements,  heavy,  in  physical  exercises, 

III.  225 

passive,  in  acute  anterior  polio-myelitis, 

II.  1056 
Moynihan  (B.  G.  A.)  on  gastrectomy  in 

gastric  cancer,  I.  140 
Mud  baths,  III.  136 

in  arthritis  deformans,  I.  398 
Mules'  operation  for  enucleation  of  the 

eyeball,  III.  660 
Mummery  (P.  Lockhart),  adhesions  of  the 

colon,  II.  559-561 
cancer  of  the  colon,  II.  578-584 
congenital  abnormalities  of  the  colon, 
II.  585-587 


77 


A    SYSTEM  OF   TREATMENT. 


Mummery  (P.  Lockhart)  (contd.} — 
multiple  polypi  of  the  colon,  II.  588 
operative   treatment    of    chronic    con- 
stipation  due   to   disease   or   abnor- 
malities of  the  colon,  II.  470 
perforating  ulcer  of  the  colon,  II.  589 
shock  and  collapse,  I.  93-105 
treatment  of  colitis,  II.  570 
surgical  treatment    of  enteroptosis,   I. 

431 

tuberculosis  of  the  colon,  II.  590 
volvulus  of  the  colon,  II.  591 
Mumps,  I.  256-257 

simple  and  secondary,  II.  157 
Muriated  baths,  III.  130 
Murphy's   method  of  artificial  pneumo- 

thorax,  I.  1170 

Murray  (George  R.)  chronic  polycythaemia 
with  cyanosis  and   enlarged  spleen, 
11.84 
Hodgkin's  disease  (lymphadenoma),  1. 

1341-1343 
leukaemia,  II.  38-42 
purpura,  II.  43-45 
splenomegaly,  II.  82-83 
Muscles,  abdominal,  rupture  of,  II.  252 

weak  electricity  in,  II.  465 
affections  of,  II.  1321 
atrophy  of,  II.  1252 

and  contractions  of,  in  fractures,  I. 

577 

in  hemiplegia,  II.  1187 
peroneal,  II.  1253 
progressive,  II.  1081-1082 
calf,  spasm  of,  II.  1160 

in   cerebral    palsies  of    infancy,   II. 

1160 
contraction  of,  in  fractures,  I.  570 

static,  physical  exercises  for,  III.  229 
contusions  of,  II.  1321 
cysts  of,  II.  1325 
dystrophy  of,  II.  1250-1251 

development  of  contractures  in,  II. 

1251 
education    of,    in    cerebral    palsies    of 

infancy,  II.  1161 
facial,  paralysis  of,  II.  995 
fibromata  of,  II.  1325 
flaps  of,  in  amputations,  I.  796 
functions  of,  disorders  of,  II.  1254 
inflammatory  affections   of,    II.   1324- 

1325 

injuries  of,  II.  1321-1323 
laryngeal,  intrinsic,   paralysis  of,   III. 

841-844 

lipomata  of,  II.  1325 
malignant  new  growths  of,  II.  1325 
massage  of,  III.  205 
new  growths  of,  II.  1325 

innocent,  II.  1325 
ocular,  cyclophoria  of,  III.  648 
diseases  of,  III.  646-655 
esophoria  of,  III.  646 
exophoria  of,  III.  647 
heterophoria  of,  III.  646 


Muscles,  ocular  (contd.~) — • 
hyperphoria  of,  III.  647 
migrainous    recurrent    paralysis    of, 

III.  649 

nystagmus  and,  III.  649 
ophthalmoplegia  of,  III.  649 
paralysis  of,  acute  nuclear,  III.  649 
haemorrhagic,  III.  648 
paralytic  diplopia  of,  III.  649 
post-diphtheritic    paralysis    of,    III. 

649 
primary  nerve  degenerations  of,  III. 

649 

ptosis  of,  III.  650 
rheumatic  paralysis  of,  III.  649 
thrombotic  paralysis  of,  III.  648 
pectoral,    removal     of,     in    malignant 

disease  of  breast,  II.  971,  972 
rupture  of,  II.  1322 
sarcoma  of,  II.  1325 
spasm  of  weight-extension  in,  I.  742 
wasting  of  in  sprains,  I.  739 
wounds  of,  II.  1321 
Muscular  atrophy  in  children,  II.  1247 

progressive,  II.  1081 
exercises,   physiological  effect   of,  III. 

206 

fibres,  hernia  of,  II.  1323 
reaction,  I.  16 
rheumatism,  I.  492-494 
Musculo-spiral  nerve,  injuries  of,  II.  1112 
Mushroom  poisoning  causing  diarrhoea,  II. 

480 

Mustard  bath  for  children,  I.  38 
leaves,  I.  36 
plasters,  I.  36 
poultice,  I.  34 

in  catarrhal  pneumonia,  I.  69 
Mutton,  chemical  composition  of,  II.  193 

in  dietary  of  children,  1.  69 
Myasthenia  gastrica,  II.  286 

gravis,  II.  1254 

Mycetoma  or  madura  foot,  III.  485 
Mycosis  fungoides,  III.  1076 
Routgen  rays  in,  III.  1076 
Mydriatics  in  acute  iritis,  III.  583 
Myelitis,  II.  1212-1218 
acute  stage  of,  II.  1213 
atrophic  flaccid  palsy  in,  II.  1217 
bedsores  in,  II.  1218 
bronchitis  in,  II.  1216 
chronic  stage  of,  II.  1216 
cystitis  in,  II.  1217 
diet  in,  II.  1216 
drugs  in, II.  1215 
local  treatment  of,  II.  1216 
pain  in,  II.  1215 

precipitate  micturition  in,  II.  1218 
prophylaxis  of,  II.  1212 
spasticity  in,  II.  1217 
Myeloid  sarcomata  of  the  jaw,  II.  110 
Myeloma  of  the  bones  of  the  skull,  I.  895 
Myelomata,  central,  of  the  jaw,  II.  Ill 

of  bones,  I.  710 
Myiasis,  III.  483 


78 


A    SYSTEM  OF  TREATMENT. 


Myocardial  affections,  I.  1240 
Myocarditis  in  acute  rheumatism,  I.  272 
Myoclonus  spasm,  II.  1049 
Myomata  of  the  skin,  III.  1057 

of  the  vagina,  IV.  553 
Myomectomy,  abdominal,  IV.  658 

when  fibroid  is  pedunculated,  IV.  658 
is  sessile,  IV.  658 

in  uterine  fibroids,  IV.  658 
Myopia,  III.  538 

high,  III.  541 
discission  in,  III.  541 
removal  of  lens  in,  III.  541 
Myositis,  acute  simple,  II.  1324 
suppurative,  II.  1324 

ossifying,  II.  1325 

rheumatic,  II.  1324 

syphilitic,  II.  1324 
Myotonia  atrophica,  II.  1252 

congenita,  II.  1252 
Myringitis  of  the  tympanic  membrane, 

III.  891 
Myxoedema  and  cretinism,  II.  72 

complicating  pregnancy,  IV.  58 


Naemo-lymphangioma,     radium     therapy 

in,  III.  314 
Neevi,  III.  1077-1081 
capillary,  II.  133 
small,  III.  1078 

carbon  dioxide  snow  in,  III.  1078 
electrolysis  in,  III.  1079 
excision  of,  III.  1080 
radium  in,  III.  1079 
vaccination  in,  III.  1080 
cavernous,  II.  133 
in  newborn  child,  IV.  3G3 
lymphatic,  II.  133 
of  the  lips,  II.  97 
of  the  tongue,  II.  133 
spider,  III.  1077 
stellate,  III.  1077 
Nails,  atrophy  of,  III.  1082 
chronic   affections  of,  X-rays  in,  III. 

351 

diseases  of,  III.  1082 
eczema  of,  III.  1082 
favus  of,  III.  1082 
hypertrophy  of,  III.  1082 
malformation  of,  III.  1082 
position  of,  during  X-rays  applications, 

III.  351 

psoriasis  of,  III.  1121 
ringworm  of,  III.  1012,  1131 
Narcotics,  poisoning  by,  I.  530-534 
Nares,  lupus  of,  III.  687 

tuberculosis  of,  III.  687,  688 
Nasal    accessory   chambers,   diseases    of, 

headache  from,  II.  1033 
bones,  fractures  of,  III.  671 
catarrh    and    Eustachian    obstruction, 

III.  945 

mucopurulent.   chronic    and    Eusta- 
chian obstruction,  III.  946 


Nasal  (contd.') — 

feeding,  method  of,  I.  33 

passages  in  children,  care  of,  I.  49 

secretion   clearance  of  in  children,  I. 

'    49 

septum,  dislocation  of,  III.  »!7'.l 
fractures  of,  III.  679 
Gleason's  operation  on,  III.  681 
injuries  and  malformations  of,  III. 

678 
malformation  of,  Kilian's  method  in, 

III.  683 
symptoms     requiring     treatment, 

III.  678 

Moure's  operation  on,  III.  681 
simple  crest  operation  on,  III.  680 
submucous  resection  of,  III.  682 

splint  for  fracture  of  the  nose,  III.  671 
Naso-pharyngeal  catarrh,  III.  739-741 

chronic    and    Eustachian   obstruction, 
III.  946 

Eustachian  obstruction  and,  III.  945 

cavity,  diseases  of,  III.  732-743 

wool-carriers,  III.  740 
Nasopharynx,  adhesions  of,  and   Eusta- 
chian obstruction,  III.  947 

growths  of,  III.  699 

in  asthma,  morbid  conditions  of,  1. 1037 

lupus  of,  III.  742 

malignant  disease  of,  III.  700 

syphilis  of,  III.  743 

tuberculosis  of,  III.  742 

tumours  of,  and  Eustachian  obstruction, 
III.  947 

voice  production  and,  III.  336 
Nastin  treatment  of  leprosy,  III.  452 
Nature,  influence  of  in  treatment,  I.  1 
Nauheim  spa,  III.  153 
Nausea  in  disordered  digestion,  II.  373 
Neck,  acute  cellulitis  of,  dangerous  for 
anesthesia,  III.  23 

aerial  fistula  of,  II.  166 

blood  cysts  of,  II.  167 

branchial  cysts  of,  II.  167 
fistula;  of,  II.  166 

bursal  cyst  of,  II.  168 

cellulitis  of,  complicating  scarlet  fever, 
1.290 

cystic  hygroma  of.  II.  169 

cysts  of,  II.  167-170 

dermoid  cyst  of,  II.  168 

diffuse  lipomata  of,  I.  107 

diseases  of,  II.  164-170 

enlarged  glands  in,  in  anaemia,  II.  14 

fistulas  of,  II.  166-167 

gunshot  wounds  of,  I.  564 

hydatid  cysts  of,  II.  169 

hydroceles  of,  II.  169 

injuries  of,  II.  164-170 

lymphangioma  of,  II.  169 

lymphatics  of,  in  epithelioma  of  tongue, 
II.  144 

malignant  cysts  of,  II.  169 

massage  of,  III.  209 

median  cervical  fistula  of,  II.  167 


79 


A    SYSTEM  OF  TREATMENT. 


Neck  (contd.*) — 

preparation  of  for  operation,  I.  88 

sebaceous  cysts  of,  II.  170 

septic  cellulitis  of,   complicating    cut 

throat,  II.  165 
thyro-glossal  cysts  of,  II.  170 

fistula  of,  II.  167 
thyro-hyoid  cyst  of,  II.  168 
thyroid  cysts  of,  II.  170 

fistula  of,  II.  167 
tics  of,  II.  1052  ' 
varix  of,  I.  1321 

Necrosis  in  acute  abscess,  I.  167,  171 
in   syphilis     of    ribs  and  sternum,   I. 

1032 

of  the  jaw,  II.  108 
of  the  labyrinth,  III.  965-966 
Needle      carrier     for     Gigli's     saw     in 

pubiotomy,  IV.  448,  449 
Nenndorff  spa,  IIT.  153 
Nepenthe  for  relief  of  pain,  I.  134 
Nephrectomy,     dangers     of,     in     renal 

growths,  II.  833 
for  primary  tuberculosis  of  the  kidney, 

immediate  mortality  in,  II.  827 
for  renal  calculus,  II.  765,  779 
for  tuberculous  disease  of  the  kidney, 

II.  825 

in  pyonephrosis,  II.  817 
partial,  in  tuberculosis  of  the  kidney, 

II.  822 
results  of,  for  primary  tuberculosis  of 

the  kidney,  II.  827 
Nephritis,  acute,  II.  796-797,  798 
chronic    diffuse    parenchymatous,    II. 

794-795 
interstitial,  II.  792-793 

with  haematuria,  II.  799 
results    of  operative   treatment,   II. 

890 

with  pain,  II.  799 

complicating  diabetes  mellitus,  I.  426 
diphtheria,  I.  202 
influenza,  I.  241 
scarlet  fever,  I.  292 
diet  in,  II.  204 
non-suppurative,  surgical  treatment  of, 

II.  798-800 

Nephro-cysto  anastomosis,  II.  777 
Nephrolithotomy,  dangers  of,  II.  761 

for  renal  calculus,  II.  759,  764 
Nephropexy    in    intermittent    hydrone- 

phrosis,  II.  774 
Nephrostomy    for     hydronephrosis,     II. 

779 

in  pyonephrosis,  II.  815 
Nephrotomy  for  tuberculosis  of  the  kidney, 

II.  828 
in  urinary  obstruction  due  to  cancer,  I. 

143 

Neris  spa,  III.  153 
Nerve  anastomosis  in  infantile  paralysis, 

II.  1059-1060 
in  nerve  injuries,  II.  1104 
auditory,  polyneuritis  of,  III.  977 


Nerve  (contd.~) 

bridging  in  injuries  of  nerves,  II.  1103 
circumflex,  injuries  of,  II.  1111 
deafness  due  to  disturbance  of  cochlea 
division  of    the    eighth   nerve,   III. 
977 

facial,  injuries  of,  II.  1108 
musculo-spiral,  injuries  of,  II.  1112 
ocular,  primary  degeneration   of,  III. 

649 

of  Bell,  injuries  of,  II.  1112 
optic,  diseases  of,  III.  645 
posterior  thoracic,  injuries  of,  II.  1112 
ulnar,  injuries  of,  II.  1112 
Nerves,  concussion  of,  I.  560 
derangement     of,     massage     in,     III. 

210 

diffuse  neuroma  of,  II.  1142 
diseases  of,  II.  1093 

division  of,  for  relief  of  pain,  in  inoper- 
able cancer,  I.  135 
in  amputations,  I.  802 
in  Berger's  operation,  I.  831 
posterior  roots    of,   in    neuritis,   II. 

1035 

effect  of  massage  on,  III.  205 
general  considerations  regarding  opera- 
tions upon,  II.  1001 
injection  of  alcohol  into,  I.  135 
injuries  of,  II.  1098-1105 
anastomosis  in,  II.  1006 
complicating  dislocations,  II.  1102 
general    lines  of    treatment  in,    II. 

1098 

in  fractures,  II.  1101 
in  gunshot  wounds,  I.  560 
in  wounds,  II.  1099 
nerve  anastomosis,  II.  1104 
nerve-bridging  in,  II.  1103 
secondary  suture  in,  II.  1102 
subcutaneous,  II.  1100 
malignant  tumours  of,  II.  1142 
musculo-spiral  injury  to,  in  fractures, 

1.592 

neuro-fibromatosis  of,  II.  1142 
neuromata      of,      circumscribed,      II. 

1142 

operations  on,  II.  1099 
paralysis  of,  deformities  due  to,  I.  988- 

990 
posterior    roots    of,    division    of,    in 

neuritis,  II.  1133 
rest  to  affected  portion  of,  in  neuritis, 

II.  1033 

secondary  suture  of,  II.  1102 
special,  injuries  of,  II.  1108-1113 
subcutaneous  injuries  to,  II.  1100 
suture  of,  secondary,  II.  1102 
tumours  of,  II.  1142 
circumscribed  neuromata,  II.  1142 
malignant,  II.  1142 
Nervous   depression  in    the    menopause, 

IV.  502 

diseases,  climate  for,  III.  99 
complicating  pregnancy,  IV.  50 


80 


A    SYSTEM   OF  TREATMENT. 


Nervous 

symptoms      complicating      pernicious 

anaemia,  II.  10 

system,     affections    of,     electro-thera- 
peutics in,  III.  108 
central,  diseases  of,  nystagmus  in,  II. 

1140 

nystagmus  in  disease  of,  II.  1042 
derangement  of,   massage  and,  III. 

210 

diseases  of,  II.  1014 
general,  II.  1054 
physical  exercises  in,  III.  2."ii; 
disorders  of,  mineral  waters  and  baths 

in,  III.  146 
effect  of  alcoholism  upon,  I.  496 

electric  shock  on,  I.  548 
in  typhoid  fever,  I.  362 
influence  of  on  process  of  repair,  I. 

12 
progressive  chronic,  physical  exercises 

in,  III.  256 

strain  of,  causes  of,  I.  8 
Neuenahr  spa,  III.  153 
Neumann  syringe,  III.  913 
Neuralgia,  II.  1114-1126 
brachial,  II.  1121 

complicating  diabetes  rnellitus,  I.  426 
dental,  II.  1114 
diathetic,  affecting  head,  II.  1122 

limbs,  II.  1122 
facial,  hypnotism  in  case  of,  III.  170 

surgical  treatment  of,  II.  1127 
following  influenza,  I.  '2  IL> 
headache  accompanied  by  soreness  of 

scalp  in,  II.  1117 
in  foramen  ovale,  II.  1119 
in  foramen  rotundum,  II.  1118 
in  infra-orbital  foramen,  II.  1118 
laryngeal,  III.  845 

maintenance  of  trophic  condition  of 
parts  supplied  by  affected  nerve  in, 
II.  1132 

mammary,  II.  976 
occipital,  II.  1120 
of  the  pharynx,  III.  782 
of  supra-orbital  notch,  II.  1117 
of  the  third  division,  II.  1119 
painful  heel  in,  II.  1123 
post-herpetic,  II.  11^-' 
scapular,  II.  1121 
supra-orbital,  II.  1115 

periodic,  II.  1115 
surgical   treatment  of,  II.  1117,  1127- 

1129 

torticollis  in,  II.  1050 
toxic,  affecting  head,  II.  1122 

affecting  limbs,  II.  1122 
trigeminal,  II.  1116 
alcohol  injection  in,  II.  1117 
drugs  in, II.  1116 
excision   of    gasserian   ganglion   for, 

II.  1128 

hot-air  douche  for,  III.  66 
ionic  medication  of,  III.  184 


81 


Neuralgia,  trigeminal  (contd.) — 

visceral,  II.  1122 
Neurasthenia,  II.  1038-1043 
•anorexia  nervosa,  II.  1042 
gastric,  II.  354 
diet  in,  II.  355 
electricity  in,  II.  354 
medicinal  treatment  of,  II.  356 
in  the  menopause,  IV.  503 
phosphaturia  and,  II.  748 
traumatic,  II.  1042 
Weir  Mitchell  method  in,  II.  1040 
Neuritis,  II.  1130-1132 
alcoholic,  II.  1134 

contractures  in,  II.  1135 
deformity  in,  II.  1 135 
drugs  in,  II.  1135 

application  of  vibration  in,  III.  221 
arsenical,  II.  1138 
beri-beri  and,  II.  1139 
chronic,  of  ulnar  nerve  at  the  elbow,  II. 

1112 

complicating  influenza,  I.  241 
compression,  II.  1131 
diabetic,  II.  1131 
division     of    posterior    roots    in,     II. 

1033 

gouty,  I.  444;  II.  1130 
lead,' II.  1137 
local,  II.  1130 

removal  of  cause  in,  II.  1130 
malarial,  II.  1131 
multiple,  II.  1134-1139 
arising    from    unknown    cause,    II. 

1139 

optic,  III.  645 

complicating  typhoid  fever,  I.  363 
in  tumours  of  brain,  II.  1201 
post-diphtheritic,  II.  1138 
prevention  of  deformity  in  the  paralysis 

of,  II.  1132 
puerperal,  II.  1139 
rest  to  affected  portion  of  nerve  in,  II. 

1131 

retro-bulbar,  III.  645 
rheumatic,  II.  1130 
sciatic,  old -standing  chronic,  II.  1125 
senile,  II.  1139 
syphilitic,  II.  1130 
traumatic,  II.  1106-1107 
Neuro-fibroma,  plexiform,  I.  112 

varieties  of,  I.  112 

Neuro-fibromatosis  of  nerves,  II.  1142 
Neuro-fibromatous  tumours  of  the  scalp 

1.893 

Neuroma,  diffuse,  of  nerves,  II.  1142 
Neuromata,  amputation,  I.  112 

circumscribed,  of  nerves,  II.  1142 
Neuropathic  arthritis,  I.  785 
Neuroses  following  spinal  injury,  I.  899 
motor,  of  the  larynx,  III.  840 
nasal,  III.  689 
of  occupation,  II.  1264 
of  the  heart,  I.  1252 
of  the  larynx,  III.  840-845 

6 


A    SYSTEM  OF   TREATMENT. 


Neuroses  (contd.~) — 

of  the  meatus,  III.  884 

of  the  pharynx,  III.  782-783 

of  the  skin,  III.  998 

rectal,  II.  614 

sensory,  of  the  larynx,  III.  844 

vasomotor,  II.  1242-1243 
Nicoll's  operation  for  inguinal  hernia  II. 

511 

Nicotine,  poisoning  by,  I.  533 
Night  terrors,  II.  1036-1037 

in  the  young,  prevention  of,  I.  55 
Nipples,  affections  of,  II.  977-978 

areola  abscess  of,  II.  977 

care  of,  in  pregnancy,  IV.  8 

cracks  of,  prevention  of,  II.  977 

depressed,    in     the    puerperium,     IV. 
332 

fissures  of.  II.  977 

management    of,    in    pregnancy,    IV. 
330 

Paget's  disease  of,  II.  978 

sore,  in  the  puerperium,  IV.  333 
Nitrate,  see  Silver,  nitrate  of 
Nitre,  sweet  spirits  of,  in  diseases  of  the 

heart,  I,  1224 
Nitrites  in  arterio-sclerosis,  I.  1293 

in  chronic  polycythemia,  II.  85 

in  diseases  of  the  heart,  1. 1223 
Nitrobenzene,  poisoning  by,  I.  533 
Nitrogen  apparatus  in  artificial  pneumo- 

thorax,  I.  1166 

Nitrogenons  food,  value  of,  I.  451 
Nitro-glycerine  in  eclampsia,  IV.  37 

in  gouty  angina  pectoris,  I.  443 
Nitrous  oxide  as  anaesthetic,  III.  2 

preceded  by  ether  as  anaesthetic,  III. 

11 
gas,  apparatus   for  administration 

of,  III.  3 
steps  of   the  administration  of, 

III.  3 
Nodal  fever,  I.  212-213 

rhythm    in  diseases  of    the   heart,   I. 

1231 

Noise  in  sick  room,  avoidance  of,  I.  26 
Noma,  II.  124-125 

and  cancrum  oris.  gangrenous,  I.  219 

of  the  auricle,  III.  882 

of  the  vulva,  IV.  508 
Noorden's  (Von)  treatment  of  oedema,  I. 

422 

Norwood  treatment  of  alcoholism,  I.  501 
Nose,  accessory  sinuses  of,  diseases  of,  III. 
716-731 

benign  growths  of,  III.  692 

bridge  of,  depression,  III.  673 

care  of,  in  children,  I.  49 

cough    in   pulmonary  tuberculosis,    I. 
1145 

deformity  of,  injection  of  paraffin  wax 
in,  III.  674 

destruction  of  parts  of,  III.  675 

diseases  of,  III.  664-666 

epistaxis  from,  III.  664-666 


Nose  (contd.) — 

examination  of,  in  epilepsy,  II.  991 

external  malformation  of,  III.  673 

foreign  bodies  in,  III.  667 

hygiene  of  in  typhoid  fever,  I.  356 

immediate  arrest  of  bleeding  from,  in 
epistaxis,  III.  666 

injection  of  paraffin  wax  in,  III.  674 

intranasal  malformation  of,  III.  672 

irritation  of,  III.  691 

lateral  deflection  of,  III.  673 

leprosy  of,  III.  780 

maggots  in,  III.  669 

malformations  of.  III.  671-677 

malignant  growths  of,  III.  694 
curative  treatment,  III.  695 
located  anteriorly  in,  III.  695 
small  size,  III.  695 

neurosis  of,  III.  689 

intranasal  treatment,  III.  691 

new  growths  of,  III.  692-698 

obstruction  of,  III.  691 

occlusion  of  the  choana  of,  III.  672 

operations    on,    and    ansesthetics,   III. 
26 

packing  of,  in  chronic  rhinitis,  III.  708 

permanent  arrest  of  bleeding  from,  III. 
666 

polypi  of,  III.  691 

powdered  pollantin  serum  for,  III.  287 

rhinitis  anterior  sicca  of,  III.  665 

rhinoleths  of,  III.  669 

stenosis  of  the  anterior  nares  of,  III. 
672 

synechiae  of,  III.  672 

syphilis  of,  III.  714-715 

general  treatment  of,  III.  714 
local  treatment  of,  III.  714 

wounds  of,  III.  671-677 
Nostril  in  harelip,  II.  90 
Novocaine,  injection  of,  for  spinal  anal- 
gesia, III.  37 
Nuchal   position   of  the  arm,   in  breech 

presentation  of  labour,  IV.  132 
Nuck,  canal  of,  hydrocele  of,  IV.  512 
Nuclein  in  boils,  III.  1008 
Nulliparse.  chronic  endo-cervical  catarrh 

in,  IV.  566 
Nursery,  fittings  and  furniture  for,  I.  45 

hygiene  of  the,  I.  44 

sanitary  arrangements  for,  I.  45 
Nurses,  cookery  to  be  undertaken  by,  I. 
42 

directions  to,  in  gynaecological  opera- 
tions, IV.  485 

duties  of,  rules  for,  I.  26 
Nursing  in  acute  disease,  I.  19 

in  chorea,  II.  1262 

in  plague,  III.  403 

in  puerperal  sepsis,  IV.  313 

of  enteric  fever,  I.  40 

of  infectious  cases.  I.  41 
Nussbaum's  bracelet  on  writer's  cramp,  II, 

1265 
Nutrient  enemata,  I.  32 


82 


A    SYSTEM   OF   TREATMENT. 


Nutrition,  disorders  of,  in  children,  causes 
of,  I.  63 

food  values  and,  I.  450 

of  infants  and  children,  I.  46 
Nuts,  chemical  composition  of,  II.  197 
Nux  vomica  in  constipation  in  adults,  II. 

446 
Nystagmus,  II,  1140-1141 

and  ocular  muscles,  III.  648 

head-nodding  ia,  II.  1141 

horizontal,  II.  1140 

in  disease  of  central  nervous  system,  II. 
1140 

in  miners,  II.  1140 


Oak  Orchard  Springs,  acid  baths  of,  III.  137 
Oatmeal  cure  of  diabetes,  I.  422 

treatment  of  diabetes,  I.  421 
Oberst's  solution  for  local  analgesia,  III. 

39 
Obesity,  anasmic,  I.  468,  472 

climate  for,  III.  92 

diet  in,  II.  212 

diabetic  treatment  of,  I.  470 

drugs  in,  I.  470 

exercises  in,  I.  469 

glandular  relations  of,  I.  473 

mineral  waters  and  baths  in,  III.  140 

ordinary,  I.  468 

salt  contra-indicated  in,  I.  470 

secretory,  I.  468,  472 

toxic,  I.  468,  472 

vegetables,  suitable  in,  I.  472 

vegetarian,  system  in,  I.  471 

Wertheim's  operation  in,  IV.  605 
Obsessive  ideas,  II.  1313-1314 
Obstetric  operations,  IV.  373-374 

general  considerations  in,  IV.  373 

preparation  of  instruments  in,  IV.  374 
of  operator  in,  IV.  373 
of  patient  in,  IV.  373 
Obstetrical  bag  in  management  of  normal 

labour,  IV.  93 
Obturators,  treatment  of  cleft  palate  by, 

II.  152 

Occipital  neuralgia,  II.  1120 
Occipito-posterior  presentation  in  labour, 

IV.  144-146 

Occupation  dermatitis,  III.  1029 
Occupations,  diseases  resulting  from,  I,  5 

incidence  of  cancer  and,  I.  117 

lead  poisoning,  I.  514 

neuroses  of,  II.  1264 

hammerman's  cramp  in,  II.  1267 
telegraphist's  cramp  in,  II.  1266 
writer's  cramp  in,  II.  1264 
Odontoma,  III.  1194 
Odontomes,  epithelial,  of  the  jaws,  II.  112 

radicular,  II.  110 

O'Dwyer's  bronchial  instrument,  III.  804 
Ody's  truss  for  inguinal  hernia,  II.  527 
OZdema,    angioneurotic,     II.     1228-1229 ; 
III.  1154-1156 

arterio-sclerosis,  I.  1294 


OZdema  (contd.~) — 

cerebral,  in  injuries  of  the  head,  I.  884 

in  fractures,  I.  578 

of  the  larynx,  III.  858-860 

of  legs  in  chlorosis,  II.  31 

of  lungs,  I.  1080 

of  prepuce  complicating  gonorrhoea,  I. 
225 

of  uvula,  III.  745 

theophyllin  in,  I.  422 
(Esophageal  bougie,  black  elastic,  II.  172 
conical-ended  black.  II.  172 
silk  web,  II.  172,  173 

feeding,  method  of,  I.  33 
(Esophagoscope,    Bruning's,    for    foreign 

bodies  in  the  oesophagus,  II.  187 
CEsophagotomy,     cervical,     for    foreign 

bodies  in  the  oesophagus,  II.  186 
Oesophagus,  burns  of,  II.  188 

cancer  of,  regurgitation,  I.  138 
relief  of  obstruction  in,  I.  139,  140 

diseases  of,  II.  171-189 

diverticular  of,  II.  189 

forceps  for  removal  of  foreign  bodies  in, 
II.  184-185 

foreign  bodies  in,  II.  184-189 

Bruning's  oesophagoscope  for,  II.  187 
gastrotomy  for,  II.  186 

injuries  of,  II.  171-189 

malformations  of,  189 

malignant  stricture  of,  II.  175 
after  treatment  in,  II.  183 
Frank's  operation  for,  II.  177 
gastrostomy  for,  II.  176 
methods  in,  II.  183 
Senn's  method  for,  II.  180 
Witzel's  method  for,  II.  182 

simple  stricture  of,  II.  171-183 

stricture  of,  continuous  dilatation   in, 

II.  174 

dilatation  of,  II.  171 
intermittent  dilatation  of,  II.  171 
medicinal  treatment  of,  II.  171 
operative  treatment  in,  II.  174 
spasmodic,  II.  175 
surgical  treatment  of,  II.  171 
treatment  by  tubes,  II.  175 

ulcers  of  complicating  typhoid  fever,  I. 
357 

wounds  of,  II.  188 

in  cut  throat,  II.  165 
Oeynhausen  spa.  III.  154 
Ogle  (Cyril),  diseases  of  the  pericardium, 
I.  1179-1187 

inflammatory    conditions    of    medias- 
tinum, I.  1176 

new  growth  in  the  mediastinum,  1. 1178 
Oil  diet  in  duodenal  ulcer,  II.  211 

dressings  in  burns  and  scalds,  I.  541-548 

inunction  of,  I.  70 

See  also  Castor  oil,  Olive  oil. 
Ointments  for  acne  vulgaris,  III.  986 

for  eczema  vulva?,  IV.  530 

in  herpes  zoster,  II.  1096 

inunction  of,  I.  70 

83  6—2 


A    SYSTEM  OF   TREATMENT. 


Olecranon,  fracture  of,  I.  596-686 
Oligo-hydramnios  complicating  pregnancy. 

IV.  44 

Olive  oil  enema,  I.  32 
injections  of,  in  constipation  in  adults. 

II.  456 

Oliver   (Thomas),   arsenical  poisoning,  I. 
503-504 

auto-intoxication,  I.  386-390 

electrical  injuries  and  burns,  I.  547-549 

lead  poisoning,  I.  512-515 

phosphorus  poisoning,  I.  525 
Oliver  on  arterio-sclerosis,  I.  1294 
Oliver's  alcoholic  instrument  for  test  of 

blood  pressure,  I.  1281 
Omentum,  wounds  of,  II.  253 
Onanitic  prostatitis,  II.  927 
Onions  in  dietary  of  children,  I.  59 
Onyalai,  III.  469 
Onychia.  III.  1082 
Onychitis,  syphilitic,  III.  1082 

tuberculous,  III.  1082 
Oophorectomy  in  dysmenorrhoea,  IV.  749 

in  mammary  cancer,  I.  150 

in  menorrhagia,  IV.  763 

in  metrorrhagia,  IV.  763 
Open-air,  exercise  in,  for  children,  I.  52 

methods  in  inoperable  cancer,  I.  133 

treatment  in  medical  climatology,  III.. 

76 
Operating  table,  description  of,  I.  28 

fittings  and  preparation  of.  I.  71 
Operation,  available,  for  varicocele,  1. 1325 

outfit  for,  I.  28 

preparation  of  patient  for,  I.  27 

room,  preparation  of,  I.  71 
Operations,  Ball's  (Sir  Charles),  for  pru- 
ritus ani,  II.  597 

Beyea's,  for  gastroptosis,  II.  324 

Garden's,  I.  862 

Cheyne's,  for  malformation  of  the  nose, 

III.  674 
Estlander's,  I.  1107 

Eve's,  for  gastroptosis,  II.  323 
Frank's,  for  malignant  stricture  of  the 

oesophagus,  II.  177 
Gaillard  Thomas's,  for  fibro-adenomata 

of  the  breast,  II.  956 
Gleason's,  on  the  nasal  septum,  III.  681 
Gritti's,  I.  862 
gynaecological,  IV.  474-486 
'  after-treatment  in,  IV.  487-497 

post  operative  complications,  IV.  487- 

497 

Halsted's  for  inguinal  hernia,  II.  507 
in  pregnancy,  IV.  58 
in  varicocele,  I.  1324 
Jordan's,  I.  868 

Krause's,  for  pruritus  ani,  II.  597 
Loreta's,  for  hypertrophic  stenosis  of 

the  pylorus,  II.  339,  342 
Lotheissen's,  for  femoral  hernia,  II.  511 
McEwen's,  for  inguinal  hernia,  II.  507 
Mayo's,  for  umbilical  hernia,  II.  513 
Miller's,  I.  861 


Operations  (c»nfd.') — 

Moure's,    on    the    nasal    septum,    III. 
681 

Mules',  for  enucleation  of  the  eyeball, 
III.  660 

Nicoll's,  for  inguinal  hernia,  II.  511 

obstetric,  IV.  373-374 

Paul's,  for  cancer  of  the  colon,  II.  580 

Schwartze's,     for     opening      mastoid 
antrum,  III.  898 

Smith's,  for  immature  cataract.  111.  (i21 

Stephen  Smith's,  I.  859-861 

surgical,  antiseptic  precautions  during, 

1.81 
Operator,    preparation    of,    in    obstetric 

operations,  IV.  373 
Ophthalmia,  gonorrhoeal,  I.  228 

in  the  adult,  III.  555 

neonatorum,  III.  553 

in  newborn  child,  IV.  366 
Ophthalmitis,  sympathetic,  III.  598 

curative  treatment,  III.  600 

prophylaxis  of,  III.  598 
Ophthalmoplegia  and  migraine,  II.  1033 

of  ocular  muscles,  III.  648 
Opium  habit,  combretum  sundiacum   in, 
1.518 

in  constipation  in  adults,  II.  446 

in  diabetes  mellitus,  I.  424 

in  diseases  of  the  heart,  I.  1 225 

in  epilepsy,  II.  998 

in  epithelioma  of  the  tongue,  II.  144 

in  melancholia,  II.  1297 

in  pericarditis,  I.  1180 

in  peritonitis,  II.  638 

in  pruritus,  III.  1099 

in  smallpox,  I.  308 

poisoning  by,  I.  531 

relief  of  pain  by,  I.  134 

use  of,  in  diseases  of  children,  I.  66 
Opsonic  index,  high,  vaccine  therapv  and, 

1.208 

in  acute  tuberculosis,  I.  334 
Opsonins  in  serum  therapy,  III.  259 
Optic  atrophy,  III.  645 

nerve,  diseases  of,  III.  645 

neuritis,  III.  645 

Oral  administration  in  vaccine  therapy, 
III.  265 

antiseptics  in  pernicious  anaemia,  II.  6 

sepsis,  II.  127-129 

prophylaxis  of,  II.  127 
Orbit,  arterio  venous  aneurysms  of,  III. 
662 

cellulitis  of,  III.  661 

diseases  of.  III.  661-663 

tenonitis  of,  III.  662 

thrombosis  of,  III.  662 

tumours  of,  III.  662 

wounds  of,  III.  661 

Orbital  foramen,   infra-neuralgia  in,    II. 
1118 

neuralgia,  periodic  supra,  II.  1115 
supra,  II.  1115 

notch,  supra-neuralgia  of,  II.  1117 


A    SYSTEM  OF   TREATMENT. 


Orchitis,  acute,  II.  906 

complicating  mumps,  I.  257 

filarial,  III.  503 

vaccine  therapy  of,  III.  281 
Organotherapy  in  cancer,  I.  149 

in  epilepsy,  II.  999 

in  sterility,  IV.  854 

of  plague,  III.  409 
Oriental  sore,  III.  454-456 

general  treatment  of,  III.  454 
Oro-pharynx,  benign  growths  of,  III.  784 

malignant  growths  of,  III.  785 

new  growths  of,  III.  784-785 
Orsudan  in  syphilis,  I.  321 
Orthopaedic  measures  in  arthritis  defor- 
mans,  I.  397 

in  osteo-arthritis,  I.  403 
Orthopaedics,  physical  exercises  in,  III.  233 
0»  calcis,  fracture  of,  I.  632 

hypertrophy  of,  III.  405 

tuberculosis  of.  I.  773 
Os  uteri,  dilatation  of,  in  normal  labour, 

IV.  103 

Osier  (Sir  W.)  on  Banti's  disease,  II.  82 
Ossiculectomy  in  chronic  inflammation  of 

the  middle  ear,  III.  913 
Osteitis  after  amputations,  I.  804 

deformans,  II.  1237 

tuberculous,  of  the  skull,  I.  889 
Osteo-arthritis,  chronic  rheumatism  and, 
1.483 

complicating  pregnancy,  IV.  57 

diet  in,  I.  400 

local  treatment  of,  I.  402 

massage  in,  I.  402 

medicinal  treatment  of,  I.  401 

of  temporo-maxillary  joint,  II.  105 

orthopaedic  measures  in,  I.  403 
Osteoarthropathy,      pulmonary,      hyper- 
trophic,  II.  1233 

Osteogenesis  imperfecta,  II.  1237 
Osteoma  of  the  jaw,  II.  109 

of  the  scalp,  I.  893 
Osteomalacia     complicating     pregnancy, 

I.  712  ;  IV.  58 
Osteomalacic  pelvis  complicating  labour, 

IV.  172 
Osteomyelitis,  acute,  in  infective  lesions 

of  the  skull,  I.  889 
of  the  spine,  I.  916-917 

after  amputations,  I.  804 

of  the  thoracic  wall,  I.  1032 

suppurative,  I.  696,  698 

traumatic   in   injected   lesions  of    the 

skull,  I.  889 
Osteo-periosteal   method  of  amputation, 

I.  801 
Osteotomy  in  ankylosis,  I.  764 

in  rachitic  deformities,  I.  972 
Otalgia  of  the  meatus,  III.  884 
Otitis     externa     circumscripta    of     the 
meatus,  III.  885 

croupous,  of  the  meatus,  III.  884 

diffusa  of  the  meatus,  III.  886 

media,  III.  894-903 


Otitis  (contd.)— 

catarrhal,    chronic,    and      Eustachian 

obstruction,  III.  944 
•  chronic,  III.  904 
complicating  diphtheria,  I.  202 
meningitis,  I.  252 
scarlet  fever,  I.  289 
purulent,  III.  904 
pyogenic,  III.  904 
Oto-fibrosis   and  Eustachian  obstruction, 

III.  944 

Otomasseur,  Delstanche's,  III.  952 
Otomycosis  of  the  meatus,  III.  886 
Otorrhcea  in  measles,  I.  246 

in  scarlet  fever,  I.  282,  289 
Otosclerosis,  III.  954-957 
deafness  in,  III.  956 
general  treatment  of,  III.  954 
local  treatment  of,  III.  955 
symptomatic  treatment  of,  III.  995 
Ovarian  dermoids,  I.  110. 
Ovaries,  abscess  of,  IV.  765 
care  of,  in  ovariotomy,  IV.  779 
cysts  of,  suppurating,  IV.  797-798 

tapping  of,  in  ovariotomy,  IV.  782 
diseases  of,  IV.  765-798 
mineral  waters  and  baths  in,  III.  145 
sterility  in,  IV.  846 
hernia  of,  IV.  767 
metabolic  disorder  and,  I.  389 
pain  in,  chronic,  IV.  766 
prolapse  of,  IV.  796 
removal  of,  in  dysmenorrhoea,  IV.  746 

in  uterine  fibroids,  IV.  639 
tumours  of,  Cassarean   section  in,  IV. 

384 

during  labour,  IV.  773-774 
during  pregnancy,  IV.  Ill-Ill 
during  puerperium,  IV.  774 
malignant,  IV.  770 
Ovariotomy,  IV.  775-795 
adhesions  in,  IV.  780 
after-treatment  of,  IV.  789 
care  of  other  ovary  in,  IV.  779 
drainage  in,  IV.  785 
dressing  in,  IV.  788 
haemorrhage  after,  IV.  793 
hiccough  after,  IV.  792 
in  pregnancy,  IV.  771 
injury  to  intestine  in,  IV.  78.". 
instruments  for,  IV.  776 
ligatures  in,  IV.  776 

of  pedicle  in,  IV.  783 
operation  of,  IV.  777 
peritonitis  after,  1  V.  7'.M 
preparation  of  patient,  IV.  775 
shock  after,  IV.  793 
sutures  in,  IV.  776 

of  abdominal  wall  in,  IV.  787 
tapping  the  cyst  in,  IV.  782 
thrombosis  after,  IV.  794 
vaginal,  IV.  795 
vomiting  after,  IV.  791 
Overstrain  in  the  menopause,  IV.  503 
mineral  waters  and  baths  in,  III.  146 


85 


SYSTEM  OF  TREATMENT. 


Ovum  forceps  for  retained  placenta,  IV.  226 
Oxalic  acid  in  foodstuffs,  II.  744 

poisoning  by,  treatment  of,  I.  528 
Oxaluria,  II.  742 

Oxybutyne  (B.),  acid  in  the  urine,  I.  417 
Oxygen  in  acute  bronchitis,  I.  1051 

in  asthma,  I.  1040 

in  diseases  of  the  heart,  I.  1225 

in  eclampsia,  IV.  37 

in  haemorrhage,  I.  1267 

in  poisoning,  I.  528,  531,  533,  535 

inhalations  in  pernicious  anaemia,  II.  9 

in  pneumonia,  I.  245,  2,61 
Oxymel  of  squill  in  laryngitis,  I.  245 
Oxyuriasis,  III.  495 

prophylaxis  of,  III.  493 


Pachydermia  laryngis,  III.  850 
Pachy meningitis,  I.  905 
Packs,  use  of,  I.  37, 38 
Paget's  disease,  II.  1237 

of  the  nipples,  II.  978 
recurrent  fibroid,  I.  114 
Pain,   abdominal,  complicating    typhoid 

fever,  I.  359 
relief  of,  I.  513 

after  abdominal  operations,  II.  263 
after  cataract  extraction,  III.  632 
as  symptom  of  cancer  of  cervix,  IV.  585 
complicating    gynaecological     surgery, 

IV.  490 

tuberculous  peritonitis,  II.  646 
ulcer  of  the  stomach,  II.  380 
.  in  aortic  aneurysm,  I.  1299 
in  ascites,  II.  627 
in  cancer,  relief  of,  I.  133,  134 
of  cervix,  IV.  617 
of  the  stomach,  II.  299 
in  chronic  nephritis,  II.  799 
in  disordered  digestion  in  the  stomach, 

II.  373 

in  gunshot  wounds,  I.  558 
in  haemorrhoids,  II.  617 
in  hemiplegia,  II.  1188 
in  herpes  zoster,  III.  1043 
in  labour,  IV.  103 
in  lead  poisoning,  I.  512 
in  myelitis,  II.  1215 
in  non-operative  appendicitis,  II.  423 
in  normal  puerperium,  IV.  264 
in  secretory  disorders  of  the  stomach, 

II.  363 

in  uterine  fibroids,  IV.  638 
in  varicose  veins,  IV.  89 
opium  in,  I.  67 
ovarium,  chronic,  IV.  766 
pre-cordial,  complicating  acute    endo- 
carditis, I.  1193 
rectal,  II.  614 
relief  of,  by  injection  of  alcohol  into 

nerve  trunks,  I.  135 
in  pleurisy,  I.  1094 

severe,    in    chronic    dilatation  of    the 
stomach,  II.  314 


Paints  for  herpes  zoster,  II.  1096 
Palate,  cleft,  II.  147-156 

after-treatment  in,  operations  for,  II. 

151 
anaesthetic  in  operation  for,  II.  149, 

III.  28 

Brophy's  operation  in,  II.  149 
gag  in  operation  for,  II.  150 
haemorrhage  in  operation  for,  II.  150 
in  newborn  child,  IV.  357] 
operation  for,  II.  149 
operative  treatment  of,  II.  147 
treatment  of  by  obturators,  II.  152 
spasmodic  affections  of,  and  neuroses  of 

pharynx,  III.  783 
Palatine    arteries,   haemorrhage  from,   I. 

1275 
Palliative  treatment,  I.  18 

of  inoperable  cancer,  I.  131 
Palmar  arteries,  wounds  of,  I.  1276 
Palpation  in  normal  labour,  IV.  97,  98 
Palpitation  in  angina  pectoris,  I.  1252 
Palsy,  atrophic   flaccid,   in   myelitis,   II. 

1217 

brachial,  in  newborn  child,  IV.  365 
bulbar,  II.  1061 
cerebral,  of  infants,  II.  1153-1156 

surgical  treatment  of,  II.  1157-1164 
craft,  II.  1267 
facial,  in  newborn  child,  IV.  365 

See  also  Paralysis. 
Pancreas,  abscess  of,  II.  720 
calculi  of,  II.  724-725 

pancreo-lithotomy  in.  II.  724 
cancer  of,  II.  729 
cysts  of,  II.  726-728 
statistics,  II.  727 
diseases  of,  II.  716-729 
enlargement  of   and  cholelithiasis,  II. 

694 

inflammation  of,  II.  717 
parenchymatous      inflammations      of, 

acute.  717 

wounds  of,  II.  716-729 
Pancreatitis,  acute,  II.  718-719 
chronic,  II.  723 
subacute,  II.  720-722 
Pancreo-lithotomy  in  pancreatic  calculi, 

II.  724 

Panhysterectomy  of  the  uterus,  IV.  401 
Pause's  flap  in  operation  for  diseases  of 

mastoid  process,  III.  924,  925 
Pansini  on  influence  of  red  and  blue  light, 

III.  194 
Fanticosa  spa,  III.  154 

Papilloma,  duct,  of  the  breast,  II.  954 
of  Fallopian  tube,  IV.  816 
single,  of  the  bladder,  II.  870 

Papillomata  of  lingual  tonsil,  III.  762 
of  the  meatus,  III.  883 
of  the  penis,  II.  878 
multiple  of  bladder,  II.  871 

of  the  larynx  in  children,  III.  851 

Paracentesis  of  anterior  chamber  of  ciliary- 
body,  III.  593 


86 


A    SYSTEM  OF  TREATMENT. 


Paracentesis  (contd.~) — 
in  ascites,  II.  628 
in  inflammations  of  middle  ear,  III.  895, 

904,  905 

in  pericarditis,  I.  1182 
method  of,  in  hydrothorax,  I.  1091 
pericardii,  I.  1188 
technique  of,  in  acute  inflammation  of 

the  middle  ear,  III.  895 
Paracretinoid  lipomatosis,  I.  108 
Parsesthesia  of  the  pharynx,  III.  782 
Paraffin  eczema,  I.  117 
in  skin  eruptions,  I.  446 
injections  in  chronic  rhinitis,  III.  709 
liquid,  in  constipation  in  adults,  II.  4~>1 
wax,  injection  of,  in  nose,  III.  674 
Paraldehyde  in  insomnia,  II.  1023 
Paralysis,  acute  nuclear,  of  ocular  muscles, 

III.  649 

associated  with  labour,  IV.  280 
with  the  puerperium,  IV.  281 
brachial  birth,  II.  1012,  1110 
complete  recurrent,  of  vocal  cords,  III. 

844 

complicating  pregnancy,  IV.  60 
diphtheritic,  forms  of,  I.  200 
diplopic,  of  ocular  muscles,  III.  649 
divers,  1. 1306 
due  to  spinal  injury,  I.  899 
facial,  II.  1093-1095 
electricity  in,  II.  1094 
massage  in,  II.  1094 
nerve  anastomosis  in,  II.  1109 
nerve  crossing  in,  II.  1 1 09 
family  periodic.  II.  1247 
flaccid,  in  paraplegia,  II.  1197 
following  anaesthesia,  III.  35 
functional,  hypnotism  in  case  of,  III. 

171 
general,  of  the  insane,  II,  1077 

anti-syphilitic  treatment  in,  II.  1078 
congestive  attacks,  II.  1079 
constipation  in,  II.  1079 
excitement  in,  II.  1079 
irritability  in,  II.  1079 
late  stages  of,  II.  1086 
refusal  of  food  in,  II.  1079 
serum  therapy  of,  II.  1079 
surgery  of,  II.  1079 
symptomatic  treatment,  II.  1079 
hasmorrhagic,   of  ocular  muscles,   III. 

648 

in  hemiplegia,  II.  1184 
in  lead  poisoning,  I.  513 
in  neuritis,    prevention    of    deformity 

from,  II.  1034 
in  spina  bifida,  I.  916 
infantile,  nerve  anastomosis  in,  II.  1059- 

1060 

Laudry's,  II.  1080 
Little's,  in  infants,  I.  886 
migrainous  recurrent,  of  ocular  muscles, 

III.  649 

of  muscles  of  the  larynx,  III.  842 
of  inter-arytenoideus  muscle,  III.  *  1 1 


Paralysis  (contd.) — 
of  pharynx,  III.  782 
of  thyro-arytenoidei  interni  tensors  of 
.    the  vocal  cords,  III.  843 
of  ulnar  nerve,  II.  1267 
post-diphtheritic,  of  ocular  muscles,  III. 

649 
prevention  of  bedsores  in,  I.  31 

deformity  in,  in  neuritis,  II.  1132 
rheumatic,  of  ocular  muscles,  III.  649 
spastic,  in  paraplegia,  II,  1197 
spinal,  deformities  due  to,  I.  988-990 
syphilitic,  II.  1069 

thrombotic,  of  ocular  muscles,  III.  648 
Paralysis  agitans,  II.  1269-1270 

drugs  in,  II.  1270 
Paralytic  deformities  of  the  upper  limb, 

I.  990 
distension      complicating      abdominal 

operations,  II.  271 
torticollis,  II.  1051 
Parametritis,  chronic,  in  pelvic  cellulitis, 

IV.  834 

remote,  in  pelvic  cellulitis,  IV.  833 
Paramyoclonus  multiplex,  II.  1255-1256 
Paranoia,  II.  1309 
Paraphimosis  of  the  penis,  II.  879 
Paraplegia,  II.  1195-1199 
bedsores  in,  II.  1199 
electricity  in,  II.  1198 
endogenous,  II.  1196 
exogenous,  II.  1196 
flaccid  paralysis  in,  II.  1197 
genito-urinary  symptoms  in,  II.  1199 
hereditary  spastic,  II.  1249 
in  severe  injuries  of  the  spine,  I.  906 
in  tuberculous  disease  of  the  spine,  I. 

926-927 

massage  in,  II.  1198 
of  cerebral  causation,  II.  1195 
of  cerebro-spinal  origin,  II.  1196 
of  spinal  origin,  II.  1196 
rectum  symptoms  in,  II.  1199 
spastic  paralysis  in,  II.  1197 
Parapsoriasis.  III.  1084 
Parasites,  certain  diseases  caused  by,  III. 

487 

intestinal  and  anaemia,  II.  15 
of  the  stomach,  II.  359 
Pardoe  (John),  diseases  and  affections  of 

the  prostate  gland,  II.  918-929 
diseases  and  affections  of  the    tunica 

vaginalis,  II.  913-929 
fibroma  of  the  prostate,  II.  950-951 
tumours  of  the  prostate,  II.  930-949 
Parenchymatous   cells,   embolism    by,   I. 

1306 

goitre,  II.  63,  67 
haemorrhage,  I.  1272 
Parker's    tracheotomy   tubes,  use   of,   I. 

196 
Parotid  gland,  inflammation  of,  II,  157- 

163 

dry  mouth  and,  II.  163 
ptyalisra  and,  II.  161 


87 


A    SYSTEM  OF  TREATMENT. 


Parotid  gland  (contd.} — 
ranula  cyst  and,  II.  158 
salivary  calculi  and,  II.  159 
salivary  fistula  and,  II.  160 
salivation  and,  II.  161 
xerostomia  and,  II.  163 
tumours  of,  II.  161 

innocent,  operation  for,  II.  161 
malignant,  operation  for,  II.  162 
wounds  of,  II.  162 
Parotitis,  I.  256-257 
complicating    gynaecological    surgery, 

IV.  495 

typhoid  fever,  I.  357 
secondary,  II.  158 
simple,  II.  157 
symptomatic,  II.  131,  158 
Partsch's  metal  band  for  fracture  of  the 

jaws.  II.  114 

Parturition.     See  Labour  and  Puerperium. 
Pasteur  (W.)  on  active  collapse  of  the 

lung,  I.  1065 

Pasteurisation  of  milk,  II.  220 
Pasteur's  inoculation  method  of  treatment 

of  rabies,  I.  264 
Patella,  dislocations  of,  I.  728 
fractures  of,  I.  620-622,  679 
Paterson    (D.  B.),   actinomycosis  of  the 

pharynx,  III.  765 

chronic    hyperplasia    of     the    mucous 
membrane  of  the  upper  respiratory 
tract,  III.  774 
glanders,  III.  670 

gout  affections  of  the  throat,  III.  775 
hypertrophy  of  the  pharyngeal   tonsil, 

III.  732-738 

keratosis  of  the  pharynx,  III.  779 
naso-pharyngeal  catarrh,  III.  739-741 
pharyngomycosis,  III.  787 
rheumatic    affections    of    the    throat, 

III.  764 

rhinoscleroma,  III.  713 
thrush,  III.  792 

Paterson    (Marcus).     The    treatment    of 

pulmonary  tuberculosis   bv   graduated 

labour,  I.  1159-1163 

Paterson's    electric-heated    infusion    ap- 
paratus, I.  100 

forceps,  III.  849 
Pathology,  recuperative  factors  in,  I.  10, 

11 
Patient,  care  of,  in  typhoid  fever,  I.  338 

fhial    directions    to,    after    abdominal 
operations,  II.  268 

general  health  of,  in  abdominal  opera- 
tions, II.  257 

general  management,  I.  9 

individuality  of,  I.  25 

position  of,  in  gynaecological  surgery, 

IV.  487 

preparation  of,  for  operation,  I.  27,  83 
in   abdominal    operations,   II.    257 ; 

IV.  485 

in  Csesarean  section,  IV.  385 
in  obstetric  operations,  IV.  373 


Patient,  preparation  of  (contd.) — 
in  shock,  I.  95 

in  vaginal  operations,  IV.  484 
protection  of.  in  X-ray  treatment,  III. 

345 

Patients  after  abdominal  operation,  treat- 
ment of,  II,  262 
Paul's  operation  for  cancer  of  the  colon, 

II.  580,  584 
Pavy's  method  of  estimation  of  sugar,  I. 

420 
Pawlik's  grip   in    palpation    in    normal 

labour,  IV.  100,  101 
Pawlow  on  food  values,  I.  449 
Pearson  (S.  V.)  and  Claude  Willingston. 
The  treatment  of  pulmonary  tubercu- 
losis by  the  induction   of  an  artificial 
pneumothorax,  I.  1164-1173 
Peat  baths,  III.  135 

in  arthritis  deformans,  I.  398 
Pedicle  needle  in  laceration  of  the  genital 

tract,  IV.  192 
Pediculosis,  III.  1086-1087 
capitis,  III.  1086 

in  anaemia,  II.  14 
corporis,  III.  1086 
pubis,  III.  1087 
Pellagra,  I.  521-524 

advanced  cases  of,  I.  521 
blood  transfusion  in,  I.  523 
diart-hoea  in,  I.  522 
drugs  in,  I.  522 
lunacy  of,  I.  523 

Pelvi-rectal  abscess  of  the  anus,  II.  604 
Pelvic  cellulitis,  IV.  824-838 

abscess  cavities  in,  drainage  of,  IV. 

848 

anti-streptococcus  serum  in,  IV.  833 
in  diseases  of  pelvic  bones,  IV.  836 
inflammation  virulent  in,  IV.  831 
moderate  acute  infection  in,  IV.  827 
parametritis,  chronic  in,  IV.  834 

remote  in.  IV.  833 
summary  of  treatment,  IV.  837 
suppuration  in,  IV.  828 
treatment  of,  IV.  826 
vaccine  treatment  of,  IV.  837 
grip  in  palpation  in  normal  labour,  IV. 

101,  102 

lifting  exercise  in  heart  disease,  III.  253 
Pelvis,  bones  of.  pelvic  cellulitis  in,  IV. 

836 
bony,  hydronephrosis  due  to  obstruction 

in,  II.  772 

cellular  tissue  of,  drainage  of  in  puer- 
peral sepsis,  IV.  306 
contractions  of,  Caesarean  operation  in, 

table  of  mortality,  IV.  402 
Cassarean  section  in,  IV.  383 
complicating  labour,  IV.  163-175 
Caesarean  section  in,  IV.  170 
cleidotomy  in,  IV.  171 
hebosteotomy  in,  IV.  171 
pubiotomy  in,  IV.  171 
symphysiotomy  in,  IV.  1171 


A    SYSTEM   OF   TREATMENT. 


Pelvis,  contractions  of  (contd.*) — 

decapitation  in,  IV.  415 

diet  in,  in  labour,  IV.  174 

induction  of  premature  labour  in.  IV. 
434 

rare,  complicating    labour,  IV.  172- 

175 
deformities  of,  symphysiotomy  for,  IV. 

454 
drainage    of,    by    vaginal    incision    in 

puerperal  sepsis,  IV.  302 
examination  of,  in  sterility,  IV.  851 
exostosis  of,  complicating  labour,  IV.  174 
flat,  complicating  labour,  IV.  168 
flattened,  podalic  version  in,  IV.  466 
floor  of,  rigidity  of,  forceps  in,  IV.  420 
fracture  of,  I.  605 

in  abdominal  injuries,  II.  249 
infective  processes  in,  subinvolution  of 

uterus  by,  IV.  723 

ky photic,  complicating  labour,  IV.  173 
malacosteon,  complicating  labour,  IV. 

172 

maternal,   disproportion  between  child 
and,  forceps  in,  IV.  417 

position  of  blades  of  forceps  to,  IV. 

431 

oblique,  complicating  labour,  IV.  173 
organs  of,  in  normal  puerperium,  IV. 

257 
osteomalacic,  complicating  labour,  IV. 

172 
pseudo  -  osteomalacic,         complicating 

labour,  IV.  172 

Robert's,  complicating  labour,  IV.  173 
spondylolisthetic,  complicating  labour, 

IV. '173 

Pemphigus,  III.  1088-1089 
acute,  III.  1088 
chronic,  III.  1088 
contagiosus,  III.  474 
foliaceus,  III.  1089 
of  the  pharynx,  III.  788 
vegetans,  III.  1089 
Pendlebury  (H.  8.),  caseating  tuberculous 

glands  in  the  mediastina,  I.  1177 
inflammation  of  the  ribs  and  sternum, 

I.  1032-1033 

inflammatory  conditions  of  medias- 
tinum, surgical  treatment  of,  I.  1176 

injuries  of  the  chest,  I.  1031 

new  growths  of  the  thoracic  wall,  I. 
1034 

surgical  treatment  of  abscess  of  the 
lung,  I.  1060-1062 

surgical  treatment  of  growths  of  the 
lung,  I.  1175 

surgical    treatment   of    hydrocephalus. 

II.  1193 

surgical    treatment    of    pericarditis,    I. 

1188-1189 
surgical  treatment  of  purulent  pleural 

effusion,  I.  1101-1109 
surgical  treatment  of  pyopneumothorax, 

I.  1114 


Penis,  bruises  of,  II.  876 

cancer  of,  relief  of  obstruction  in,  I.  142 

chordee  and  painful  erections  of,  com- 
.  plicating  gonorrhoea,  I.  226 

diseases  of,  II.  874 

dressing  of,  in  operation  for  elephan- 
tiasis scrote,  III.  513 

flaps  to,  in  operation  for  elephantiasis 
scrote,  III.  511 

grafting  of  in  operation  for  elephantiasis 
scrote,  III.  511 

injuries  of,  II.  876 

lacerations  of,  II.  876 

malformations  of,  congenital,   II.  875- 
876 

malignant  disease  of,  II.  877 

papillomata  of,  II.  878 

paraphimosis  of,  II.  879 

phimosis  of,  II.  879 

rupture  of  fraenal  artery  of,  II.  876 

sloughing  of,  I.  316 

Pepsin,  effect  on  gastric  function,  II.  291 
Peptonised  beef-tea,  preparation  of,  I.  42 

milk,  II.  226 

preparation  of,  I.  42 
Peptonuria,  II.  733 
Perambulators  for  young  children,  use  of, 

I.  52 
Perchloride  of  mercury,  in  lotions,  I.  73 

solution,  strength  of,  I.  81 
Pericardial  adhesions,  I.  1189 
Pericarditis,  I.  1179 

chronic,    mediastinal,      and     adherent 
pericardium,  I.  1186 

complications  of,  I.  1179 

drugs  in,  I.  1180 

in  acute  rheumatism,  I.  272,  278 

in  rheumatism,  I.  1179 
in  childhood,  I.  278 

pneumococcus,  infection  with,  I.  1182 

purulent,  I.  1184 

surgical  treatment  of,  I.  1188-1189 

tuberculous,  I.  1184 

with  kidney  disease,  I.  1185 
Pericardium,  adherent,  and  chronic  medi- 
astino-pericarditis.  I.  1186 

diseases  of,  I.  1179-1187 

operation  and  drainage  in,  I.  1183 

drainage  of,  I.  1188 

injuries  of,  I.  1030 
Perichondritis  of  the  auricle,  III.  881 

of  the  larynx,  III.  861-862 
Pericolitis.  II.  574 

general  peritonitis  in,  II.  576 

localised  abscess  in.  II.  575 

perforation  in,  II.  576 
Perigastritis,      complicating     hour-glass 

stomach,  II.  336 
Perineal     dressing      in      operation     for 

elephantiasis  scroti,  III.  513 
Perineorraphy,  IV.  549 
Perinephritic  abscess,  II.  801-802 

results  of  operation  for,  II.  801 
Perineum,  blow  on,  injuries  of  the  urethra 

by,  II.  882 


A    SYSTEM  OF  TREATMENT. 


Perineum  (contd.) — 

examination  of,  in  labour,  IV.  126 

falls  on,  injuries  of  urethra  by,  II.  882 

laceration  of,  complicating  labour,  IV. 
204 

pedunculated  fibromata  of,  I.  112 

rupture  of,  treatment,  IV.  208 

support  of,  in  second  stage  of  labour, 
IV.  113 

threatened  rupture  of,  forceps  in,  IV. 

420 

Permeal  muscular  atrophy,  II.  1253 
Periodontal   membrane,  diseases  of,  III. 

1174 
Periodontitis  suppurative,    chronic,    III. 

1176 

Periosteal  flaps,  I.  800 
Periosteum,  treatment  of,  in  amputations, 

I.  800 
Periostitis,  acute,  I.  694 

in    infective  lesions  of    the    skull,    I. 
889 

non-suppurative,  I.  694,  703 

of  the  spine,  I.  916-917 
Peritoneal  infusion  in  shock,  I.  101 

toilet  in  perforation  of  the  intestine,  II. 

554 

Peritoneum,  adhesions  of,  division  of,  in 
constipation  in  adults,  II.  467 

contained  in  lipomata,  I.  107 

diseases  of,  II.  626-642 

fistulas  of,  II.  280 
Peritonitis,  II.  632-642 

abdominal  distension  in,  II.  638 

acute,  table  of  cases  of,  at  St.  Thomas' 
Hospital,  II.  633 

administration  of  fluids  per  rectum  in, 
II.  635 

after  ovariotomy,  IV.  794 

.artificial  leucocytosis  in,  II.  637 

colon  bacillus,  II.  641 

complicating  gynaecological  surgery,  IV. 

492 
typhoid  fever,  I.  359 

diffuse,  in  appendicitis,  II.  422 

feeding  in,  II.  640 

general,  and  appendicitis,  II.  405 
in  appendicitis,  II.  422 
in  pericolitis,  II.  576 

gonorrhceal,  II.  642 

hiccough  in,  II.  639 

in  abdominal  injuries,  II.  244 

in  gunshot  wounds,  I.  566 

incision  in  operation  for,  II.  634 

morphia  in,  II.  639 

operation  for,  II.  633 

opium  in,  II.  638 

pneumococcal,  II.  641 

proctoclysis  in,  II.  635 

purgatives  in,  II.  638 

repeated  sickness  in,  II.  638 

rules  before  operation,  II.  633 

serum  treatment  of,  II.  637 

special  forms  of,  II.  641-642 

staphylococcic,  II.  641 


Peritonitis  (contd.*) — 

stimulants  in,  II.  638 

streptococcic,  II.  641 

tuberculous,  II.  645-647 
appendix  and,  II.  411 
complications  of,  II.  645 
general  measures  in,  II.  645 
medicinal  measures  in,  II.  645 
removal  of  ascetic  fluid  in,  II.  647 
tuberculin  in,  II.  646 

vaccine  treatment  of,  II.  637 
Peri-urethral  abscess,  II.  895-896 

complicating  gonorrhoaa,  I.  226 
Perkins  (J.  J.),  abscess  of  the  lung,  1. 1059 

gangrene  of  the  lung,  I.  1059 

hasmothorax,  I.  1090 

hydrothorax,  I.  1091-1092 

pneumothorax,  I.  1112-1113 

pyopneumothorax,  I.  1113 
Perlsucht  tuberculin,  III.  294 
Permanganate,  potassium  in  gastric  lavage, 

I.  528,  531 

Peroxide  of  hydrogenas  a  haemostatic,  I. 
138 

of  iron,  hydrated  in  arsenical  poisoning, 

I.  504 

Persuasion  method  in  hysteria,  II.  1012 
Perversions,  II.  1315 
Pes  arcuatus,  I.  963 

cavus,  I.  963 

Pessaries  in  prolapse  of  uterus,  IV.  690- 
692 

mechanical  treatment  of  retroflexion  of 

uterus,  IV.  678,  680 
Petrissage  and  massage,  III.  204 
Phagedaena  in  syphilis,  I.  316 

tropical,  III.  472 
Phagedsenic  ulcers,  I.  369 
Phagocytosis,  invigoration  of,  I.  7,  11 
Phalanges,  fracture  of,  I.  605 

of  the  thumb,  congenital  lateral  devia- 
tion of,  I.  938 
Phalanx,  middle,  amputation  through,  I. 

806 
Pharyngeal  fibromata,  I.  113 

tonsil  diseases  of,  III.  732-738 
Pharyngitis,  acute  catarrhal,  III.  766-767 

chronic  catarrhal,  III.  767-769 

complicating  influenza,  I.  239 
Pharyngo-keratosis  of  lingual  tonsil,  III. 

762 

Pharyngomycosis,  III.  787 
Pharynx,  actinomycosis  of.  III.  765 

acute  septic  inflammation  of,  III.  772 

anaesthesia  of,  III.  782 

and  voice  production,  III.  335 

cancer  of,  relief  of  obstruction  in,  I. 
139 

diseases  of,  III.  765-783 

haemorrhage  from,  III.  776-777 

herpes  of,  III,  778 

hyperaasthesia  of,  III.  782 

keratosis  of,  III.  779 

leprosy  of,  III.  780 

lupus  of,  III.  781 


90 


A    SYSTEM  OF  TREATMENT. 


Pharynx  (contd.~) — 

malignant  growths  of,  III.  786 

mycosis  of,  III.  787 

naso-diseases  of,  III.  732-743 

neuralgia  of,  III.  782 

neuroses  of,  III.  782-783 
motion  of,  III.  782 
sensation  of,  III.  782 

new  growths  of,  III.  699-700 

parassthesia  of,  III.  782 

paralyses  of,  III.  782 

pemphigus  of,  III.  788 

spasmodic  affections  of  the  palate,  III. 
783 

syphilis  of,  III.  791-792 

tuberculosis  of,  III.  793-794 

ulceration  of,  III.  795-796 

wounds  of,  in  cut  throat,  II.  165 
Phenacetin  for  relief  of  pain,  I.  134 

in  influenza,  I.  233 

poisoning  by,  I.  533 
Phenazone  in  diabetes  insipidus,  I.  429 

in  whooping  cough,  I.  382 
Phenol,  poisoning  by,  I.  527 
Phimosis  in  the  newborn  child,  IV.  360 

of  the  penis,  II.  879 
Phlebitis  and  thrombosis,  I.  1328-1338 

gouty,  I.  1330 

in  gout  and  gouty  conditions,  I.  444 

in  varicose  veins,  IV.  89 

non-infective,  I.  1328 

septic  cases  of,  I.  1329 

simple,  I.  1328 

syphilitic,  I.  1330 
Phlebotomus  fever,  III.  400 
Phlegmasia    alba    dolens     in    puerperal 

sepsis,  IV.  321 

Phlegmonous  gastritis,  II.  353 
Phlyctenular  conjunctivitis,  III.  552 

ulceration  of  the  cornea,  III.  567 
Phosphaturia,  II.  746 
Phosphoretted  hydrogen,  poisoning  by,  I. 

535 

Phosphorus,  effect  of,  on  the  teeth,  II. 
108 

in  rickets,  I.  480 

poisoning,  I.  525 

acute,  I.  528 

Photophobia  in  measles,  I.  242 
Phthisis     complicating    pregnancy,    IV. 
49 

pulmonary,  I.  1117-1126 
Physical  exercises,  III.  222-257 

methods  in  hysteria,  II.  1012 
Physostegmine  or  eserine,  poisoning  by, 

I.  533 

Piedra,  III.  476 

Pieniazek  on  tracheoscopy,  III.  805 
Pigmentations,       preceding       melanotic 

cancer,  I.  120 
Piles,  operations  for,  II.  618 

palliative  treatment,  II.  615 
Pillows,  arrangement  of,  I.  30 
Pilocarpine  in  eclampsia,  IV.  37 

poisoning  by,  I.  533 


Pinard's   registering  separator  for  sym- 

pbysiotomy,  IV.  457 
Pinhble  os,  leucorrhoea  in,  IV.  567 
Pinna,  deviated,  III.  877 
Pinta  or  caraate,  III.  477 
Pirogoff  's  amputation,  I.  848 
von  Pirquet's  skin  reaction  in  diseases  of 

the  pericardium,  I.  1185 
Pituitary  body,  influence  on  obesity,  I. 

473 

extract  in  obesity,  I.  473 
in  pneumonia,  I.  261 
infusion  in  shock,  I.  103-5 
Pituitous  catarrh  or  bronchorrhoea  serosa, 

I.  1058 
Pityriasis  rosea,  III.  1090-1091 

general  treatment  of,  III.  1090 
local  treatment  of,  III.  1090 
rubra,  III.  1093 
pilaris,  III.  1092 
gravis  of  Hebra,  III.  1151 
versicolor,  III.  1095 
Placenta,  adherent,  complicating  labour, 

IV.  228,  234 
removal  of,  IV.  234 
examination  of,  in  third  stage  of  labour, 

IV.  123 
expression  of,  in  third  stage  of  labour, 

IV.  120,  121 
expulsion  of,  in  third  stage  of  labour, 

IV.  119 

prasvia,  Cassarean  section  in,  IV.  385 
central  insertion  of  de  Ribes'  bag  in, 

IV.  67,  68 

complicating  pregnancy,  IV.  65. 
epitome  of  treatment  of,  IV.  69 
lateral  insertion  of  de  Ribes'  bag  in, 

IV.  66,  68 
marginal  insertion  of  de  Ribes'  bag 

in,  IV.  66,  68 
occurring  before  labour  has  begun, 

IV.  65 

post-partum  haemorrhage  in,  IV.  68 
syncope  in,  IV.  69 

removal  of,  in  Caesarean  section,  IV.  391 
retention  of,  complicating  labour,  IV. 

225-237 
in  hour-glass  contraction  of  uterus, 

IV.  230,  231 

in  missed  abortion,  IV.  225 
in  third  stage  of  labour,  IV.  229 
in  uterine  atony,  IV.  229 
succenturiate,  in  third  stage  of  labour, 

IV.  124 

Placental  extract  in  cancer,  1. 150 
Plague,  III.  401—409 
antiseptic  drugs  in,  III.  406 
bubo  in,  III.  405 
carbuncles  in,  III.  406 
contacts  in,  III.  402 
convalescence  of,  III.  406 
diet  in,  III.  403 
disinfection  during  illness  from,   III. 

402 
general  management  of,  III.  401 

91 


A    SYSTEM  OF   TREATMENT. 


Plague  (contd.')— 

initial  precautions  in,  III.  401. 
nursing  in,  III.  403 
organo-therapy  of,  III.  409 
pneumonic,  III.  405 
point  of  inoculation  in,  III.  405 
preventive  inoculation  in,  III.  284 

results,  III.  284 
re-inoculation  in,  III.  284 
serum-therapy  of,  III.  407 
specific  methods  of  treatment  of,  III. 

406-409 

stimulants  in,  III.  403 
symptomatic  treatment  of,  III.  404 
ulcer  in,  III.  406 
vaccine  therapy  of,  III.  284 
Plantar  neuralgia,  I.  964 
Plaster  of  Paris  splinting,  I.  574 

splints,  I.  628 

splint  in   tuberculous   disease   of    hip- 
joint,  I.  760 

Plasters,  application  of,  I.  36 
Plastic  operations  in  ulceration,  I.  375 
Pleura,  wounds  of,  I.  1027 
Pleural  cavity,  injections  into,  in  pleural 

effusion,  I.  1097 

Pleurisy,  after-treatment  of,  I.  1097 
and  pleural  effusion  (sero-fibrinous),  I. 

1093-1098 
complicating    artificial   pneumothorax, 

1.1170 

pregnancy,  IV.  50 
pulmonary  tuberculosis,  I.  1158 
delayed    re-expansion    of    lung   in,    I. 

1098 

physical  exercises  in,  III.  252 
relieved    by     belladonna     plaster,     I. 

1307 
with  effusion  and  tumours  of  the  lung, 

I.  1174 

(purulent),  I.  1099-1100 
surgical  treatment  of,  I.  1101 
treatment  by  tapping  or  aspiration, 

I.  1095 

Plombieres  spa,  III.  154 
Plumbism  and  anemia,  II.  16 
complicating  pregnancy,  IV.  56 
industrial,  prevention  of,  I.  514 
"Pneumatic  cabinet"  in  emphysema.  I. 

1086 

treatment  of  asthma,  I.  1042 
Pneumatoceles  of  the  skull,  I.  896 
Pneumaturia,  II.  749 
Pneumococcal  arthritis,  I.  783-784 
Pneumococcic      vaccine      treatment     in 

diseases  of  the  pericardium,  I.  1184 
Pneumococcus  infections,  serum  therapy 

of,  III.  285 
in  pericarditis,  I.  1182 
meningitis,  I.  250 
peritonitis,  II,  641 
vaccine,  dose  of,  III.  286 
Pneumokoniosis.  I.  1115 
Pneumonia,  I.  258-263 
abscess  of  lung  following,  I.  1060 


Pneumonia 

bronchial,  I.  1066-1073 

horse  serum  in,  III.  262 
catarrhal,  external  applications  in,  I.  69 
chronic  interstitial,  I.  1074-1075 

prophylaxis  of,  I.  1074 
complicating    gynaecological     surgery, 

IV.  494 

influenza,  I.  240 
typhoid  fever,  I.  361 
delayed  resolution  after,  III.  252 
drugs  in,  I.  259-261 
feeding  in,  I.  258 
glandular  extracts  in,  I.  261 
in  injuries  of  the  spine,  I.  909 
ice-poultice  in,  I.  259 
jacket,  how  to  make,  I.  34 
lobar,  complicating  pregnancy,  IV.  49 
in  pericarditis,  I.  1182 
in  measles,  I.  245 
serum  treatment  of,  I.  262 
sleeplessness  in,  I.  259 
stimulants  in,  I.  259 
vaccine  treatment  of,  I.  263 
Pneumonic  plague,  III.  405 
Pneumothorax,  artificial,  choice  of  patient, 

I.  1171 
completion  and  the  maintenance  of, 

I.  1168 

complications  of,  I.  1171 
difficulties  in  the  course  of  the  opera- 
tion, I.  1167 

duration  of  treatment,  I.  1169 
dyspepsia  complicating,  I.  1170 
Forlanini's  method  of,  I.  1170 
modifications  of  method,  I.  1170 
Murphy's  method  of,  I.  1170 
pleurisy  complicating,  I.  1170 
technique  of,  I.  1165 
treatment  of  pulmonary  tuberculosis 

by  the  induction  of,  I.  1164-1173 
complicating  pregnancy,  IV.  50 
in  injuries  of  the  thorax,  I.  1029 
Poisoning,  artificial  respiration  in,  I.  530, 

532,  534 

by  acetanilide,  I.  533 
by  aconite,  I.  532 
by  aconitine,  I.  532 
by  ammonia,  I.  527 
by  aniline,  I.  533 
by  antifebrin,  I.  533 
by  antimony,  I.  529 
by  antipyrin,  I.  533 
by  arsenic,  I.  529 
by  arseniuretted  hydrogen,  I.  535 
by  atropine,  I.  532 
by  belladonna,  I,  532 
by  benzene,  I.  533 
by  calabar  bean,  I.  533 
by  cantharides,  I.  532 
by  carbolic  acid,  I.  527 
by  carbon  dioxide,  I.  534 
by  carbon  monoxide,  I.  534 
by  carbonic  acid,  I.  534 
by  caustic  alkalies,  I.  527 


92 


A    SYSTEM  OF  TREATMENT. 


Poisoning  (contd.) — 

by  chloral  hydrate,  I.  530 
by  chloroform,  I.  531 

in  fatty  liver,  II.  668 
by  cocaine,  I.  532 
by  colchicine,  I.  533 
by  colchicum,  I.  533 
by  digitalis,  I.  533 
by  ergot,  I.  533 
by  eserine,  I.  533 
by  gabarandi,  I.  533 
by  hellebore,  black,  I.  533 

green,  I.  533 

white,  I.  533 
by  henbane,  I.  532 
by  hydrocyanic  acid,  I.  530 
by  hyoscine,  I.  5  32 
by  hyoscyamine,  I.  532 
by  laburnum,  I.  533 
by  mercury,  I.  530 
by  mineral  acids,  I.  526 
by  morphia,  I.  531 

coma  in,  II.  984 

by  mushroom  causing  diarrhoea,  II.  480 
by  nicotine,  I.  533 
by  nitro-benzene,  I.  533 
by  opium,  I.  531 
by  oxalic  acid,  I.  528 
by  phenacetin,  I.  533 
by  phenol,  I.  527 

by  phosphoretted  hydrogen,  I.  535 
by  phosphorus,  I.  525,  528 
by  physostigmine,  I.  533 
by  pilocarpine,  I.  533 
by  potassium  chlorate,  I.  532 
by  pyridine,  I.  533 
by  salts  of  barium,  I.  529 

of  copper,  I.  529 

of  lead,  I.  529 

of  tin,  I.  529 

of  zinc,  I.  529 
by  savin,  I.  533 
by  scopolamine,  I.  532 
by  stramoniun,  I.  532 
by  sulphonal,  I.  531 
by  sulphuretted  hydrogen,  I.  534 
by  tetronal,  I.  531 
by  tobacco,  I.  533,  534 
by  trional,  I.  531 
by  turpentine,  I.  532 
by  vegetable  irritants,  I.  533 
by  veratrme,  I.  533 
by  veronal,  I.  531 
by  yew,  I.  533 

oxygen  in,  I.  528,  531,  533,  535 
potassium  permanganate  in,  I.  528,  631 
renal  complications  in,  I.  530,  532 
Poisons  and  antidotes,  I.  526-535 
corrosive,  I.  526-528 
gaseous,  I.  534-535 
irritant,  I.  528-530 
narcotic,  I.  530-534 

Polio-myelitis,  acute,  anterior,  II.  1055- 
1058 

electricity  in,  II.  1056 


Polio-myelitis,  acute,  anterior  (contd.) — 
massage  in,  II.  1056 
passive  movements  in,  II.  1056 
pyrexial  stage,  II.  1055 
Politzer's  method  in  patency  of  Eustachian 

tube,  III.  948 
Pollantin,  Uunbar  antitoxic  serum,   III. 

28(5-287 
Polycythsemia,  chronic,  with  cyanosis  and 

enlarged  spleen,  II.  84 
Polydactylism,  I.  943 
Polyneuritis  of  auditory  nerve  caused  by 
general  neurasthenic  state  of  the  system, 

III.  977 
Polypus,  aural,  III.  909-911 

ribrinous,     of    placenta     complicating 

labour,  IV.  228 
fibroid,  of  the  meatus,  III.  882 

uterine,  IV.  658-661 
mucous,  of  cervix,  IV.  567,  662 

of  uterus,  IV.  662 
multiple,  of  the  colon,  II.  588 
of  the  nose,  III.  691 
placental,  complicating  labour,  IV.  228 
Polysarcia     abdominalis    in    the    meno- 
pause, IV.  501 

Polyuria  of  diabetes  insipidus,  I.  428 
Pomegranate  root  in  intestinal  tseniasis, 

III.  518,  519 
Ponos,  III.  440-441 

prophylaxis  of,  III.  440 
treatment  of,  III.  440 
Pontine  hemorrhage,  II.  1175 
Pork,  chemical  composition  of,  II.  193 
Poroplastic    sheet    cut    for    a    moulded 

shoulder  cap,  1. 588 
Port  wine  in  gout,  I.  457 
stains,  III.  1077 

carbon  dioxide  in,  III.  1078 
Portal  vein,  thrombosis  of,  1.  1331  ;  II. 

666-667 

Posthitis,  II.  874 

Postures,  faulty,  in  children,  I.  56 
Pbstyen  spa,  III.  154 
Potam's  bottle  aspirator  apparatus    for 

pleural  effusion,  I.  1095 
Potash,  bicarbonate  of,  in  influenza,  1. 234 
chlorate  of,  in  ulcerative  stomatitis,  II. 

121 
Potassium,  bromide   of,  in  exophthalmic 

goitre,  II.  55 
in  insomnia.  II.  991 
in  whooping  cough,  I.  380 
chlorate,  dosage  of  in  children's  diseases, 

1.67 

poisoning  by,  I.  532 
impotence  due  to  use  of,  I.  231 
iodide  of,  in  actinomycosis,  I.  178 
in  aortic  aneurysm,  I.  1298 
in  diseases  of  the  heart,  I.  1224 
in  gouty  joints,  I.  436 
in  lead  colic,  I.  513 
in  new  growth  in  the  mediastinum, 

I.  1178 
in  tabes  dorsalis,  II.  1087 


93 


A    SYSTEM  OF  TREATMENT. 


Potassium,  iodide  of  (contd.~) — 
in  typhoid  fever,  I.  355 
in  undefined  tropical  fevers,  III.  410 
permanganate    in     gastric    lavage,    I. 

528-531 

salts  in  sub-acute  gout,  I.  435 
Potato  diet  in  gout,  I.  453 

in  dietary  of  children,  I.  59 
Potts'  disease,  line  of  incision  in,  I.  916 

of  the  spine,  I.  922-927 
fracture,  I.  629 
Pouges  spa,  III.  154 
Poultices  in  acute  bronchitis,  I.  1050 
in  broncho-pneumonia,  I.  1067 
in  chronic  rheumatism,  I.  486 
preparation  and  use  of,  I.  33 
Poultry,  chemical  composition  of,  II.  193 
Powders  in  herpes  zoster,  II.  1096 

in  pruritus,  III.  1099 
Powell  (Llewelyn),  anaesthetics   in  preg- 
nancy and  labour,  IV.  373-381 
Pozzuoli  spa,  III.  154 
Practice,  medical,  general  considerations, 

1.22 

Predisposition  to  diseases,  causes  of,  I.  5, 6 
Pregnancy,  abnormalities  of,  IV.  14-90 
abortion  in,  IV.  14 
incomplete  in,  IV.  21 
inevitable  in,  IV.  18 
later  than  first  twelve  weeks,  IV.  20 
missed  in,  IV.  22 
threatened  in,  IV.  117 
accidental     haemorrhage     in,     Bossi's 

dilator  for,  IV.  26 
Caesarean  section  for,  IV.  25 
cases  before  labour  has  begun,   IV. 

26-28 

hysterectomy  for,  IV.  25 
morphia  in,  IV.  26 
perforation  of  membranes  and,  IV.  25 
plugging  the  vagina  in,  IV.  24 
rest  in,  IV.  24 
sedatives  in,  IV.  24 
shock  from,  IV.  26 
use  of  a  dilating  bag  for,  IV.  25 
vaginal  hysterectomy  for,  IV.  26 
Addison's  disease  in,  IV.  50 
affections  of  the  breasts  in,   IV.   330- 

336 

albuminuria  in,  IV.  7,  30-33 
anaesthetics  in,  III.  24  ;  IV.  58,  375-376 
anthrax  in,  IV.  49 
appendicitis  in,  II.  406  ;  IV.  54 
ascites  in,  IV.  65 
auto-intoxications  in,  I.  389 
blood  or  carneous  mole,  IV.  59 
cancer  in,  I.  128 
care  of  nipples  in,  IV.  8 
cerebro-spinal  meningitis  in,  IV.  49 
chorea  gravidarum  in,  IV.  51 
clothing  during,  IV.  8 
complicating  cancer  of  the  breast,  II. 

965 

pulmonary  tuberculosis,  I.  1155 
complications  of,  IV.  14-90 


Pregnancy  (coittd.') — 
cystitis  in,  IV.  272 
danger  signals  of,  IV.  4 
death  of  fretus  during,  IV.  14 
diabetes  insipidus  in,  IV.  55 

meUitus  and,  I.  425  ;  IV.  54 
diet  during,  IV.  6 
diphtheria  in,  IV.  49 
diseases  of,  induction  of  abortion  in,  IV. 
433 

induction  of  premature  labour  in,  IV. 

434 

eclampsia  in,  IV.  34-41 
erysipelas  in,  IV.  49 
exercise  in,  IV.  7 
exophthalmic  goitre  in,  IV.  57 
extra-uterine,  complicated  with  fibroids, 

IV.  82 
conditions  simulating  rupture  of  a 

gravid  tube  in,  IV.  84 
risks  of  operation  in,  IV.  83 
troubles  with  decidua  in,  IV.  83 

unavailing  labour  at  term,  IV.  87 
filariasis  in  IV.  57 
general  management  of,  IV.  1-13 

treatment  of,  IV.  3 
haemorrhage,    accidental,    during,  IV. 

23-29 

occurring  after  labour,  IV.  28 
haemorrhoids  in,  IV.  42 
heart  disease  in,  IV.  52 
herpes  in,  IV.  56 
hydatidiform  mole  in,  IV.  59 
hydramnios  in,  IV.  43 

chronic,  IV.  43 
in  bicornate  uterus,  IV.  712 
insanity,  complicating,  IV.  45 
intra- abdominal  tumours  in,  IV.  55 
jaundice  in,  IV.  53 
later  months  of,  deformities  of  the  foetus 

obstructing  labour  in,  IV.  178 
leucorrhoea  in,  II.  557,  558 
lobar  pneumonia  in,  IV.  49 
malaria  in,  IV.  48 
management    of    the    breasts    in,    IV. 

330 

of  the  nipples  in,  IV.  330 
medicines  during,  IV.  9 
mental  diseases  complicating,  IV.  46-58 
minor  ailment  in,  IV.  11 
mollities  ossium  in,  IV.  58 
myxcedema  in,  IV.  58 
nervous  diseases  in,  IV.  50 
oligo-hydramnios  in,  IV.  44 
operations  in,  IV.  58 
osteo-arthritis  in,  IV.  57 
osteo-malacia  in,  IV.  58 
ovarian  tumours  complicating,  IV.  771- 

772 

ovariotomy  in,  IV.  771 
paralyses  of,  IV.  60 
pendulous  belly  in,  IV.  61 
pernicious  vomiting  in,  IV.  62-64 

starvation  in,  IV.  62 
phthisis  in,  IV.  49 


94 


A    SYSTEM   OF  TREATMENT. 


Pregnancy  (cmtd.) — 

placenta  praevia  in,  IV.  65 

occurring  before  labour   has    begun 

in,  IV.  65 
pleurisy  in,  IV.  50 
plumbism  in,  IV.  56 
pneumothorax  in,  IV.  50 
prolapse  of  pregnant  uterus  in,  IV.  70 

of  the  vagina  in,  IV.  71 
prolongation  of,  induction  of  premature 

labour  in,  IV.  436 
pruritus  in,  IV.  56 

vulva  in,  IV.  72-73 
psoriasis  in,  IV.  56 
pyelitis  in,  II.  806 
pyelonephritis  of,  II.  806 
regulation  of  the  bowels  in,  IV.  8 
retroflexion  of  the  uterus  in,  IV.  74-75 
rheumatoid  arthritis  in,  IV.  57 
scarlet  fever  in,  IV.  48 
spleno-medullary  leuchasmia  in,  IV.  55 
syphilis  in,  IV.  76-77 
foetal  in,  IV.  77 
maternal,  IV.  76 

table  of  diseases  complicating,  IV.  46,  47 
tetany  in,  IV.  51 
therapeutics    of    the     unborn     infant 

during,  IV.  12 
tubal,  IV.  78-88 

and  uterine,  concurrent,  IV.  81 

colpotomy  in,  IV.  87 

conditions     simulating    rupture    in, 

IV.  84 

of  a  gravid  tube  in,  IV.  84 
diagnostic  doubts  in,  IV.  85 
expectant  treatment  of,  IV.  78 
extra-uterine  pregnancy  complicated 

with  fibroids  in,  IV.  82 
hysterectomy  in,  IV.  87 
transfusion   in  haemorrhage  in,   IV. 

85 
treatment  of  non-gravid  tube  in,  IV. 

86 

operative,  IV.  79 
tuberculosis  in,  IV.  50 
typhoid  fever  in,  IV.  48 
urticaria  in,  IV.  56 
vaginal  examination  in,  IV.  5 
vaginitis  in,  leucorrheal,  IV.  564 
varicose  veins  in,  IV.  89-90 
vesicular  mole  in,  IV.  59 
Premaxillary  bones,  harelip  and.  II.  91, 

92 
Premolars,  lower,  extraction  of,  III.  1184 

upper,  extraction  of,  III.  1181 
Prepuce,  oedema  of,  complicating  gonor- 
rhoea, I.  225 

of  the  newborn  child,  IV.  339 
Presbyopia,  III.  533 
Pressure  bandage  in  ulcers,  I.  370 

local,  in  haemophilia,  II.  33 
Price  (Frederick  W.),    bronchiectasis,  I. 

1043-1048 

chronic  interstitial  pneumonia,  I.  1074- 
1075 


Price  (Frederick  W.)  (contd)— 
pneumokonissis,  I.  1115 
pulmonary  aspergillosis,  I.  1116 
Prickly  heat,  III.  470 
general  management  of,  III.  470 
local  treatment  of,  III.  471 
prognosis  in,  III.  470 
Principles  of  treatment,  I.  1-25 
Probangs,  II.  185 
Probe,  aural,  III.  908 
Proctitis,  epidemic  gangrenous,  III.  437 

infective  ulcerative,  II.  610 
Proctoclysis,  electrical  apparatus  for,  II. 

637 

in  peritonitis,  II.  635 
Prostate  gland,  abscess  of,  II.  922 

after-treatment  of  operation  for,  II. 

922 

operation  for,  II.  922 
adenoma  of,  II.  940-949 
complications.  II.  944-946 
cystitis  in,  II.  945 
epididymitis  in,  II.  945 
haemorrhage  in,  II.  94.r> 
operations  for,  conclusions,  II.  948 
operative  treatment,  II.  941 
palliative  treatment,  II.  941 
perineal  prostatectomy  in,  II.  946-948 
prognosis  in,  II.  946 
supra-pubic    prostatectomy    in,    II. 

942 
calculi  of,  II.  918 

in  bed  of,  complicating  adenoma  of 

prostate,  II.  945 
carcinoma  of,  II.  933 
operation  for,  conclusions,  II.  940 
permanent  supra-pubic   drainage  in, 

II.  939 

diseases  of,  II.  918-929 
endothelioma  of,  II.  932 
enlargement  of,  permanent,  obstruction 

to  micturition  in,  II.  930 
X-rays  in,  III.  367 
fibroma  of,  II.  950-951 

perineal  prostatectomy  for,  II.  950 
malignant  tumours  of,  II.  932-938 

operation  for,  II.  933 
sarcoma  of,  II.  932 
syphilis  of,  II.  927 
tumours  of,  II.  930-949 

obstruction  to  micturition  in,  II.  930 
wounds  of,  II.  919 
Prostatectomy,    perineal,    advantages  of, 

II.  948 

after-treatment  of,  II.  947 
disadvantages  of,  II.  948 
for  fibroma  of  the  prostate,  II.  950 
in  adenoma  of  the  prostate,  II.  946 
operation  of,  II.  946 
supra-pubic,  in   adenoma  of  the  pros- 
tate, II.  S42 

Prostatic  veins,  thrombosis  of,  I.  1331 
Prostatitis,  acute,  II.  920-923 

recto-urethal  fistula  and,  II.  923, 
chronic,  II.  924-926 


95 


A    SYSTEM  OF   TREATMENT. 


Prostatitis,  chronic  (contd.} — 

Janet's  method  of  posterior  irrigation 

in,  II.  925 
complicating  gonorrhoea,  I.  226 

gouty,  II.  926 

onanitic,  II.  927 

tuberculous,  II.  928-929 
Proteid  food  and  over-nutrition,  I.  451 
Protein  diet  for  diabetics,  I.  419 

effect  of,  on  kidneys,  II.  204 

food  in  dietetics,  II.  200 

foods  arranged   in   order   of    value  in, 

II.  197 

Proteins,  digestion  of,  II.  191 
Protene  Company  diabetic  food.  I.  414, 418 

flour,  I.  423 
Prurigo,  III.  1096 
Pruritus,  alcohol  in,  III.  1098 

carbolic  acid  in,  III.  1098 

chemical  remedies  in,  III.  1098 

complicating  diabetes  mellitus,  I.  425 
pregnancy,  IV.  56 

creams  in,  III.  1099 

electrical  methods  in,  III.  1101 

external  treatment  of,  III.  1098 

general  remarks  on,  III.  1097 

gouty,  I.  446 

hydrotherapy  in,  III.  1100 

ichthyol in,  III.  1099 

in  jaundice,  II.  670 

internal  treatment  of,  III.  1098 

lead  in.  III.  1099 

localised,  III.  1100 

lotions  for,  III.  1098  ;  IV.  530 

of  the  vulva,  IV.  517-519 

opium  in,  III.  1099 

or  itching,  III.  1097-1101 

physical  methods  in,  III.  1100 

powders  in,  III.  1099 

tar  in,  III.  1099 

X-rays  in,  III.  359 
Pruritus  ani,  II.  593  ;  III.  1102-1105 

electrical  methods  in,  III.  1104 

local  treatment  of,  III.  1103 

vulvae,  III.  1106-1108 

complicating  pregnancy,  IV.  72-73 

treatment  of,  local,  III.  1107 
Prussic  acid,  poisoning  by,  I.  530 
Pseudo-angina  pectoris  in  gout,  1.  444 

dipsomania,  I.  498 

leukaemia,  II.  42 

osteomalacic  pelvis  complicating  labour, 

IV.  172 
Psoas  abscess,  I.  916 

evacuation  of,  in  tuberculous  disease 
of  the  spine,  I.  931 

contraction    in    Potts1  disease    of    the 

spine,  I.  927 
Psoriasis,  III.  1109-1123 

after-treatment  of,  III.  1122 

alkalies  in,  III.  1114 

anthrarobin  in,  III.  1119 

arsenic  in,  III.  1111 

chrysarobin  in,  III.  1117 

complicating  pregnancy,  IV.  56 


96 


Psoriasis  (contd.~) — 
diet  in,  III.  1110 
general  management  of,  III.  1110 
general  remarks  on,  III.  1109 
of  the  nails,  III.  1121 
of  the  scalp,  III.  1121 
pyrogallol  in,  III.  1121 
salicin  in,  III.  1114 
tar  in,  III.  1119 
thyroid  extract  in,  III.  1114 
treatment  of,  internal,  III.  1111 

local,  III.  1115 
tuberculous,  III.  1152 
X-rays  in,  III.  351,  1122 
Psychalgia,  II.  1123 
Psychasthenia,  II.  1044-1046 
agoraphobia  in,  II.  1044 
claustrophobia  in.  II.  1044 
echolalia  in,  II.  1045 
treatment  of,  II.  1046 
Psychical  impotence,  I.  231,  II.  911 
Psycho-analysis  in  hysteria,  II.  1010 
Psychoses    associated    with    changes    in 

thyroid  gland,  II.  1301-1302 
exhaustion,  II.  1299-1300 
toxic.  II.  1303-1304 
Psychotherapy  in  constipation  in  adults, 

II.  441 

in  melancholia,  II.  1295 
in  morphinism,  I.  519 
Pterygium  of  conjunctiva,  III.  561 
Ptomaine    poisoning    or    bacterial    food 

poisoning,  I.  507-510 
Ptosis,  adiposa,  III.  650 
congenital,  III.  650 
Fuchs'  myopathic,  III.  650 
hysterical,  III.  650 
morning,  III.  650 
neurasthenic,  III.  650 
of  ocular  muscles,  III.  650 
of  the  eyelids,  III.  579 
reflex,  III.  650 
Ptyalism,  II.  130 
and  inflammation  of  parotid  gland,  II. 

161 

Puberty,  dysmenorrhoea  in,  IV.  501 
management  of,  IV.  498-501 
mastitis  at,  II.  960 
menorrhagia  in,  IV.  501 
precocious,  IV.  500 

Pubic  dressing  in  operation  for  elephan- 
tiasis scroti,  III.  513 
Pubiotomy,  IV.  446-450 
Gigli's  saw  in,  IV.  447 
in      contracted     pelvis     complicating 

labour,  IV.  171 
operation  of,  IV.  447 
results  of,  IV.  448 
Puddings,  necessary  in  dietary  of  children, 

I.  59 
Pudenda,    granuloma    of,    constitutional 

treatment  of,  III.  457 
local  treatment  of,  III.  457 
palliative  measures  in,  III.  458 
ulcerating  granuloma  of,  III.  457-458 


A    SYSTEM   OF   TREATMENT. 


Puerperal  infection,  IV.  282-323 
bacteriology  of,  IV.  284 
consecutive  lesions  in,  IV.  283 
metastatic  lesions  in,  IV.  283 
method  of,  IV.  285 
nature  of  lesion  in,  IV.  282 
primary  lesion  in,  IV.  282 
insanity,  IV.  277-278 
mania,  hypnotism  in  case  of,  III.  173 
neuritis,  II.  1139 

sepsis,  abdominal  drainage  in,  IV.  300 
administration  of  saline  solution  in, 

IV.  311 
application  of   strong  antiseptics  to 

the  uterus  in,  IV.  310 
curative  treatment  of,  IV.  294-307 
curettage  of  the  uterus  in,  IV.  299 
drainage  of  pelvic  cellular  tissue  in, 

IV. 306 
drainage  of  the  pelvis  in,  by  vaginal 

incision,  IV.  :;oi.' 
drugs  in,  IV.  313 
eclampsia  and,  IV.  34-41 
empty  uterus  and,  IV.  290 
femoral  thrombo-phlebitis  in,  IV.  321 
fever,  breast,  in,  IV.  315 

continued  in,  IV.  317 

early  acute,  in,  IV.  317 

early  slight,  in,  IV.  314 

reaction  in,  IV.  315 
free  vaginal  drainage  in,  IV.  290 
Livneral  management  of,  IV.  313 
hysterectomy  in.  IV.  302 
identification  of  causative  organism 

in,  IV.  3U7 

intra-uterine  douching  in,  IV.  310 
isolation   of  causative   organism   in, 

IV.  307 

ligation  of  pelvic  veins  iu,  IV.  304 
notification  of,  IV.  322 
nursing  in,  IV.  313 
particular  classes  of,  treatment,  IV. 

314-323 

phlegmasia  alba  dolons  in,  IV.  321 
prevention  of.  I  V.  2S7-294 
prevention  of  injury  to  the  soft  parts 

in,  JV.  i".»i! 

removal  of  a  pyosalpinx  in,  IV.  307 
re-sterilisation  of  general  tract  after 

probable  infection  in,  IV.  290 
salpingectomy  in,  IV.  300 
serum  treatment  of.  IV.  308 
sterilisation  of  hands  in,  IV.  288 

instruments  in,  IV.  288 

lower  genital  tract  in.  1  V.  289 
treatment  of,  non-operative.  IV.  307- 

314 

uterine  exploration  in,  IV.  295 
vaccine  treatment  of.  IV.  .'ln'.t 
vaginal  douching  of.  IV.  311 
va.LMiiitis.  I  V.  .".liij 
Puerperium.  affections  of  the  breasts  in, 

IV.  33(i-33i! 

complications  of.  IV.  •_>72-l'7t; 
cystitis  in.  IV.  272 


Puerperium  (i'ontd.) — 
fever,  late,  in,  IV.  320 
galactocele  in,  IV.  330 
'mastitis  in,  1  V.  334-335 
nipples,  depressed  in.  I  V.  332 

sore  in,  IV.  333 
normal,  anatomy  of,  IV.  257 

blood  in,  IV.  258 

bowels  in,  IV.  266 

breast-feeding  in,  IV.  266 

breasts  in,  IV.  258 

care  of  breasts  in,  IV.  266 

cleanliness  of  vulva  in,  IV.  260 

centra-indications    to    breast-feeding 
in,  IV.  268 

diet  in,  IV.  269 

involution  of  uterus  in,  IV.  261 

lochia  in,  IV.  257,  262 

management  of,  IV.  256-271 

pain  in,  IV.  264 

passage  of  urine  in,  IV.  265 

pelvic  organs  in,  IV.  257 

physiology  of,  IV.  257 

pulse  in,  IV.  261 

removal  of,  discharges  in,  IV.  260 

sleep  in,  IV.  264 

temperature  in,  IV.  261 

time  of  staying  in  bed  in,  IV.  270 

urine  in,  IV.  258 

uterus  in,  IV.  257 

vagina  in,  IV.  257 
painful  engorgement  of,  oreasts  in,  IV. 

331 

paralysis  associated  with,  IV.  281 
pulmonary  embolism  in,  IV.  324-325 
tetanus  in,  IV.  326-327 
tumours  of  ovary  complicating,  IV.  790 
urethritis  in,  IV.  329 
Pulley  and  weight  for  elbow  exercises,  I. 

778 

extension  apparatus  for  fractures,  1. 576 
Pulp,  diseases  of,  III.  1173 
Pulse,  failure  of,  in  cholera,  III.  426 
in  gynaecological  surgery,  IV.  487 
in  normal  puerperium,  IV.  261 
in  typhoid  fever,  I.  364 
Pulse-rate   as  a  guide  to   treatment    in 

pulmonary  tuberculosis,  I.  1141 
in  non-operative  appendicitis,  II.  424 
Pupils,    condition    of    in    cerebral   com- 
pression, I.  880 
dilatation  of,  after  mature  cataract,  III. 

630 
Purgation,  in  iutra-cerebral  haemorrhage, 

II.  1171 

predisposes  to  shock.  I.  95 
Purgatives,  anthracene,  in  constipation  in 

adults,  II.  447 
choice  of,  in  constipation  in  adults,  II. 

445 
dosage  of,  in  constipation  in  adults,  II. 

I):, 

in  ascites,  II.  627 
in  constipation  in  adults,  II.  444 
in  non-operative  appendicitis,  II.  423 


97 


A    SYSTEM  OF    TREATMENT. 


Purgatives  (contd.) — 
in  peritonitis,  II.  638 
in  taeniasis  intestinal,  III.  518 
in  typhoid  fever,  I.  355 
mercurial,  in  constipation  in  adults,  II. 

450 

saline,  in  constipation  in  adults,  II.  449 
sunthesised,  in  constipation  in  adults,  II. 

449 
vegetable,  in  constipation  in  adults,  II. 

447,  454 

Purin  bodies,  effect  of  in  food,  II.  207 
Purin-free  diet  in  gout,  I.  452 
Purpura,  II.  43-45  ;  III.  1124 
general  treatment  of,  II.  43 
hajmorrhagica,  II.  44 
medicinal  treatment,  II.  44 
Parslow  (C.  E.),  air  embolism  in  labour, 

IV.  161-162 
albuminuria    during     pregnancy,    IV. 

30-33 
complications  of  the  puerperium,  IV. 

272-276 

eclampsia,  IV.  34-41 
insanity  of  lactation,  IV.  279 
insanity  of  pregnancy,  IV.  45 
paralyses  associated  with  labour,  IV.  280 
paralyses  of  pregnancy,  IV.  60 
puerperal  insanity,  IV.  277-278 
pulmonary  embolism  in  the  puerperium, 

IV.  324-325 

tetanus  in  the  puerperium,  IV.  326-327 
tetany  in  the  puerperium,  IV.  328 
urethritis  in  the  puerperium,  IV.  329 
Pus,  evacuation  of   in  Bier's  treatment, 

III.  50 

formation,  Gauvain's  method  in,  I.  757 
in  abcess  of  the  liver,  II.  649 
in  the  liver,  needle  in  search  for,  II. 

650 

in  pelvic  cellulitis,  IV.  828 
tuberculous,  antibacterial  properties  of, 

I.  174 

Pustulation  in  herpes  zoster,  III.  1013 
Pyaemia  and  septicremia,  general  and  local 

treatment  of,  I.  295-298 
Pyelitis,  II.  803-806 
diagnosis  of,  II.  803 
in  childhood,  II.  805 
of  infancy,  II.  805 
of  pregnancy,  II.  806 

operative  treatment  of,  II.  806 
treatment  of,  II.  806 
Pyelolithotomy  for  renal  calculus,  II.  763, 

764 

Pyelonephritis,  ascending,  II.  810 
acute,  II.  811 

acute  operative  treatment  of,  II.  811 
chronic,  II.  812 
prognosis  in,  II.  810 
haematogenous,  II.  807 
infective,  II.  807-813 
drugs  in, II.  808 
medicinal  treatment  of,  II.  808 
operative  treatment  of,  II.  809 


Pyelonephritis,  infective  (contd.') — 
prognosis  in,  II.  807 
vaccine  treatment  of,  II.  808 
of  pregnancy,  II.  806 
primary,  II.  807 
secondary,  II.  810 
Pylephlebitis,  suppurative,  of  the  liver, 

II.  666 
Pylerodiosis  for  pyloric  stenosis,  II.  316 

Loreta's  operation,  II.  317 
Pylorectomy    for     hypertrophic     pyloric 

stenosis,  II.  342 
for  pyloric  stenosis.  II.  316 
in  gastric  cancer,  II.  306 
Pyloroplasty  for  liypertrophic  stenosis  of 

the  pylorus,  II.  339,  342,  343 
for  pyloric  stenosis,  II.  316 
in  ulcer  of  the  stomach,  II.  385 
three  stages  of  operation  of,  II.  384 
Pylorus,  congenital  atresia  of,  II.  344 
hyperplasia  of,  II.  337 
obstruction  of,  due  to  gastric  cancer, 

I.  140 

stenosis  of,  II.  312-315 
in  gastric  cancer,  II.  298 
surgical  treatment,  II.  316 
hypertrophic,  II.  337-341 
after-treatment  in.  II.  340 
infantile,  II.  338 
spasm  in,  II.  337 
surgical  measures,  II.  339-342 

treatment  of,  II.  342-344 
Pyonephrosis,  II.  814-818 

drainage  by  ureteral  catheter,  II.  815 
nephrectomy  in,  II.  817  . 
nephrostomy  in,  II.  815 
plastic  operations  in,  II.  815 
X-rays  in,  II.  814 
Pyopneumothorax,  I.  1113 

cases  of  an  entirely  tuberculous  nature, 

1.1114. 

surgical  treatment  of,  1114 
Pyorrhoea  alveolaris,  III.  1176 
vaccine  therapy  of,  III.  287 
Pysosalpinx,    removal   of,    in    puerperal 

sepsis,  IV.  307 
Pyothorax  in  injuries  of  the  thorax,  I. 

1029 
Pyrexia,     complicating     operation     for 

goitre,  II.  69 
in  fevers,  relief  of,  I.  159 
in  typhoid  fever,  I.  348 
of  relapsing  fevers,  I.  2G6 
Pyridine,  poisoning  by,  I.  533 
Pyrmont  spa,  III.  l.vi 
Pyrogallic  acid  in  lupus,  III.  1150 
Pyrogallol  in  psoriasis,  III.  1121 
Pyuria,  II.  749 


Quackery,  cancer  cures  and,  I.  147, 148 
Quarantine  for  small-pox,  I.  310 
Quinine  in  arthritis  deformans,  I.  395 

in  blackwater  fever,  III.  386 

in  chlorosis,  II.  27 


A    SYSTEM  OF   TREATMENT. 


Quinine  (cuntd.) — 

in  chronic  dysentery,  III.  434 
in  gonorrhoeal  arthritis,  I.  ~s:! 
in  typhoid  fever,  I.  352 
in  undefined  tropical  fevers,  III.  41U 
in  whooping  cough,  I.  382 
ointment  inunction  of,  I.  70 
rectal  administration  of,  III.  396 
use  of,  in  malaria,  III.  392,  394 
value  of  during  convalescence.  I.  65 


Rabies,  I.  264-265 

incnhatnm  period  in,  I.  2<>5 
Pasteur's  inoculation  method  of  treat- 
ment. I.  .Ml I 

treatment  at  sight  of,  I.  264 
yeast  in.  III.  288 

Racket  incision  in  amputations,  I.  796 
Radiant  heat,  treatment  by,  III.  316-326 
Radicularodontom.es,  II.  110 
Radio-active  waters  in  rheumatism,  I.  491 
Radio-activity,  induction  of,  III.  315 
of  mineral  waters,  I.  458 
i if  waters.  III.  115 
Radium,  application   of,   to   the  mucous 

cavities,  III.  308 
to  the  skin,  III.  308 
effect  of  on  growth  of  cancer  cells,  I. 

129 
in  cancer,  I.  155 

of  cervix.  IV.  <!1.~> 
in  epithelioma  of,  II.  139,  144 
in  lupus,  III.  1150 

erythema)  OH  is.  III.  1071 
in  rodent  ulcer,  I.  115 
in  small  capillary  n:rvi,  III.  1079 
therapy,  III.  303-315 

caustic  method  in,  III.  308 
combined   with   surgical    operations, 

ill.  :u:< 
composite-ray     apparatus     in,      III. 

306 

method  in,  III.  305 
induction   of   radio-activity   in,    III. 

:i  i :, 
introduction  of  tubes  into  the  tissues 

in,  III.  :U1 

method  of  implication  by.  III.  3i>3 
methods  of  use,  III.  3nX 
topographical  view  of,  III.  306 
ultra-penetrant  ray  apparatus  in,  III. 

306 

method  in.  III.  305 
tubes,  introduction  of,  into  the  tissues, 

III.  311 

Radius,  absence  of.  I.  936 
Colles's  fracture  of,  I.  578 
congenital  defects  of,  I.  936 

dislocation  of  head  of.  I.  936 
dislocations  of,  I.  721 
epiphysis  of,   lower,    separation   of,  in 

fractures,  I.  603 
fracture  of.  I.  686 
head  of,  fracture  of,  I.  598 


Radius  (contd.) — 
separation  of  the  upper  epiphysis  of,  in 

fractures,  I.  599 

shaft  of.  fracture  of,  I.  599,  600,  601 
Ragatz-Pfaefer's  spa,  III.  154 
Ranula   cyst   and    inflammation    of    the 

parotid  gland,  II.  158 
of  floor  of  mouth,  II.  145 
of  the  tongue,  II.  1  r> 
Rashes  following  ether  anaesthesia,  III.  9 

use  of  antitoxin,  I.  193 
Rational  treatment,  principles  of,  I.  2 
Raw  beef  essence,  preparation  of,  1 .  1 1' 
Raynaud's  disease,  I.  218-219;  IT.  1238- 

1241 

gangrene  in,  II.  1240 
general  treatment  of,  I.  218 
local  treatment  of,  I.  218 
of  the  auricle,  III.  ssn 
Rays,  infra-penetrant.  III.  304 
ultra-penetrant,  III.  304,  310 
Reach  in  physical  exercises,  III.  230 
von  Recklinhausen's  disease,  I.  112  ;  III. 

1074 
Rectal  feeding  in  scarlet  fever,  I.  284 

in   stricture    of    the   oesophagus,   II. 

171 

methods  of,  I.  29 
infusion  in  shock,  I.  99 
inje  'lions  for  lowering  temperature,  I. 

69 
Rectocele  of  the  vagina  complicated  by 

ulceration,  IV.  547 
operative  treatment,  IV.  551 
palliative  treatment  of,  IV.  517 
surgical  treatment  of,  IV.  693 
Recto-urethral    fistula    and    acute    pro- 

statitis,  II.  923 
Recto-vaginal   tistuhe,   complications  of, 

II.  609 
Rectum,  administration   of  fluids  by,   in 

peritonitis,  II.  635 
quinine  by.  in  malaria,  III.  396 
cancer  of,  relief  of  obstruction  in,  1.  141 
diseases  of,  II.  593-625 
in  bilharzia,  III.  500 
enemata  by,  in  constipation  in  adults, 

II.  455 

in  Wcrtheim's  operation,  IV.  607 
malignant  growths  of,  II.  625 
neurosis  of,  II.  614 
operations  up,  anaesthetics  in.  III.  32 
pain  in.  II.  till 
procidentia  of.  II.  r,2l-<;23 
prolapse  of,  11.621-623 
operations  for,  II.  622 
simple  tumours  of,  II.  624 
symptoms  in  paraplegia,  II.  1199 
wound  of,  complicating  perineal  prosta- 
tectomy in  adenoma  of  prostate,  II. 
948 
Rectus  abdominalis,    tetanic  rupture  of, 

II.  LM'.i 

Red  light,  use  of,  III.  187 
bath,  III.  193 

99  7—2 


A    SYSTEM  OF  TREATMENT. 


Reflector  bath  in  radiant   heat  therapy, 

III.  321 

Reflex  epilepsy,  II.  991 
Refraction  and  cataract,  III.  618 
errors  of,  headache  in,  II.  1033 
of  the  eye,  errors  of,  III.  528-542 
Regime   lactee  in  chronic  congestion  of 

the  lungs,  I.  1079 
Reichenhall  spa,  III.  154 
Reichmann  on  irrigation  of  the  stomach, 

II.  365 
Relapse  in  rheumatism,  acute,  I.  273 

in  childhood,  I.  279 
Repair,  factor  of  inflammation,  I.  10 
process  of,  influence  of  nervous  system 

on,  I.  12 

Resistance,  natural,  to  pathological  pro- 
cesses, I.  3,  5 
Resolvent  baths,  III.  126 
Respiration,  artificial,  in  electrical  injuries 

and  burns,  I.  547 
in  poisoning,  I.  530,  532,  534 
Schultze's  method  of,  in  asphyxia  of 

newborn  child,  IV.  352 
children  to  be  taught  correct  method 

of,  I.  49 

effect  of  shock  on,  I.  94,  97 
impaired  in  diphtheritic  paralysis,  I.  201 
rate  in  gynecological  surgery,  IV.  487 
See  also  Breathing. 
Respiratory   organs,  cancer  of,  relief  of 

obstruction  in,  I.  142 
system  and  typhoid  fever,  I.  360 

anthrax  of,  I.  179 
tract,    upper,    chronic    hyperplasia    of 

mucous  membrane  of,  III.  774 
Rest  and  fixation  in  tuberculous  disease 

of  the  hip-joint,  I.  755 
of  the  knee-joint,  I.  765 
and  pelvic  support  for  applying  a  plaster 

spica  to  the  hip,  I.  946 
automatic  provision  of,  I.  16 
during  accidental  haemorrhage  in  preg- 
nancy, IV.  24 
arthritis  deformans,  I.  392 
importance  of  in  treatment,  I.  12 
in  acute  endocarditis,  I.  1191 
in  acute  rheumatism,  269,  274 
in  aortic  anenrysm,  I.  1299 
in  bed  in  gynaecological  surgery,  IV.  489 
in  chlorosis,  II.  20 
in  chorea,  II.  1260 
in  diphtheria,  I.  187 
in  diseases  of  the  heart,  I.  1203 
in  exophthalmic  goitre,  54 
in  guides  to  the  control  of  auto-inocu- 
lation, I.  1162 
in  hemorrhage,  I.  1262 
in  pernicious  anemia,  II.  1 
in  pleurisy,  I.  1093 
in  pulmouar}'  tuberculosis,  I.  1122 
in  rheumatism  (chronic),  I.  489 
in  treatment  of  ulcers,  I.  368 
in  the  tropics,  III.  379 
in  tuberculous  disease  of  joints,  I.  752 


Rest  (contd.~) — 
in  wounds,  I.  554 
influence  of  in  dietetics,  II.  199 
question  of,  for  young  children,  I.  56 
stage  in  sanatorium  treatment  of  tuber- 
culosis, I.  1128 
therapeutic  value  of,  1. 16 
Restlessness    complicating    acute    rheu- 
matism, I.  272 
Retina,  arteria  centralis  of,  embolism  of, 

III.  644 

detachment  of,  III.  643 
diseases  of,  III.  042-644 
tumours  of,  III.  644 
Retinal  veins,  thrombosis  of,  III.  (544 
Retinitis  complicating  diabetes  mellitus, 

1.426 

pigmentosa,  III.  644 
Retro-peritoneal  lipoma,  I.  106 
Retro-pharyngeal  abscess,  III.  789-790 

in  diseases  of  the  spine,  I.  916 
Retro-rectal    abscess    of    the    anus,    II. 

604 

Rheinerz  spa,  III.  155 
Rheinfelden  spa,  III.  155 
Rheumatic  fibrositis,  II.  1023,  1121 
Rheumatism  (acute),  I.  268-275 

calomel  or  hydrargyrum    cum  creta 

in,  I.  270 

complications  of,  I,  272 
convalescence  from,  I.  273 
diet  in,  I.  270 
general  measures  in,  I.  269 
in  anemia,  II.  15 
local  applications  in,  I.  269 
medicinal  measures  in,  I.  270 
persistence  of  temperature  in,  I.  272 
prophylaxis  of,  I.  275 
salicylates  in,  I.  271 
serum  treatment  of,  I.  272 
affections  of  the  throat  in,  III.  764 
(chronic),  I.  483-491 

allied  conditions  of,  I.  483 
clothing  in,  I.  485 
diet  in,  I.  486 
drugs  in,  I.  490 
electricity  in,  I.  488 
exercise  in,  I.  489 
external  applications  in,  I.  486-488 
heat  therapy  in,  I.  486 
ianisation  in,  I.  488 
liniments  for.  I.  487 
massage  in,  I.  488 
rest  in,  I.  489 
spa  treatment,  I.  491 
climate  for,  III.  94 
gonorrhoea!,  I.  228 
hypnotism  in  case  of,  III.  171 
(in  childhood),  I.  276-279 
after-treatment  of,  I.  279 
cardiac  lesions  in,  I.  278 
details  of  treatment  calling'for  special 

comment,  I.  277 
drugs  in,  I.  278 
prophylaxis  of,  I.  277 


100 


A    SYSTEM  OF   TREATMENT. 


Rheumatism  (in  childhood)  (contd.) — 
treat  mi-lit   of.  every  rheumatic  mani- 

I'e-tation,  I.  277 
iritis  in.  III.  ."iS7 

mineral  waters,  and  baths  in,  III.  142 
(muscular),  I.  I'.HM'.M 

chronic,  massage  in,  III.  209 
drugs  in.  I.  4!'3 
heat  therapy  in,  I.  493 
massage  in,  I.  494 
in\  iritis  iii.  1 1.  1324 
m-iiritis  in,  II.  1130 
paralysis  of  ocular  muscles  in,  III.  649 
pericarditis  in,  I.  1179 
scarlatinal,  I.  290 
MM-  of  the  blister  in,  I.  69 
Rheumatoid   arthritis.     See   utulrr  Arth- 
ritis. 

conditions,  climate  for,  III.  94 
Rhinitis,  acute,  III.  701-704 
prophylaxis  of.  III.  702 
simple,  III.  701 
atrophic,  III.  706 

local  treatment  of,  III.  707 
chronic,  III.  7<C.-712 
anti-toxins  in,  III.  709 
friction  in,  III.  709 
general  treatment  of,  III.  708     ' 
local  complications  of.  III.  708 
packing  the  nose  in,  III.  708 
paraffin  injections  in,  III.  709 
simple,  III.  705 
vaccine  treatment  of,  III.  709 
vibratory  massage  in,  III.  709 
fibrinous.  ill.  703 
hypertrophic,  III.  710 
chronic,  and  Eustachian  obstruction, 

111.  ;>lt; 

purulent,  III.  703 
sicca,  III.  711 

anterior  of  nose,  III.  665 
local  treatment  of,  III.  711 
traumatic.  III.  7"! 
vasomotor,  III.  704 
Rbinoliths.  III.  f.c.'.i 
Rhinophyma,  III.  1 135-1 136 
Rhinorrhcea  in  scarlet  fever,  I.  282 
paroxysmal,  III.  ('*'.' 
vasomotor,  III.  689 
Rhinoscleroma.  III.  713 
deRibes'  bag,  IV.  isr, 

central     insertion    of     in    placenta 

pncvia,  IV.  67,  68 
in  forcible  methods  of  delivery,  IV. 

442 
in  induction  of  premature   labour,  IV. 

440 

in  placenta  prajvia,  IV.  66,  68 
position   of  in   uterus   in  induction  of 

premature  labour,  IV.  441 
Ribs  cartilage,  of  tuberculous  disease  of,  I. 

1032 
cervical,  brachial  plexus  injury  and,  II. 

1012 
injury  of  brachial  plexus  in,  II.  1110 


Ribs  (contd.)— 

fracture  of,  in  newborn  child,  IV.  352 

inflammation  of,  I.  1032-1033 

new  growths  of,  I.  1034 

re-section  of,  in  generalised  empyema, 

I.  1104 

syphilis  of,  I.  1032 
tuberculous  disease  of,  I.  1032 

Richet  (Charles),  method  of  hypnotism, 

III.  165 
Rickets,  climate  for,  III.  96 

clothing  in,  I.  478 

cod-liver  oil  in,  I.  66 

deformities  of,  I.  970-972 
of  bones  in,  I.  481 

diet  in,  1.479 

digestive  disorders  in,  I.  479 

drugs  in,  I.  479 

hydrotherapy  in,  I.  478 

in  anajmia,  II.  14 

in  newborn  child,  IV.  371 

open-air  treatment,  I.  478 

special  measures  in,  I.  480 
Ricketts  (T.  F.),  small-pox,  I.  302-311 

vaccination,  I.  311-314 
Ricord's  paste  in  soft  chancre,  I.  315 
Riedel's  lobe  of  the  liver,  II.  659 
Rigg's  disease,  vaccine  therapy  of ,  III.  287 
Ring  forceps,  IV.  475,  476 
Ringworm,  III.  1125-1131 

in  the  tropics,  III.  473 

of  the  beard,  III.  1130 

of  the  nails,  III.  1082,  1131 

pustular,  III.  1129 

X-rays  in,  III.  354,  1125 
Rippoldsau  spa,  III.  155 
Robert's  pelvis  complicating  labour,  IV. 

173 

Roberts  (C.  Hubert),  pubiotomy,  IV.  446- 
450 

symphysiotomy.  IV.  452-460 
Roberts  (J.  Reid),  typhoid  fever,  I.  335- 

364 
Roberts    (Sir    Wm.),     paraffin    in    skin 

eruptions,  I.  446 

Robson  (A.  W.  Mayo),  acute  post-opera- 
tive dilatation  of  the  stomach,  11.311 

fistula;    of    the  gall-bladder   and  bile 
ducts,  II.  698-6W 

hour-glass  stomach,  II.  334-336 

inflammatory    affections    of    the    gall 
bladder  and  bile  ducts,  II.  700-709 

injuries  and  diseases  of  the  pancreas, 

II.  716-729 

injuries  of  the  bile  passages,  II.  680- 

681 

injuries  to  the  stomach,  II.  282 
perforation  of  ulcer  of  the  duodenum, 

II.  396-398 
perforation  of  ulcer  of   the  stomach, 

II.  389-390 
surgical   treatment   of    cancer  of    the 

stomach,  II.  302-3U9 
surgical  treatment  of  cholelithrasis,  II. 

686-697 


101 


A    SYSTEM  OF  TREATMENT. 


Robson  (A.  W.  Mayo)  (w/rfrf.)— 

surgical  treatment  of  gastroptosis,  IT. 

328-324 
surgical  treatment  of  haemorrhage,  II. 

881-333 
surgical     treatment    of    pertrophichy 

pyloric  stenosis,  II.  342-344 
surgical  treatment  of  pyloric  stenosis 

and  obstructive  dilatation,   II.   316- 

317 
surgical  treatment  of  ulcer  of  duodenum, 

II.  391-394 
surgical  treatment  of  ulcer  of  stomach, 

II.  3X2-388 

tetany  of  stomach,  II.  399 
tumours  of  bile  ducts.  II.  713-715 

of  gall  bladder,  II.  710-712 

(simple)  of  stomach,  II. 
volvulus  of  the  stomach,  II.  400 
Rodagen  in  exophthalmic  goitre,  II.  56 
Rodent  ulcer,  III.  1132-1134 
excision  of,  I.  114 

free  and  wide,  III.  1132 
extension  of,  I.  123 
Finsen  light  in,  III.  1134 
freezing  in,  I.  115 
ionic  medication  of,  III.  184 
ionisation  in,  III.  1133 
of  the  cornea,  III.  566 
of  vulva,  IV.  508 
radium  in,  I.  115 
Rontgen  rays  in,  III.  1133 
solid  carbon  dioxide  in,  I.  115 
spread  of,  I.  125 
X-rays  in,  I.  114 
Rolleston  (H.  D.),  acute  yellow  atrophy 

of  the  liver,  II.  657-658 
anomalies  in  form  and  position  of  the 

liver,  II.  659 
ascites,  II.  626-631 
cholelithiasis,  II.  682-685 
degenerations  of  the  liver,  II.  668 
functional   derangement   of   the  liver, 

1 1.  668 

hydatid  cysts  of  the  liver,  II.  669 
hypertrophic  biliary  cirrhosis  (Hanoi's 

disease),  II.  664 
jaundice,  II.  670-675 
lavdaceous  or  amyloid  liver,  II.  675 
portal  or  common  cirrhosis  of  the  liver, 

II.  660-663 

syphilitic  cirrhosis  of  the  liver,  II.  665 
thrombosis  of  the  portal  vein,  II.  666- 

667 

tumours  of  the  liver,  II.  679 
Romer  (Frank),  sprains,  I.  737-740 
Roncegno  .spa.  1 1 1 .  1  .V> 
Rontgen  rays.     See  under  X-rays. 
Rood's   apparat  us  for   intravenous  anaes- 
thesia, III.  35 
Rooms,  aspect  of,  to  be  south  or  west,  I. 

44 

preparation  of,  for  operation,  I.  26-31 
Roots  of  teeth,  lower,  extraction  of,  III. 
1186 


Rosacea,  III.  1135-1136 

Rotch  on  modified  milk  in  infant  feeding, 

II.  224 

Roth-Drager   apparatus  for  anaesthetics, 

III.  14. 

Rough  ton's  splint,  I.  630 

Roulte's     Hushing    curette    in    retained 

placenta,  IV.  227 

Round  ligaments,  shortening  of,  in  retro- 
flexion  of  the  uterus,  IV.  681 
Roux's  curette,  IV.  624 
Rowntree    (Cecil),   general   principles  of 
the  treatment  of  cancer,  I.  116-156 

surgical  treatment  of  tumours,  I.  106- 

156 

Royat  spa,  III.  155 

Rubber  cord,  application  of,  in   elephan- 
tiasis scroti,  III.  505 

gloves  in  gynaecological  operations,  IV. 
483 

goods,  disinfection  of,  I.  161 

tooth  cleaner,  II.  128 

tourniquet  in  haemorrhage,  I.  1258 
Rubella,  I.  280 

Rudel  on  urea  solution,  I.  437 
Rupture  of  muscles,  II.  1322 

subcutaneous,  of  tendons,  II.  1328. 
Russell  (J.  Risien),  disseminated  sclerosis, 
II.  1070-1076 

tabes  dorsalis,  II.  1085-1092 
Rye  bread,  gangrene  from  use  of.  I.  219 


Saccharin  in  obesity,  I.  472 
Saccharine  foods  in  gout,  I.  453 
Sacculus  of  the  female  urethra,  IV.  S7<i 
Sacro-iliac  disease,  I.  920 

joint,  tuberculous  disease  of,  I.  780 
Sacrum,  fracture  of,  I.  608 
Saint- Armand  spa,  III.  155 
St.  George's  Hospital  diet  table,  II.  202 

statistics  of  appendicitis  at.  II.  402 
Saint-Gervais  spa,  III.  155 
Saint-Honore  spa,  III.  155 
St.  Moritz  spa,  III.  155 
St.  Nectaire  spa,  III.  155 
St.  Sauveur  spa,  III.  155 
St.  Thomas'  Hospital,  table  of   cases  of 

acute  peritonitis  at,  II.  633 
Sal  alembroth  gauze  and  wool,  I.  78 
Salads,  danger  of,  in  the  tropics,  III.  384 

vegetables  and,  in  obesity,  I.  472 
Salicine  in  influenza,  I.  234 

in  psoriasis,  III.  1114 
Salicylate  of  soda  in  erythema  nodosum, 
I.  213 

in  rheumatism  in  childhood,  I.  278 

ionisation  with,  I.  488 
Salicylates,  action  of,  I.  388 

in  acute  rheumatism,  I.  271 

in  chronic  rheumatism,  I.  487 

in  typhoid  fever,  I.  352 
Salicylic  acid  in  lupus,  III.  1150 

gauze  and  wool,  I.  78 
Salies  de  Beam  spa,  III.  155 


102 


A    SYSTEM  OF   TREATMENT. 


Saline  enema.  I.  33 

infusion  in  ha-morrliage.  I.  1262 
intravenous,  in  eclampsia,  IV.  3.". 
subcutaneous  in  eclamp-ia,  IV.  M."> 
intra-peritoneal,   administration   of,  in 

haemorrhage,  I.  1208 
normal,  infusion  of,  in  shock,  I.  98 
purgatives  in  constipation  in  adults,  II. 

149 

solution,    administration   of,    in    puer- 
peral sepsis.  IV.  311 
injection  of,  in  sciatica,  II.  Io27 
intravenous   injection    of,   in   scarlet 

fever,  I.  288 

Salines  in  alcoholic  gastritis,  II.  353 
Salins  spa.  II  I.  l.'.i! 
Salins-Moutiers    spa.        See    Brides     les 

Bains. 
Salisbury  dietary  in  chronic  rheumatism, 

I.  486 

treatment  of  obesity.  I.  468.  471 
Salit  liniment  in  rheumatism,  I.  487 
Salivary    calculi    and    inflammation    of 

parotid  gland.  II.  l.~>9 
fistula  and  inflammation  of  the  parotid 

gland,  II.  160 
glands,  diseases  of.  II.  130-131,  157-163 

injuries  of,  IT.  157-163 
Salivation   and  inflammation  of   parotid 

gland.  II.  161 
increased,  II.  I"" 
Salmon's   truss   for  inguinal  hernia,   II. 

527 

Salol  in  typhoid  fever,  I.  354 
Salpingectomy   in   puerperal   sepsis,   IV. 

soo 

Salpingitis.  IV.  so.vsi  I 

acute,  of  Fallopian  tube.  IV.  810 
chronic .  of  Fallopian  tube,  IV.  813 
gonoroccus  in,  IV.  831 

ii-liu-al,  in  children,  IV.  807 
of  Fallopian  tubes,  IV.  821-830 

complicating  cancer  of  the  uterus,  IV. 

830 

preventive  treatment  of,  IV.  815 
septic  infection  of  tubes  in,  IV.  807 
si  reptococcus  in,  IV.  831 
treatment  of.  preventive,  IV.  831 
tubercle  bacillus  in,  IV.  831 
tuberculous.  IV.  833-835 

Salpingostomy  in  inflammation  of  Fallo- 
pian tubes.  IV.  M«.I 

Salsomaggiore  spa,  III.  156 

Salt  contra-indicated  in  obesity.  I.  470 
diminution  of,  in  typhoid  fever,  I.  343 
effect  of.  on  kidneys,  II.  206 
muriatcd  waters.  III.  118,  129 
restriction  of,  in  chlorosis,  II.  28 

Salts  in  malaria,  III.  393 

irritant,  poisoning  by.  I.  .">28-530 

Salvarsan  ("606")  in  spinal  syphilis,  I. 

917 

in  Frambresia  tropica,  III.  463 
in  syphilis.  I.  14'.'.  3i'L' 
in  tabes  dorsalis.  II.  1088 


Sanatorium     treatment     of     pulmonary 

tuberculosis,  I.  1127-1158 
Sand  baths,  III.  136 

flea  (dermatophiliasis),  III.  481 
"  fly  fever,  III.  400 
Sandefjord  spa.  III.  15ii 
Sandwith  (F.  M.)  pellagra,  I.  521-524 
Sanitasa  useful  douche,  I.  137 

Electrical  C'o.'s  vibrator,  III.  214 
Santonin  in  ascariasis,  III.  494 
Sarcoid  of   Boeck,  multiple  benign,  111. 

1152 
Sarcoma,  amputation  in,  I.  791 

Coley's    fluid    in,    I.    153,    920;     III. 
299 

cutis,  III.  1037 

extension  of,  I.  124 

melanotic,  true  nature  of,  I.  125 

of  bones,  I.  711 

of  muscle,  II.  1325 

of  nerves,  II.  1044-1142 

of  the  breast,  II.  975 

of  the  female  urethra,  IV.  872 

of  tjie  gall  bladder,  II.  712 

of  the  jaws,  II.  112 

of  the  prostate,  II.  932 

of  the  scalp,  I.  893 

of  the  spleen,  II.  81 

of  the  tongue,  II.  144 

of  the  umbilicus,  II.  281 

of  the  uterus,  IV.  718-719 
leucorrhoea  in.  IV.  r>71 

of  the  vulva,  IV.  516 

operability  of,  I.  122 

primary,  of  the  vagina,  IV.  553 

radium  therapy  of,  III.  312 

secondary  growths  of,  I.  1 2"> 
Sarcomata,  myeloid,  of  the  jaw,  II.  110 

of  the  bones  of  the  skull,  I.  895 
Sarsaparilla  in  syphilis,  I.  323 
Saturnine  cachexia  in  lead  poisoning,  I. 
514 

encephalopathy   in    lead  poisoning,   I. 

514 
Saugman's  needle  in  artificial  pneumo- 

thorax.  T.  1167 
Saundby  (Sir  Eobert),  enteritis  (acute  and 

chronic)  in  adults,  II.  479-482 
Sausages,   chemical    composition  of,   II. 
193 

poisoning  by,  I.  510 
Savin,  poisoning  by,  I.  533 
Sazin  in  obesity,  I.  472 
Sayres's  strapping  in  fractures,  I.  583-586 
Scabies,  III.  1137-1138 
Scafati  (Signer),  and  voice  production,  III. 

338 
Scalds  of  the  trachea,  III.  797 

and  burns,  I.  540-544 

general  treatment  of,  I.  543 
immediate  treatment  of,  540 
local  treatment  of  burnt  areas  in,  I. 

540 

treatment  of  contractions  following, 
I.  r.43 


103 


A    SYSTEM   OF   TREATMENT. 


Scale  preparations  in  chlorosis,  II.  24 
Scalp,  alopecia  dependent  on  morbid  con- 
ditions of,  III.  1000 

avulsion  of,  I.  875 

bald,  after  X-rays,  "5-exposure  method," 
III.  358 

contusions  of,  I.  873 

dermoid  cysts  of,  I.  110 

generalised  infections  of,  I.  888 

haemorrhage  from,  I.  1275 

infective  lesions  of,  I.  888 

injuries  of,  I.  873-875 

localised  infections  of,  I.  888 

psoriasis  of,  III.  1121 

scales  on,  in  psoriasis,  III.  1116 

seborrhoea  of,  III.  1141 

soreness  of,  neuralgic  headache  in,  II. 
1116 

surgical  diseases  of,  I.  888 

tumours  of,  I.  892-896 

wounds  of,  I.  874 

Scapula,  acromion  process  of,  fracture  of, 
I.  586 

coracoid  process  of,  fracture  of,  I.  586 

detachment  of,  in  Berger's  operation,  I. 
834 

fractures  of,  I.  585-586 

neck  of,  fracture  of,  I.  585 

neuralgia,  II.  1121 
Scarification  in  cheloid,  III.  1018 

in  lupus,  III.  1149 
Scarlet  fever,  I.  281-294 

acute  inflammation  of  middle  ear  in, 
III.  902 

adenitis  complicating,  I.  290 

arthritis  complicating,  I.  290 

cardiac  affections  complicating,  I.  293 

cervical  cellulitis  complicating,  I.  290 

complicating  pregnancy,  IV .  48 

complications  of  treatment  of,  I.  289 

diet  in,  I.  283 

general  management  of,  I.  281 

hyperpyrexia  in,  I.  289 

infectivity  of,  I.  282 

nephritis  complicating,  I.  292 

otitis  media  complicating,  I.  289 

remedial  treatment  of,  I.  284 

"  return  cases  "  of,  I.  282 

septic,  I.  283,  284,  287 

serum  therapy  in,  I.  286 

toxic,  I.  288 

ulcerative  stomatitis  in,  I.  293 

vaccine  therapy  of,  I.  288 
Scars  in  burns  and  scalds,  I.  543 

seat  of  carcinoma,  I.  1 17 
Schatz's  method  in  face  presentation  of 

labour,  IV.  141 
Schinznach  spa,  III.  156 
Schlangenbad  spa,  III.  156 
Schlatter  (Prof.),  on  results  of  operations 

on  jaws,  II.  117 
Schleich's    solution   for    local  analgesia, 

III.  38 
Schlbsser's  method  of  division  of  nerves 

I.  135 


Schnee  four-cell  bath,  I.  747 

School   children,  sleeplessness  in,  causes 

of,  I.  55 
work,   pressure  in,    to   be   avoided,    I. 

8,  9 
Schools,  diphtheria  in,  prophylactic  use  of 

antitoxin,  I.  192 
Schroeder's  operation  in  endometritis,  IV. 

629,  630 
Schrotter's  hollow  vulcanite  bougie,  III. 

865 

Schultze's    artificial    respiration    in    as- 
phxyia   of    the   newborn   child,  IV. 
352 
pessary  in   retroflexion  of  uterus,  IV. 

680 
Schummelbusch's   mask    in    anaesthetics, 

III.  9,  10 

Schwalbach  spa,  III.  156 
Schwartze's    operation  for    opening  the 

mastoid  antrum.  III.  898 
technique  of,  III.  898 
post-aural  operation  in  diseases  of  mas- 
toid process,  HI.  922,  923 
tenotomes,  III.  914 
Sciatic  arteries,  injuries  to,  I.  1276 

neuritis,  old-standing  chronic,  II.  1125 
Sciatica,  II.  1123 
acute,  II.  1123 
chronic,  II.  1125 

complicating  diabetes  mellitus,  I.  426 
hypnotism  in  case  of,  III.  170,  171 
in  gout  and  gouty  conditions,  I.  444 
massage  in,  III.  210 
mineral  waters  and  baths  in,  III.  142 
surgical  treatment  of,  II.  1129 
Scirrhus.  atrophic,  of  the  breast,  II.  964 
Scissors,  long,  for  enucleation  of  tonsil, 

III.  753 

Sclavo's  anti-anthrax  serum,  I.  179 
Sclerodermia,  III.  1139 
Sclerosis,  amyolrophic  lateral,  II.  1054 
disseminated,  II.  1070-1076 
fibrolysin  in,  II.  1074 
general  treatment,  II.  1071 
mercurial  inunction  in,  II.  1072 
prophylaxis  of,  II.  1071 
special  symptoms  of,  II.  1075 
tonic  medicines  in,  II.  1073 
Sclerotomy,   posterior,  in  glaucoma,  III. 

602 

Scoliosis,  active  movements  for  the 
muscles  on  the  convex  side  in,  III. 
246 

deformities  of  the  shoulders,  and  tor- 
ticollis, I.  972-988 
four-footed  exercises  for,  III.  248 
movements  giving  equal  work  to  back 
muscles  in,  III.  243 
to  exercise  muscles  in,  III.  248 
to  improve  mobility  in,  III.  242 
physical  exercises  for,  III.  241 
Zander  treatment  in,  III.  372 
Scopolamine  and  morphine,  injection  of. 
in  labour.  IV.  378 


104 


A    SYSTEM  OF   TREATMENT. 


Scopolamine  (rnntd  )  — 

(Jivoscvamine   or   hyoscine),   poisoning 

by,  f.  532 
Scrofuloderma,  III.  1152 

X-rays  in.  III.  ii.">2 
Scrotum.  diseases  of,  II.  !»ou 

elephantiasis  of.  III.  :.u|-:,lC, 

epithelioina  of.  1 1.  Hi  MI 

tihirial  lymph.  III.  .litf 

luematoma  of.  II.  '.mil 

wound*  of.  II.  '.Mill 
Scurvy    ami     infantile    scurvy,    curative 

treatment  of,  I.  476 
<liet  in,  I.  J7.1 

preventive   I  reatllieiit,   I.  475 

in  newborn  child,  IV.  371 
Sea-bathing  in  diseases  of  the  heart,  I. 
1210 

Sea-sickness,  II.  H'.c, 

Seawater,    purified,    subcutaneous  injec- 
tions of.  in   marasmus.  I.  407 
Sebaceous  adenomata.  I.  109 
cysts,  J.  MS;  III.  114U 
suppuration  of,  I.  109 
of  neck.  11.  17o 
of  the  scalp,  I.  MI2 
horns.  I.  lo'.i 

Seborrhcea.  III.  1141-1142 
eapitis,  III.  1141 
X-rays  in.  III.S.IO 
Seborrtioeic  dermatitis,  III.  1143 
Secretions,  abnormal,  application  of  vibra- 

tion  in.  III.  22<) 
internal,  disorders  of,  I.  388 

and  obesity.  I.  K'.s,  472 
Sedative  baths,'  III.  125 
Sedatives,  dosage  of,  in  diseases  of  chil- 
dren. I.  <J7 

during  accidental  ha-m.-.rrhage  in  preg- 
nancy. 21 

in  diseases  of  the  heart,  I.  1224 
in  relief  of  pain  in  inoperable  cancer,  I. 

134 
Seminal   vesicles,   tinal  separation  of,  in 

carcinoma  of  the  prostate,  II.  936 
vesiculitis  complicating  gonorrhoea,    I. 

227 
Semple  on    vaccine    therapy    in    typhoid 

fever.    I.    ;M."> 

Senile  alopecia,  III.  998 

decav.  mineral  waters  and  baths  in,  III. 
1  IT. 

endonietritis.  leucorrlnea  in,  IV.  570 

•jaiiurene.  I.  21"> 

neuritis,  II.  lull,  HIV.i 

v:v_rinitis.  leueorrhrea  in,  IV.  .">(!•"> 

warts.  III.  1159 
Senn's  method  for  malignant  stricture  of 

the  (esophagus,  II.  180 
Senna    in    constipation    in    adults,    II. 

IIS 

Sepsis  after  amputations,  I.  803 

of  the  cord  in  newborn  child,  IV.  370 
puerperal,  prevention  of,  IV.  287-294 

Septic  cases,  management  of,  I.  92 


Septic  (contd.) — 

infection    complicating    operation     for 
goitre,  II.  68 

states  in  anasmia,  II.  16 

wounds,  I.  558 

Septicaemia    and    pyremia,    general    and 
local  treatment  of,  I.  295-298 

following  compound  fractures,  I.  581 
Sequelae  and  complications  of  disease,  I. 

22 

Sera,  administration  of,  III.  261 
Sere-vaccines  in  infective  endocarditis,  I. 

SKM 

Serum,  anti-plague,  III.  285 
anti-pneumococcus,  III.  285 
antirabic  injection  in  rabies,  I.  265 
anti-streptococcus,  III.  290 

in  pernicious  anasmia,  II.  8 

in  pelvic  cellulitis,  IV.  833 
anti-tetanic,  in  tetanus  in  puerperium, 

IV.  326 
diphtheritic,  dangers  and  ill-effects  of, 

III.  274 

Dunbars  antitoxic,  III.  286-287 
Flexner's  anti-meningitis,  III.  282 
Moebius's  antithyroid,  in  exophthalmic 

goitre,  II.  56 
rabbit,  effect  on  coaguability  of  blood, 

I.  129 

sickness  in  serum  therapy,  III.  261 
staphylococcus,  III.  288 
therapy,  administration  of  sera  in,  III. 
261 

doses,  summary  of,  III.  301 

general  principles  of,    III.   258-270, 
260 

horse  serum  in,  III.  261 

in  epilepsy,  II.  999 

in  gonorrhosal  arthritis,  I.  783 

in  infective  endocarditis,  I.  205 

in  purulent  meningitis,  I.  250 

in  pyasmia  and  septicaemia,  I.  297 

in  scarlet  fever,  I.  286 

of  acute  dysentery,  III.  430 

of  bacillus  coli  communis,  III.  271 

of  cancer,  I.  152 

of  cholera,  III.  273 

of  diphtheria,  III.  273 

of  dysentery,  III.  279 

of  general  paralysis   of  the    insane, 

II.  1079 

of   gonococcus  infections,    III.   280- 

281 

of  intermittent  claudication,  II.  1235 
of  leprosy,  III.  451 
of     meningococcus     infection,     III. 

282-283 
of  micrococcus  catarrhalis  infections, 

III.  283-284 

of  peritonitis,  II.  637 

of  plague,  III.  284-285,  407 

of  pneumococcus  infections,  III.  285- 

286 

of  pneumonia,  I.  262 
of  puerperal  sepsis,  IV.  308 


105 


A    SYSTEM   OF   TREATMENT. 


Serum  therapy  (contd.) — 

of  pyorrhoea  alveolaris,  III.  287 
of  rheumatism,  acute,  I.  272 
of  streptococcus  infections,  III.  289 
of  tetanus,  I.  329-330 
of  tuberculosis,  III.  297 
of  typhoid  fever,  I.  345  ;  III.  300 
serum  sickness  in,  III.  261    . 
Sexual  function,  female  disorders  of,  IV. 

839-864 

obesity  and,  I.  473 
hypochondriasis  in  impotence,  I.  232 
neurasthenia,  I.  231 
Shattock  (S.  G.),  on  lipomatosis,  1. 108 
Shaving,  previous  to  operation,  I.  84-93 
Shaw-Mackenzie,  on  trypsin  treatment  of 

cancer,  I.  151 

Sheep,  anthrax  amongst,  I.  179 
Sheets,  arrangement  of,  before  and  after 

operation,  I.  30 
Shellfish,  chemical  composition  of,  II.  194 

poisoning,  I.  506 
Sherren    (James),   division    of    posterior 

roots  in  neuritis,  II.  1035-1133 
infantile   paralysis,  nerve  anastomosis 

in,  II.  1059-1060 
injuries  of  nerves,  II.  1100-1107 
injuries    of    special   nerves,   II.   1108- 

1113 
surgical   treatment   of    neuralgia,    II. 

1127-1129 

traumatic  neuritis,  II.  1106-1107 
tumours  of  nerves,  II.  1142 
Shock  after  amputations,  I.  803 
after  cataract  extraction,  III.  632 
after  ovariotomy,  IV.  793 
after  radical  operation  for  cancer  of  the 

breast,  II.  967 

anassthesia  in  relation  to,  I.  95 
and  anaesthetics,  III.  24 
and  collapse,  I.  93-105 

bibliography  of,  I.  105 
causes  of,  I.  93 
complicating  abdominal  operations.  II. 

269 

gynecological  surgery,  IV.  491 
due  to  heat,  I.  537 
electric,  I.  547 
from    accidental    haemorrhage    during 

pregnancy, IV.  26 
from  burns  and  scalds,  I.  540.  548 
in  abdominal  injuries,  II.  244 
in  emergency  cases  of  abdominal  opera- 
tions, II.  260 
in  gunshot  wounds,  558 
in  injuries  of  the  stomach,  II.  283 
in  post-partum  haemorrhage,  IV.  222 
in   severe  contusions  of  the  spine,   I. 

898 

in  Wertheim's  operation,  IV.  607 
position  during  operation  in,  I.  95 
preparation  of  the  patient  in,  I.  95 
prevention  of,  I.  95 

by  strychnia,  I.  84 
technique  of  operation  in,  I.  96 


Shock  (eontd.) — 

treatment  of,  96-104 
by  drugs,  I.  102 
by  feeding,  I.  103 
by  infusion  of  normal  saline,  1.  98 
by  intra-peritoneal  infusion,  I.  101 
by  intravenous  infusion,  I.  100 
by  rectal  infusion,  I.  99 
by  subcutaneous  infusion,  I.  99 
by  transfusion  of  human  blood,  I.  102 
Shoulder,  congenital  elevation  of,  I.  9sr> 
deformities  of,  scoliosis  and  torticollis, 

I.  972-988 

hot-air  apparatus  for.  III.  322 
operative  treatment  of  tuberculous  dis- 
ease of,  I.  770 

tuberculous  disease  of,  I.  775-777 
Shoulder-joint,  congenital  dislocation  of, 

I.  935 

disarticulation    of   by  a    racket    inci- 
sion, I.  827 

through,  the,  I.  827-830 
dislocation,   complicating   fracture,    I. 

587 

reduction  of,  I.  715 
Shoulders,  round,  I.  986 
Shrnbsall  (Frank  C.),  physical  exercises, 

III.  222-257 

Sickness,  repeated,  in  peritonitis,  II.  638 
Sick-room  cookery,  I.  42 

and  dietary  for,  I.  42 
duties  of  the  nurse  in,  I.  27 
fittings  and  furniture  in,  I.  26 
hygienic  measures  in,  I.  26,  40 
management  of,  I.  2(5-43 

for  typhoid  fever,  I.  338-340 
preparations  for  operation  in,  I.  27 
Siegel's  speculum  in  massage  of  tympanic 

membrane,  III.  952 
Sigmoid.     overloaded     condition     of,    in 

constipation  in  children,  II.  435 
sinus,     thrombosis     of,     complicating 

diseases  of  the  ear,  III.  941-943 
Sigmoidoscope  in  chronic  mucous  colitis. 

II.  570 
Silk  ligatures,  sterilisation  of,  I.  72 

web  cesophageal  bougie,  II.  172,  173 
Silk's  celluloid  mask,  III.  733 
Silkworm  gut  sutures,  I.  86 
Silver,    nitrate    of,   in    diseases    of    the 

conjunctiva,  III.  548 
in  gonorrhoea,  I.  223,  227,  229 
in  lupus,  III.  1150 
wire  netting  in  operation  for  umbilical 

hernia,  II.  513 

Sim's  dilator,  modification  of,  IV.  623 
Simpson   (W.    J.),   personal   and  general 

hygiene  in  the  tropics.  III.  375-385 
Singer's  nodules  of  the  larynx,  III.  851 
Singing,, voice  production' and,  III.  331- 

340 
Sinus,  accessory  of  nose  diseases  of,  III. 

716-731 

and  fistula,  general  and  local  treatment 
of,  I.  299-301 


106 


A    SYSTEM  OF   TREATMENT 


Sinus  (i-nntil.) 

cthnioid.il,  diseases  of,  III.  727 
formation  in  tuberculous  disease  of  hip- 
joint,  I.  7.V.» 

frontal,  diseases  of,  III.  727-730 
irregularity  of  the  heart,  I.  1228 
maxillary,  diseases  of,  III.  721-727 
persistent,  of  the  breast,  II.  960 
spenoidal.  diseases  of,  III.  730 
Sitting  in  physical  exercises,  III.  229 
with  Legs  crossed,  exercise  for  flat  foot, 

III.  2:r> 

"  Skewed  "  heel  for  weak  foot,  I.  968 
Skey's  modification  of  Lisfranc's  amputa- 
tion. I.  840 
Skin,  anthrax  of,  I.  179 

application  of  radium  to,  III.  308 
carcinoma  of,  secondary  growths  rare 

in,  I.   I2."> 
care  of,  in  infants,  I.  48 

in  scarlet  fever,  I.  288 
cough,   in    pulmonary   tuberculosis,   I. 

1144 
diseases  of,  III.  982- In.". 7 

ascribed  to  vaccination,  I.  313 

electro-therapeutics  in,  III.  110 

gouty,  I.  -Hi; 

mineral  waters  and  baths  in,  III.  144 

tropical,  III.  470-486 

X-ray  treatment  of,  III.  341-359 
elasticity  of,  restoration  of,  I.  69 
epithelioma  of,  III.  1037-1038 
Haps,  in  amputations,  I.  796 
functions  of,  modified  by  X-rays,  III. 

S69 
grafting  in  burns  and  scalds,  I.  543 

in  nlceration.  I.  :i7:{-H7."> 

in  wound  contraction,  I.  555 
hygiene  of.  in  arterio-sclerosis,  I.  12!>1 
inunction  of.  value  of,  I.  70 
Kaposi's  diM-iise  of,  III.  1057 
localised    inflammations  of  X-rays  in, 

111.  349 

myomataof,  III.  1057 
preparation  of,  in  abdominal  operations, 
II.S69 

in    emergency    cases    of    abdominal 
operations.  II.  260 

in  ovariotomy,  IV.  775 
protection  of,  in  small-pox,  I.  305 
sarcoma  of,  III.  UU7 
scarring  of,  in  acne  vulgaris,  III.  986 
-tcrilisation  of,  I.  27,  557 

before  operation,  I.  84 
treatment  of,  in  burns  and  scalds,  I.  541 

in  typhoid  fever,  I.  356 
tuberculosis  of, X-rays  in.  III.  353 
tumours  of,  innocent,  III.  1057 
Skinner's  mask  in  ana-sthetic-.  III.  9,  10 
Skull,  actinomycosis  of,  I.  891 

air-containing  tumours  of  the.  I.  896 
bones,  diseases  of,  headache  from,  II. 

1088 

bony  tumours  of,  I.  895 
fractures  of,  I.  875-878 


Skull,  fractures  of  (cantd.}-— 

base  of,  I.  877 

Gushing1  s  method  in,  1.  882 

depressed,  I.  876 

in  infants,  I.  886 

in  newborn  child,  IV.  364 

in  separation  of  the  upper  jaws  from, 

II.  100 

gunshot  fractures  of,  I.  562 
infective  lesions  of  bones  of,  I.  889-891 
injuries  of,  I.  875-878 
surgical  diseases  of,  I.  888 
syphilis  of,  I.  890 
tuberculous  osteitis  of,  I.  889 
tumours  of,  growing  from  the  bony  walls 

of,  I.  894 

vault  of,  fractures  of,  I.  876 
Sleep,   amount   required  by  infants  and 

children,  I.  54 

in  acute  bronchitis,  I.  1050,  1052 
in  broncho-pneumonia,  I.  lui;9 
in  normal  puerperium,  IV.  264 
in  the  tropics,  III.  379 
Sleeping  in  open-air  for  children,  I.  52 
sickness  in  the  tropics.  III.  383 

See  also  Trypanosomiasis. 
suits  for  children,  I.  45 
Sleeplessness.     See  Insomnia. 
Smallpox,  I.  302-311 
complications  of,  I.  308-310 
confluent,  treatment  of,  I.  306 
distribution  of  eruption  in,  I.  303 
drugs  in,  I.  308 
general  management  of,  I.  307 
ha-morrhagic,  I.  310 
moist  applications  in,  I.  306 
protection  of  the  skin  in,  I.  l?o."i 
protective  measures  in,  I.  302 
quarantine  for,  I.  310 
vaccination  and,  311-314 
varieties  of,  I.  310 

Smith  (A.  Lionel),  abortion,  IV.  14-22 
hydramnios,  IV.  43-44 
mole,  blood  or  carneous  in  pregnancy, 

IV.  59 
mole,     hydatidiform     or    vesicular    in 

pregnancy,  IV.  59 

Smith  (Eustace),  food  fever,  II.  233-241 
hygiene  and  care  of  infants  and  children, 

'  I.  11-70 

on  treatment  of  whooping  cough,  I.  382 
Smith  (G.  F.  Darwall).  contracted  pelvis 

and  labour,  IV.  163-175 
precipitate  labour,  IV.  224 
tonic  contraction  of  the  uterus,  IV. 

248-249 

uterine  exhaustion,  IV.  250-251 
uterine  inertia.  IV.  252-255 
Smith  (L.  G.  Bellingharm.  diseases  of  the 

female  bladder,  IV.  s7.">-883 
diseases  of  the  urethra,  IV.  868-874 
Smith  (Maynard),  acute  abscess,  I.  166-172 
burns  and  scalds,  I.  540-544 
cellulitis,  I.  181-184 
contusions  and  hsetnatoma,  I.  545-546 


107 


A    SYSTEM  OF   TREATMENT. 


Smith  (Maynard)  (contd.) — 
erysipelas,  I.  209-211 
gangrene,  I.  214-220 
lardaceous  disease  (albuminoid  or  amy- 
loid degeneration),  I.  462 
septicaemia  and  pyaemia,  I.  295-298 
sinus  and  fistula,  I.  299-301 
tuberculous  abscess,  I.  173-176 
ulceration,  I.  368-375 
wounds,  I.  550-556 
Smith's  gag  in  operation  for  cleft  palate, 

II.  150 
operation  for  immature  cataract,  III. 

621 

(Stephen)  operation,  I.  859-861 
Smoking,   effect  in  affections  of  tongue, 

II.  135 

Snare,  aural,  III.  901 
Snow,  carbon  dioxide,  for  naevi,  III.  1078 

in  rodent  ulcer,  I.  115 
blindness  of  the  conjunctiva,  III.  560 
Soamin  in  cancer,  I.  149 
in  syphilis,  I.  321 
in  trypanosomiasis,  III.  420,  421 
in  undefined  tropical  fevers,  III.  411 
Soap  and  water  enema,  I.  32 
for  acne  vulgaris,  III.  985 
suitable  for  infants,  I.  48 
Socket  (tooth),  septic  infection  of,  after 

extraction,  III.  1190 
Soda,  bicarbonate,  in  acute  gastritis,  II. 

847 

in  diabetes,  I.  423,  425 
in  rheumatism,  I.  271,  278 
to  produce  alkalinity  of  urine,  I.  410, 

418 
chlorate,  dosage  of,  in  children's  diseases, 

1.67 

chloride,  ionisation  with,  I.  488 
citrate  of,  added  to  milk  in  infant  feed- 
ing, II.  225 

potassium  in  trypanosomiasis,  III.  421 
salicylate  in  diabetes  mellitus,  I.  424 

in  rheumatism,  I.  271,  278 
sulphate  of,  in  constipation  in  adults. 

11.449 

Soden  spa,  III.  156 

Soil,  influence  of,  in  rheumatism,  I.  484 
Solanum  carolinense  in  epilepsy,  II.  998 
Soldiers,  avoidance  of  sunstroke  by,  I.  536 
Soloids,   Burroughs  and   Wellcome's    in- 
fusion of,  I.  98 
Solutions  for  infusions,  I.  98 
Somatic  heniasis,  III.  521 
Sound,  reposition  by,  in  retroflexion   of 

the  uterus,  IV.  677 
sterilisation  of,  I.  92 
Southey's  tubes  for  dropsy,  in  diseases  of 

the  heart,  I.  1244 
Spa,  choice  of,  for  gout,  I.  459 
treatment  in  arterio-sclerosis,  I.  1291 
in  cholelithiasis,  II.  683 
in  chorea,  II.  1263 
in  diseases  of  the  heart.  I.  1210 
of  chronic  rheumatism,  I.  491 


Spa  treatment  (contd.*) — 

of  constipation  in  adults,  II.  465 
of  uterine  leucorrhoea,  IV.  571 
Spas,  (Belgium)  III.  156 
for  chlorosis,  II.  26 
index  of,  III.  147-158 
Spasmodic  diseases,  infantile,  warm  baths 

in,  I.  70 

Spasms.  II.  1047-1049 
facial,  II.  1<>47 
hysterical,  II.  1049 
laryngeal,  in  adults,  III.  840 

in  children,  III.  827-830 
myoclonus,  II.  1049 
of  calf  muscles,  II.  1062 

in  cerebral  palsies  of  infancy,  II.  1160 
of  hiccough.  II.  1048 
phonetic,  of  the  larynx,  III.  841 
pyloric,  II.  337 

reflex,  in  disseminated  sclerosis,  II.  In7."> 
trismus,  II.  1048 
Spasticity  in  hemiplegia,  II.  1186 

in  myelitis,  II.  1217 
Speaking,  voice  production  and,  III.  331- 

340 

Spectacles,  cataract,  III.  633 
dark,  in  cataract,  III.  618 
for  accommodation  and  refraction  of  the 

eyes,  III.  »42 
Speech,  defects  of,  of  cerebral  origin,  II. 

1143 

effect  of  cleft  palate  upon,  II.  147 
restoration  of,  by  functional  compensa- 
tion, II.  1147 

in  aphasia,  by  functional  compensa- 
tion, II.  1147 
Speuce's  method  of  disarticulation  through 

shoulder-joint,  I.  827-830 
Spencer  (Major  C.  J.),  gunshot  wounds,  I. 

557-567 

Spencer's  table,  IV.  479 
Spermatic  cord,  diseases  of,  II.  917 
encysted  hydrocele  of,  II.  917 
h;ematoma  of,  II.  917 
Sphenoidal  sinuses,  III.  730 
Sphincter  ani,  spasmodic  construction  of 

in  constipation  in  children,  II.  436 
Spider  nasvi,  III.  1077 
Spigelia  anthelmintica  in  epidemic  gan- 
grenous proctitis,  III.  437 
Spinabifida,  I.  912-<.tl6 
age  for  operation  in,  I.  915 
centra-indications  to  operation  in,  I.  915 
excision  in,  I.  914 
injection  of  iodo-glycerin  solution  in,  I. 

913 

of  the  newborn  child,  IV.  361 
palliative  treatment  of,  I.  912 
pressure  in,  I.  912 
simple  tapping  in,  I.  912 
spontaneous  cure  in,  I.  912 
strangulation  of  the  sac  in,  I.  912 
Spinal  anaesthesia.    See  under  Anaesthesia, 
analgesia,  III.  36 
canal,  haemorrhage  into,  I.  904 


108 


A    SYSTEM  OF  TREATMENT. 


Spinal  (contd.}— 

cord,  affections  of,  II.  12o,s 

degeneration  of,  sub-acute,  combined, 

II.  1083 
diseases  of,  II.  1208 

electro-therapeutics  in,  III.  108 
disseminated    sclerosis  of,    II.    1070- 

1076 

gummatous  meningitis  of,  II.  1068 
injuries  of.  I.  1)00-911 

complications  in.  f.  908-911 
tumours  of,  II.  1221-1225 

medicinal  treatment,  II.  1222 
operation  in.  1 1.   1223 
paralysis,  deformities  due  to  I.  9SX-990 
paraplegia.  1 1.  1196 

Spine,  abscess  in  connection  with  tuber- 
culous disease  of,  I.  92S.  932 
actinomveosis  of,  I.  919 
caries  of',  I.  922-927 
concussion  of  I.  *99 
counter-irritation        in        rheumatoid 

arthritis,  I.  |or,-|u7 
curvature   of,   application  of  vibration 

in,  III.  220 
lateral,  I.  972 

physical  exercises  for,  III.  236 
rotate-lateral,  I.  972 
deformities  of,  in  children,  I.  56 
dislocations    and    fracture-dislocations 

of,  I.  902 

gunshot  wounds  of.  I.  r>ii3.  902 
hvdatid  disease  of,  I.  918 
injuries  of,  I.  898-911 
concussion,  I.  899 
contusions,  I.  898 
dislocations,  I.  902 
fracture-dislocations,  I.  903 
non-operative  treatment.  I.  907-911 
operative  treatment  of,  I.  905,  907 
severe,    non-operative   treatment  of, 

I.  907,  911 

operative'  treatment  of,  I.  905,  907 
wounds  ,,f,  I.  9(U 
new  growth-,  of.  I.  919-920 
Sprains  of.  I.  9oi> 
syphilis  of,  I.  917-91 S 
tuberculous     disease     of,     ambulatory 

treatment  of,  I.  921 
paraplegia  in,  I.  92(5-927 
summary,  I.  925 

treatment  by  recumbency,  I.  923 
tumours  of,  f.  919 
Spirits,  effect  on  the  tongue,  II.  135,  138 

in  gouty  conditions.  I.  l.~,r> 
Spitta  (Harold),  anthrax,  I.  179,  180 
bacillus   coli  communis,   infections  of, 

III.  271-27:. 
cholera,  III.  27:: 
disinfection,  I.  1(51 -1C,:, 
dysentry,  III.  279-280 
glanders,  I.  221-222 
gonococcus  infections.  I  [I.  280-281 
pollantin     (l)unbar    antitoxic    serum), 
III.  286-287 


Spitta  (Harold)  (contd.)— 

pyorrhoea   alveolaris    (Rigg's    disease), 
III.  287-288 

rabies,  I.  264-265 

streptococcus      infections,       vaccine 
therapy  of,  III.  289-291 

tetanus,  1.  329-331 
Spleen,  abscess  of,  II.  81 
.    contusions  of,  II.  79 

cysts  of,  II.  81 

diseases  of,  II.  81-8-1 

embolism  of,  I.  1307 

enlarged,  chronic  polycythremia  with 
cyanosis  and.  II.  84 

injuries  of,  II.  79-80,  251 

laceration  of,  II.  79 

malarial,  II.  81 

removal  of  in  leukasmia,  II.  41 

sarcoma  of,  II.  81 

surgical  treatment  of,  II.  83 

wandering,  II.  81 

X-rays  in,  II.  82 
Spleno-medullary  leukamiia,  II.  38 

complicating  pregnancy,  IV.  55 
Splenomegaly,  II.  82-83 

general  treatment  of,  II.  82 

medicinal  treatment  of,  II.  82 
Splint  sore,  I.  572 

Splints,    abduction,    and    pad    for    the 
shoulder,  I.  776 

adjustable,  for  the  knee,  I.  769 
for  the  wrist,  I.  779 

back  and  side,  I.  630 
for  fractures  of  tibia,  I.  625,  627 

Bavarian,  I.  574 

Bryant's,  I.  617 

Carr's,  I.  603 

complicated,  in  fractures  of   the  jaws, 
II.  102 

Croft's,  I.  574,  629 

Dupuytren's,  I.  630 

for  fractures  of  lower  jaw,  II.  101 

for  gunshot  fractures,  I.  5(51 

for  paralytic  dropped  wrist,  I.  992 

for  prevention  of  claw  hand,  II.  1014 

forms  of,  for  fractures,  I.  572 

fraction,  in  tuberculous  disease  of  the 
hip-joint,  I.  765 

(iooch's,  I.  573 

hallus  valgus  or  rigidus,  I.  966 

Hodgen's,  I.  614 

in  fractures  of  jaws,  II.  114 

in  rickets,  I.  4S1 

internal  angular  for  the  arm  and  fore- 
arm in  fractures,  I.  593 

leather,  for  the  knee,  I.  766 

Listen's,  I.  617 

in  hip-joint  disease,  I.  754,  7t!2 

Maclntyre's,  I.  618 

measurements  of,  I.  575 

metal,  I.  574 
suspension,  for  the  ankle,  I.  773 

plaster  of  Paris,  I.  628 

posterior  moulded,  for  the  elbow,  I.  600 

Roughton's,  I.  630 


109 


A    SYSTEM   OF   TREATMENT. 


Splints  (coHtd.) — 

Thomas's  caliper,  I.  767 

hip,  I.  756,  765 
Spondylitis  deformans,  I.  404 

syphilitic,  I.  917 
Spondylolisthetic      pelvis      complicating 

labour,  IV.  173 
Spondylotomy,  dangers  of,  IV.  451 

in  labour,  IV.  451 
Sponging,  cold,  in  typhoid  fever,  I.  350 

for  young  children,  I.  47 

methods  of,  I.  37 
Sporotrichosis,  III.  1143 
Sprains,  I.  737-740 

electro-therapeutics  in,  III.  109 

massage  in,  I.  737,  740  ;  III.  207 

of  the  spine,  I.  900 

weight-extension  in,  I.  742 
Spray  chambers  in  emphysema,  I.  1086 
Spraying,  disinfection  by,  I.  163 
Sprays  in  asthma,  I.  1040 
Sprengel's  deformity,  I.  985 
Spriggs   (E.    I.),    diabetes    insipidus,    I. 
428-429 

diabetes  mellitus,  I.  408-427 

infant  feeding,  II.  214-232 

marasmus,  I.  463 

principles  of  dietetics,  II.  190-213 
Spring  catarrh  of  the  conjunctiva,  III. 

560 

Springs,  mineralisation  of,  III.  114 
Sprue,  III.  442-446 

complications  of,  III.  445 

convalescence  in,  III.  445 

fruit  in,  III.  443 

local  treatment  in,  III.  445 

meat  diet  in,  III.  443 

medicinal  treatment  of,  III.  444 

milk  diet  in,  III.  442 

soured  milk  in,  III.  443 
Squill,  oxymel  of,  in  laryngitis,  I.  245 
Squills  in  diseases  of  the  heart,  I.  1223 
Stab-wound  over  stomach  region,  II.  282 
Stacke's  post-aural  operation  in  diseases 

of  mastoid  process,  III.  922,  923,  926 
Stammering,  III.  327-330 
Standing  in  physical  exercise?,  III.  229 
Stapes,  removal  of,  in  chronic  inflamma- 
tion of  middle  ear,  III.  916 
Staphylococcus  infections,  vaccine  therapy 
of,  I.  182  ;   III.  288 

peritonitis,  II.  641 

serum,  III.  288 

Starch  diet,  effect  on  young  children,  I. 
58,  61 

foods  in  gout,  I.  453 

without,  in  infant  feeding,  II.  229 

-free  flour,  I.  421 

in  food,  effect  on  diabetes,  I.  411 

poultice,  I.  34 

Starches,  chemical  composition  of,  II.  195 
Starvation    in     perniciuus    vomiting    of 
pregnancy,  IV.  62 

predisposes  to  shock,  I.  95 

treatment  in  acute  gastritis,  II.  346 


Statical  treatment,  III.  106 
Status  epilepticus,  II.  1004 

lymphaticus  and  anesthetics,  III.  25 
Steam,  disinfection  by  means  of,  I.  162 

kettle  and  tent,  I.  39 

in  broncho-pneumonia,  I.  1067 

pressure,  disinfection  by,  I.  162 

tents  in  diphtheria,  I.  192,  194 
Steel  plate,  use  of,  in  operative  treatment 

of  fractures,  I.  644 
Stegomyia  calopus  and  yellow  fever,  III. 

382 

Stellate  naevi,  III.  1077 
Stephens  (G.  A.),  on  lead  colic,  I.  513 
Sterilisation    in    cesarean    section,    I V. 
394,  396 

in  gynecological  operations,  IV.  483 

of  instruments,  methods  of,  I.  72 

of  surgical  dressings,  I.  75-77 

preparatory  to  operation,  methods  of, 

I.  27-30 

Sterilisers,  preparation  of,  I.  28-30 
Sterility,  dilatation  of  cervix  in,  IV.  854 

electricity  in,  IV.  857 

epididymitis  causing,  I.  227 

female,  marriage  and,  IV.  843 
pelvic  examination  in,  IV.  851 
voluntary,  IV.  844 

from  discharge  from  vagina,  IV.  852 

in  azoospermia,  IV.  849 

in  caruncle  of  female  urethra,  IV.  852 

in  diseases  of  the  ovary,  IV.  846 

in  endometritis,  IV.  845 

in  general  diseases,  IV.  847 

in  inflammation  of  Fallopian  tubes,  IV. 
845 

in  man,  IV.  848 

treatment  of,  IV.  850 

in  nietritis,  IV.  845 

in  spasmodic  dysmenorrhoea,  IV.  847 

in  the  female,  IV.  843-859 

lacerated  cervix  in,  IV.  857 

organo-therapy  in,  IV.  854 

removal  of  Fallopian  tubes  and,  IV.  856 

retroflexion  of  uterus  in,  IV.  856 

vaginal  discharge  in,  IV.  845 
Sterno-mastoid,   hematoma  of,   in    new- 
born child,  IV.  365 
Sternum,  inflammation  of,  I.  1032-1033 

syphilis  of,  I.  1032 

tuberculous  disease  of,  I.  1032 
Stevens     (Thos.     G.),     hemorrhoids     in 
pregnancy,  IV.  42 

pendulous  belly  in  pregnancy,  IV.  61 

pernicious  vomiting  of  pregnancy,  IV. 
62-64 

prolapse  of  the  pregnant  uterus,  IV.  70 

prolapse  of  the   vagina  in  pregnancy, 
IV.  71 

pruritus  vulvas  in  pregnancy,  IV.  72-73 

retroflexion  of  the  pregnant  uterus  in 
pregnancy,  IV.  74-75 

syphilis  in  pregnancy,  IV.  76-77 

varicose  veins  in  pregnancy,  IV.  89-90 
Stewart  (Purves),  alcoholism,  I.  495-502 


110 


A    SYSTEM   OF   TREATMENT. 


Stewart  (Purves)  (coitttl.*) 

lumbar  puncture,  II.  1025-1026 
paralysis  agitans,  II.  1269-1270 
Stewart  (T.  Grainger),  cerebral  embolism, 

II.  11G7 

cerebral  hfemorrhage.il.  1168-1176 
cerebral  thrombosis,  II.  1179-1180 
coma,  II.  '.>S2-!IH.-) 
medical  treatment  of   tumours   of   the 

brain,  II.  1200-1203 
multiple  neuritis,  II.  1134-1139 
neuritis.  II.  1130-11:52 
Stiles    (Harold   J.),   intussusception,    II. 

641-549 
Still's  organism  in  basilar  meningitis,  I. 

2.-)  1 

Stimson's  method  in  dislocations,  I.  725 
Stimulants,  contra-indicated  in  shock,  I. 

97 

in  acute  bronchitis,  I.  1051 
in  blackwater  fever,  III.  389 
in  chronic  bronchitis.  1.  1055 
in  pericarditis,  I.  1180 
in  peritonitis,  II.  638 
in  plague.  III.  403 
in  typhoid  fever,  1.311 
in  typhus  fever,  I.  367 
use  of,  in  diphtheria,  I.  193 

in  fevers,  directions  for,  I.  158 
Stitch  sinuses  complicating  gynaecological 

surgery.  IV.  l'.C> 
Stitches,    removal    of,    after    abdominal 

operations,  II.  267 
Stockings  for  young   children,   necessity 

of,  I.  51 
Stokes's    supracoudyloid  amputation,   I. 

863 
Stomach,  achylia  of,  II.  368 

acidity  in  disordered  digestion  in,  II.  370 
atonic  dyspepsia  of,  II.  2S6 
atony  of,  II.  286-292 
baths  in.  II.  !'*'.» 
climate  in.  II.  289 
diet  in.  11.  28'.i 
electricity  in,  II.  288 
general  treatment  in,  II.  287 
lavage  in.  II.  288 
medicinal  treatment,  in,  II.  290 
prophvlaxis  of.  1 1.  286 
atrophy  of  0«-»ylia).  "•  2!i3-2!J."» 
from  chronic  gastritis,  II.  21)4 
from  ingestion  of  corrosives,  II.  291 
general  treatment  in.  II.  293 
with  pernicious  anajmia,  II.  293 
cancer  of,  II.  296-3OI 
acidity  in,  II.  3(in 
anorexia  and,  II.  i".i8 
constipation  in,  II.  3ou 
diet  in.  II.  297 
general  treatment  of,  II.  296 
ha'tnatemesis  in,  II.  3iiu 
jejunostomy  for,  II.  305 
lavage  in.  II.  296 
medicinal  treatment  of,  II.  298 
mortality  from,  II.  3i>2 


Stomach,  cancer  of  (cuntd.*)— 
pain  in,  II.  299 

partial  gastrectomy  for,  II.  308 
.radical  operation  for,  II.  308 
relief  of  obstruction  in,  I.  139,  140 
surgical  treatment  of,  II.  302-309 
symptomatic  treatment  of,  II.  298 
vomiting  and,  II.  299 
cardiospasin  of,  II.  357 
catarrh  of,  diet  in,  II.  209 
colic  fistulas  of,  II.  490 
concretions  of,  II.  35'.) 
contraction  of,  II,  334-336 

partial  gastrectomy  for,  II.  336 
perigastritis  complicating,  II.  336 
cough    in    pulmonary   tuberculosis,    I. 

1146 

crisis  of,  in  tabes  dorsulis,  II.  1090 
descent  of  total,  II.  319 
dilatation  of,  II.  310-311 
acute  post-operative,  II.  311 
chronic,  diet  in,  II.  313 
general  treatment  of,  II.  312 
lavage  in,  II.  312 
medicinal  treatment  of,  II.  314 
pyloric  stenosis,  II.  312 
in  pulmonary  tuberculosis,  I.  1150 
obstructive,  II.  316 
diseases  of,  diet  in,  II.  209 
displacements  of,  II.  318-322 
upward,  II.  318 
vertical,  II.  318 
distension  of,  complicating  abdominal 

operations,  II.  270 
electrical  treatment  of,  II.  355 
examination  of,  in  epilepsy,  II.  992 
external  injuries  associated  with  wound 

of,  II.  282 
flatulence  in  disordered  digestion    in, 

II.  371 

foreign  bodies  in,  II.  285 
gastrotomy  for,  II.  285 
gunshot  injuries  of,  II.  283 
habitual  rcgurgitation  of,  II.  357 
haemorrhage  from,  II.  325-330 
acute  gastric  ulcer  and,  II.  325 
in  cancer,  II.  329 
in  hepatic  cirrhosis,  II.  329 
hour-glass,  II.  334 
hyperacidity  of,  II.  360 
hypersecretion  of,  II.  364-365 

medicinal  treatment  of,  II.  367 
inflammations  of.     iSee  Gastritis, 
injuries  of,  II.  282-285 
caused  by  blow,  II.  283 

by  kick,  II.  283 
due  to  swallowing  caustic  fluids,  II. 

284 

puncture  from  within  in,  II.  284 
rupture  from  within  in,  II.  284 
without  external  wound,  II.  283 
lavage  of,  in  acute  alcoholism,  I.  495 
in  acute  catarrh,  I.  506 
in  poisoning,  I.  528 
motor  insufficiency  of,  II.  209 


111 


A    SYSTEM  OF   TREATMENT. 


Stomach  (contd.) — 
nausea  in  disordered  digestion  in,  II. 

373 
nervous  diseases  of,  II.  354-358 

eructation  of,  II.  357 
neurasthenia  of,  II.  354 
operations  upon,  food  before,  II.  259 
pain  in  disordered  digestion  in,  II.  373 
parasitis  of,  II.  359 
region,  stab-wound  over,  II.  282 
rupture  of,  within,  II.  284 
secretory  disorders  of,  II.  360-369 

diet  in,  II.  361 

lavage  in,  II.  361 

medicinal  treatment  of,  II.  363 
symptoms  of  disordered  digestion  in,  II. 

370-374 

tetany  of,  II.  399 
tumours  of,  simple,  II.  400 
ulcer  of,  II.  375-381 

acute,  II.  325,  382 

chronic,  II.  382 

simple,  II.  327 

complications  of,  II.  380 

constipation  in,  II.  381 

diet  in,  II.  210,  376 

gastro-enterostomy  in,  II.  386 

general  treatment,  II.  375 

medicinal  treatment  of,  II.  378 

pain  in,  II.  381 

perforated,  II.  389 

preceding  cancer,  I.  119 

prophylaxis  of,  II.  375 

pyloroplasty  in,  II.  385 

surgical  treatment,  II.  382-388 

symptoms  of,  II.  381 

tetany  in,  II.  381 

vomiting  in,  II.  380 
volvulus  of,  II.  400 
vomiting  in  disordered  digestion  in,  II. 

373 
water-rash   in  disordered  digestion  in, 

II.  374 

Stomatitis,  II.  120-125 
aphthous,  II.  120-121 

food  administration  in,  II.  121 

general  treatment  of,  II.  121 

local  treatment  of,  II.  120 

prophylaxis  of,  II.  120 
catarrhal,  II.  120 
follicular,  III.  1192 
gangrenous,  II.  124-125 
in  measles,  I.  246 
mercurial,  II.  125 

prophylaxis  of,  II.  125 

treatment  of,  II.  125 
parasitic,  prophylaxis  of,  II.  122 

(thrush),  II.  122-124 

treatment  of,  II.  123 
recurrent,  II.  122 
ulcerative,  II.  121-122  ;  III.  1192 

chronic,  III.  1192 

complicating  scarlet  fever,  I.  293 

diet  in,  II.  122 

general  hygiene  in,  II.  122 


Stomatitis,  ulcerative  (cantd.) — 
local  treatment  of,  II.  121 
prophylaxis  of,  II.  121 
Stools,  characteristics  of,  infant   feeding 

and,  II.  231 

disinfection  of,  I.  40,  164 
examination  of,  I.  510 
Stoppany's  plate  for  fracture  of  the  jaws, 

II.  114 

Stovaine,  injection  of,  for  spinal  analgesia, 

III.  37 
Strabismus,  III.  651 

convergent,  III.  651 

divergent,  III.  654 

operative  treatment,  III.  653 

vertical,  III.  655 

Strain  caused  by  excessive  exercise,  I.  8 
Stramonium,  poisoning  by,  I.  532 
Strapping  in  fractures  of  clavicle,  I.  584 
Strathpeffer  spa,  III.  156 
Strawberries,  idiosyncrasy  to,  I.  454 
Streptococcus  angina,  III.  771 

directions  for  isolating,  III.  289 

in  infective  endocarditis,  I.  203 

in  salpingitis,  IV.  815 

infectious,  vaccine  therapy  of,  I.  182  ; 
III.  289-291 

meningitis,  I.  250 

peritonitis,  II.  641 
Streptothrix  infection,  I.  177 

leproides  in  leprosy,  III.  452 
Stretch  in  physical  exercises,  III.  280 
Stretching  movements  for  scoliosis,  III.  i'  1 1 
Strophauthus,  in  diseases  of  the  heart,  I. 

1222 

Strophulus,  in  newborn  child,  IV.  371 
Strychnine,  contra-indicated  in  shock,  I. 
97 

in  alcoholism,  I.  501 

in  beri-beri,  III.  415 

in  chronic  congestion  of  the  lungs,  I. 
1079 

in  constipation  in  adults,  II.  446 

in  diseases  of  the  heart,  I.  1227 

in  epilepsy,  II.  998 

in  heart  failure,  I.  193,  200 

in  infantile  debility,  I.  66 

in  pellagra,  I.  522 

in  pneumonia,  I.  260 

in  poisoning,  I.  527,  531,  533 

injection  of,  in  dangers  arising  during 
anaesthesia,  III.  33 

prevention  of  shock  by,  I.  84 
Stapes  and  fomentations,  I.  35 
Styptics  in  haemophilia,  II.  32 

in  haemorrhage,  I.  1261 
Sub-thermal  baths,  III.  125 
Subastragaloid       disarticulation,      Fara- 

boeuf's,  I.  843 
Subclavian  aneurysm,  I.  1304 

artery,  haemorrhage  from,  I.  1275 
Subcutaneous  infusion  in  shock,  I.  99 
Sublingual  abscess  and  affections  of  the 
tongue,  II.  133 

glands,  inflammation  of,  II.  158 


112 


A    SYSTEM  OF  TREATMENT. 


Submaxiliary  irlands.  inflammation  of,  II. 
158 

tumours  of,  II.  162 
Subphrenic  abscess,  II.  643-644 
Suction-apparatus   for  hyperremic  treat- 
ment, III.  56-60 
Sugar  in  diet  for  trout,  I.  453 

in  urine  in  diabetes,  quantities  of.  I.  410 

milk  diluted  with,  II.  223 
Suggestion  in  hysteria,  II.  1009 

in  nocturnal  enuresis,  II.  76 

treatment  by,  III.  159-1 7!> 
Sulphated  purgative  waters,  III.  121 
Sulphonal  in  diseases  of  the  heart,  I.  1225 

in  insomnia.  I  \.  !•!>!.  1023 

IM  iisiinin<_'  by,  I.  531 
Sulphur  baths,  III.  133 

in  boils,  III.  K07 

in  chlorosis,  II,  27 

in  osteo-arthritis,  I.  401 

waters,  111.  117 

Sulphuretted  hydrogen  poisoning,  I.  534 
Sulphurous  acid  in  typhoid  fever,  I.  355 
Sulphurous  acid  -as,  use  of,  for  fumiga- 
tion, I.  162 
Sun  in  troiiics,  precautions  when  exposed 

to,  III.  377 
Sunderland  (Septimus),  leucorrhcea,  IV. 

566-574 

Sunshine  in  chlorosis,  II.  20 
Sunstroke,   preventive    treatment   of,   I. 
536-537 

sequelae  of,  I.  538-539 
Suppositories,  glycerine,  in  constipation 
in  adults.  II.  453 

in  constipation  in  adults,  II.  452 
Suppuration,  acute,  in  disease  of  the  hip- 
joint,  I.  763 

complicating  wound  after  abdominal 
operation,  II.  273 

following  compound  fractures,  I.  582 

in  pelvic  cellulitis,  IV.  828 

in  tuberculous  disease  of  the  knee-joint. 
I.  768 

pelvic.  I.  917 

prolonged,  disease  of  the  hip-joint,  I. 

7C.5 
Supracondyloid      amputation      through 

thigh.  I.  Sii2 
Supramalleolar  amputation  (Guvon),  I. 

860 
Supra-orbital  neuralgia,  II.  1115 

notch,    alcohol     injection     into,      for 

neuralgia,  II.  1117 

Suprapubic  drainage  in  carcinoma  of  the 
prostate,  II.  939 

fistula,  failure  of  closure  of,  com- 
plicating adenoma  of  the  prostate, 
11.946 

prostatectomy     in    adenoma     of     the 

pi -state.  II.  942 
Suprarenal  extract  in  hirmatemesis,   II. 

300 

Suture  of  arteries  for  injury  to   I.  1279 
Surgeon,  antiseptic  precautions  for,  I.  80 


Surgery,  antiseptic  methods  of,  I.  84-92 
gynaecological,  after-treatment  of,  IV. 

487-489 

operative,  technique  of,  I.  71-92 
radium  therapy,  combined  with,    III, 

313 

technique,  operation  room,  I.  71-71 
preparation  of  instruments,  I.  30 
of  patient,  I.  27,  83-87 
of  room,  I.  28,  71 
of  special  regions,  I.  87-91 
septic  cases,  I.  92 
surgeon  and  assistants,  I.  80-83 
surgical  dressings,  I.  74-80 
Sutherland  (G.  A.),  colic  in  children,  II. 

428-431 

constipation  in  children,  II.  432-438 
diarrhoeal  diseases  in  children,  II.  471- 

478 

scurvy  and  infantile  scurvy,  I.  475-477 
Sutures  in  ovariotomy,  IV.  776 
methods  of,  in  wounds,  I.  553 
sterilisation  of,  I.  72 
Swabs  in  gynaecological  operations,   IV. 

483 
Swayne  (Walter  Charles),  pelvic  cellulitis, 

IV.  824-838 
Sweat  glands,  adenoma  of,  III.  1044 

hydradenomata  of,  III.  1044 
Sweating,  coloured,  or  chromidrosis,  III. 

1021 

excessive,  III.  1044-1045 
in  pulmonary  tuberculosis,  I.  1143 
Swedish   gymnastics  in   constipation   in 

adults,  II.  459,  460 
Sweep's  eczema,  I.  117 
Switzerland,  Fb'hn  wind  of,  III.  75 
Sycosis,  III.  1144-1145 

X-rays  in,  III.  350 
Sydenham  on  small-pox,  I.  302 
Symblepharon  of  the    conjunctiva,  III. 

548 
Syme's  disarticulation  at  the  ankle-joint, 

I.  845 
operation,  comments  on,  I.  848 

incisions  in,  I.  845 
Syraonds'  short  resophageal  tube,  II.  175 

with  terminal  opening,  II.  176 
short  tube,  special  form  of,  introducer 

for,  II.  176 

Symphysiotomy,  IV.  452-460 
anatomy  of.  IV.  454 
child  alive  and  at  term  in,  IV.  453 
dangers  to  patient  in,  IV.  459 
in     contracted     pelvis,     complicating 

labour,  IV.  171 

injuries  to  soft  parts  in,  IV.  460 
limits  of  operation  in,  IV.  453 
mortality  of,  IV.  l.V.i 
open  method  of,  IV.  457 
operation  of,  IV.  456 
pelvis  greatly  deformed  and.  IV.   151 
Pinard's  register  for,  IV.  457 
prognosis  in,  \\' .  45'J 
repeated,  IV.  460 


113 


A    SYSTEM   OF  TREATMENT. 


Symphysiotomy  (contd.) — 
results  of,  IV.  459 

division  of  symphysis  in,  IV.  452 
separation  of  bones  in,  IV.  453 

•  subcutaneous,  IV.  458 
Symphysiotomy  knife,  Galbiati's,  IV.  457 
Symphysis,  division   of,   results    of,   IV. 

452 

Symptomatic  treatment,  I.  18 
Syncope  in  placenta  praevia,  IV.  69 
Syndactyly  or  webbed  fingers,  I.  943 
Synechia  of  the  nose,  III.  672 
Synovial  disease,  primary,  of  the  ankle 

and  tarsus,  I.  772 
effusion  in  tuberculous  disease  of   the 

knee-joint,  I.  767 
Synovitis,  I.  483 
acute,  I.  741-742 
deformity  of,  I.  742 
or  sub-acute  in  gonorrhoeal  arthritis, 

I.  781 
chronic.  I.  745-748 

ionic  medication  of,  III.  185 

•  electro-therapeutics  in,  I.  746 
fibi-olysin  in,  I.  748 
hydro-therapeutics  in,  I.  745 
local  applications  in,  I.  748 
scarlatinal,  I.  290 
teno-acute,  suppurative,  I.  170 
tuberculous,  I.  752 

Syphilis.  I.  316-324 
and  anaemia,  II.  17 
and  aphasia,  II.  1144 
arsenic  in,  I.  321 
aryl-arsonate  groups  in,  I.  321 
bursitis  in,  II.  1335 
calomel  in,  I.  318 
cerebral,  headache  from,  II.  1034 

thrombosis  in,  II.  1069 
cerebro-spinal,  II.  1063-1069 

anti-syphilitic  therapy,  II.  1065 

arsenic  in,  II.  1067 

intracranial  gumma  in,  II.  1067 

iodides  in,  II.  1065 

mercury  in,  II.  1065 

prophylaxis  of,  II.  1063 

cirrhosis  of  the  liver  in,  II.  665 
clinical    pathology  of,  in   relation    to 

treatment,  I.  325-328 
complicating  pregnancy,  IV.  76-77 

pulmonary  tuberculosis,  I.  1156 
congenital,  in  newborn  child,  IV.  369 

jaundice  and,  II.  672 
constitutional  treatment  of,  I.  316 
cranial,  I.  890 
drugs  in,  I.  317,  319,  324 
foatal,  complicating  pregnancy,  IV.  77 
grey  oil  injections  in,  I.  319 
hectine  in,  I.  323 
hygiene  of  the  month  in,  I.  318 
intramuscular  injections  in,  I.  318 
intravenous  injections  in,  I.  320,  322 
inunctions  in,  I.  319 
iodine  in,  I.  321 
iritis  in,  III.  588 


Syphilis  (coiitil.) — 

mercury  in  treatment  of,  I.  317 

mineral  waters  and  baths,  in,  III.  143 

myositis  in,  II.  1324 

neuritis  in,  II.  1130 

of  bones,  I.  703 

of  joints,  I.  784 

of  the  internal  ear,  III.  978 

of  the  larynx,  III.  868-869 

of  the  meatus,  III.  883 

of  the  naso-pharynx,  III.  743 

of  the  nose,  III. '714-715 

of  the  pharynx,  III.  791-792 

of  the  prostate,  II.  927 

of  the  ribs  and  sternum.  I.  1032 

of  the  spine,  I.  917-918 

of  the  testis,  II.  907 

of  the  tongue,  II.  134-137 

of  the  tonsil,  III.  756 

of  the  vulva,  IV.  520-521 

paralysis  in,  II.  1069 

salvarsan  ("  606")  in,  I.  322  ;  II.  1144 

sarsaparilla  in,  I.  323 

tenosynovitis  in,  II.  1330 

Wassermann  reaction  in,  I.  325 
Syphilitic  onychitis,  III.  1082 

phlebitis,  I.  1330 

vascular  disease,  cerebral  thrombosis  due 

to,  II.  1177 
Syringe,  Blake's  tympanic,  III.  912 

Neumann's,  III.  913 
Syringomyelia,  II.  1219-1220 

arthritis  in,  I.  786 

Kb'ntgen  rays  in, II.  1219 


Tabes  dorsalis,  II.  1085-1092 

electricity  in,  II.  1091 

fibrolysin,  II.  1086 

Fraenkel's  exercises  in,  II.  1091 

gastric  crises  in,  II.  1090 

hydropathy  in,  II.  1092 

iodide  of  potassium  in,  II.  1087 

massage  in,  II.  1091 

medicinal  remedies  in,  II.  1088 

mercury  in,  II.  1086 

salvarsan  in,  II.  1088 

sphincter   of  bladder  troublesome  in, 

II.  1090 
Tachycardia,  I.  1235 

and  anaesthetics,  III,  23 

in  the  menopause,  IV.  502 

paroxysmal,  I.  1236 
Tseniasis,  intestinal,  III.  517-520 

anthelmintic  treatment  of,  III.  518 

preparatory  treatment  in,  III.  518 

prophylaxis  of,  III.  517 

purgative  treatment  of,  III.  518 

somatic,  III.  521 

visceral,  III.  521 

Takadiastase  in  gouty  dyspepsia,  I.  442 
Talipes  equino-varus,  I.  952,  953 

in  newborn  child,  IV.  362 

physical  exercises  for,  III.  233 


114 


A    SYSTEM   OF   TREATMENT. 


Tampons  in  puerperal  vaginitis,  IV.  5 1 1 3 
wool,  in  retroversion  of  the  uterus,  IV. 

674 

Tannin  in  haemorrhage,  I.  li't',1 
Tapotement  and  massage,  III.  L'o4 
Tapping,  in  pletiral  effusion,  I.  1095-1097 

in  spina-bifida,  I.  902 
Tar,  Harbados,  in  water  itch,  III.  486 
in  pruritus.  III.  lo'.i'.i 
in  psoriasis,  III.  1119 
workers' dermatitis.  III.  Io3n 
Tarasp-Schuls  spa.  III.  156 
Tarsal  bones,  fractures  of,  I.  632-633 
Tarsus,  disease  of.  I.  773 
operations  on,  in  congenital  club-foot, 

[.  957 

tuberculous  disease  of,  I.  772-775 
Tartar  emetic    in    trypanosomiasis,  III. 

421 
Taylor  (Ames),  psychasthenia,  II.    H'll- 

1046 

Taylor  (E.  H.).  amputations,  I.  789-872 
Taylor  (Gordon),  ha-morrhage  and  injuries 

of  arterirs.  I.  12.W1277 
sui'L'ieal  diseases  of  arterio-sclerosis,  I. 

1296 

wounds  of  arteries,  I.  1278-1280 
Taylor  (James),   neurasthenia,   II.   1038- 

1043 

Tea  in  typhoid  fever,  I.  343 
Teale's  amputation,  I.  s.">l 
Teeth,  abnormalities  of  position  of.  III. 

1165 

artificial,  cleansing  of,  II.  128 
care  of,  II.  127 
in  children,  I.  49 
in  cleft  palate  operation,  II.  152 
in  scarlet  fever,  I.  294 
in  sprue.  III.  44."i 
in  syphilis,  I.  318 
caries  of.  III.  1 1  72 
cleaner,  rubber,  II.  128 
crowns  of.  artificial,  III.  1178 
dislocation  of,  III.  1177 
displacement  of  in  fracture  of  the  jaw, 

II.  99 

examination  of  in  epilepsy,  II.  992 
extraction  of.  III.  117'.» 
anaesthetics  for,  III.  29 
casualties  in.  III.  1188 
complications.  III.  11^-- 
luemorrhage  following.  1 1 1.  1  IS'.i 
local  anaesthetics  and.  III.  1190 
methods    applicable     to     individual 

teeth,  III.  1181-1188 
septic  infection  of  socket  following, 

III.  1190 

under  anesthetics.  III.  1190 
fracture  of,  III.  1177 
nrcroMs  of  jaw  and.  II.  Ins 
pulp  of.  diseases  of,  111.  1 1  7:> 
temporary,  extraction  of.  III.  1188 
ulcer    in     tuberculous    disease    of    the 

tongue.  11.1  33 
Telegraphist's  cramp.  II.  12i'.»; 


Telephone  ear.  III.  880 
Telling  (W.  H.  Maxwell),  actinomycosis, 
-      1.177 

erythema  nodosum,  I.  212-213 
Glenard's  disease  (enteroptosis),  I.  430 
rheumatism  in  childhood,  I.  276-279 
Temperance,  general,  a  principle  of  treat- 
ment, I.  9 
Temperature  (body)  in  blackwater  fever, 

III.  388 

in  infectious  diseases,  I.  159,  160 
in  non-operative  appendicitis,  II.  424 
in  sanatorium    treatment  of   tuber- 
culosis, I.  1132 

in  tuberculin  therapy,  I.  1141 
in  typhoid  fever,  I.  348 
methods  of  reduction  of,  I.  36 
persistent,  complicating  acute  rhcu- 

mati-m,  I.  271' 
reduction  of,  by  baths,  I.  69 
effect  of  the  mind  on,  I.  1141 
gastro-intestinal   in    pulmonary  tuber- 
culosis, 1.  1 139 

in  gynaecological  surgery,  IV.  487 
in  normal  puerperium,  IV.  261 
in  sanatorium  treatment  of  pulmonary 

tuberculosis,  I.  1131,  1135 
increase  of  in  pulmonary  tuberculosis, 

I. 1140 

post-hiemorrhagic  rise  of,  I.  1141 
changes  of,   children  require  pro- 
tection from,  I.  50 
of  baths  and  packs,  I.  36,  38 
of  nurseries,  regulation  of,  I.  44 
Temporo-maxillary    joint,    inflammatory 

diseases  of,  II.  105 
injuries  of.  II.  104 
sphenoidal  abscess  complicating  diseases 

of  the  ear,  III.  939 
Tendo  Achillis,  rupture  of,  II.  1328 
Tendon  sheaths,  affections  of,  II.    1330- 

1333 

ganglion  of,  II.  1332 
excision  in,  II.  1332 
puncture  in,  II.  1332 
infection  of,  I.  169 
tumours  in  connection  with,  II.  1331 
Tendons,  diseases  of,  II.  1326-1333 
dislocation  of,  II.  1326 
division  of,  II.  132<> 
injuries  of,  dropped  finger  in,  II.  1329 
rupture  of,  subcutaneous.  II.  1328 
stitf  and  painful  action  of  in  fractures, 

1.578 

wounds  of,  II.  1326-1329 
Tenonitis  of  the  orbit,  III.  662 
Tenosynovitis.  acute  septic,  II.  1330 

simple.  II.  1330 
chronic  simple,  II.  1330 
massage  in.  III.  209 
suppmative.  I.  169 
syphilitic.  II.  1330 
tuberculous,  II.  1331 
cassation  in,  II.  1331 
early  stages  of,  II.  1331 


lit 


A    SYSTEM  OF   TREATMENT. 


Tenotomes,  Schwartz's,  III.  914 
Tenotomy  of  the  plantar  fascia  in  con- 
genital club-foot,  I.  954 
Tent  and  steam  kettle,  I.  39 
Teplitz  spa,  III.  156 

Terminations  of  disease,  aspects  of,  I.  21 
Testis,  diseases  of,  II.  901 
ectopia  of,  II.  904 

enucleation  of,  in  operation  for  elephan- 
tiasis scroti,  III.  507 
hernia  of,  II.  901 
imperfect  descent  of,  II.  902-905 
inflammation  of,  II.  906 
non-descent  of,  in  newborn  child,  IV. 

360 

syphilitic  disease  of,  II.  907 
torsion  of,  II.  907 
tuberculous  disease  of,  II.  908-909 
tumours  of,  II.  910 
wounds  of,  II.  907 

penetrating,  II.  907 
Tetanic  rupture  of  rectus  abdominalis,  II. 

248 
Tetanus,  I.  329-331 

complicating  the  puerperium,  IV.  326- 

327 

incubation  period  of,  I.  329 
local  treatment  of  wound  in,  I.  329 
means  of  infection  in,  I.  329 
medicinal  treatment  of,  I.  330 
methods  of  examination  in,  I.  329 
prophylactic  treatment  with  anti-teta- 
nic serum,  I.  330 
serum  therapy  of,  I.  329 
Tetany,  II.  1271 

complicating  pregnancy,  IV.  51 
the  puerperium,  IV.  328 
ulcer  of  the  stomach,  II.  381 
gastric,  I.  388 
in  children,  II.  1272-1273 
of  the  stomach,  II.  399 
Tetronal,  poisoning  by,  I.  531 
Thecal  whitlow,  I.  169 
Theocin  in  oadema,  I.  422 
Theocin-sodium  acetate  in   chlorosis,  II. 

27 

Theophyllin  in  oedema,  I.  422 
Therapeutic  procedure,  diagnosis  to  pre- 
cede, I.  23 

Therapeutics,  principles  of,  I.  1-25 
Thermal  baths,  III.  124,  126 
mineral  waters,  III.  116 
or  hot  douche  bath,  III.  127 
Thermo-cautery,  use  of,  in  operable  cancer, 

I.  137 
Thermometers,  use  of,  in  baths  and  packs, 

I.  36,  38 

Thiersch  grafts  in  cheloid,  I.  113 
in  tropical  phagedena,  III.  473 
value  of,  I.  118 

method  of  skin  grafting,  I.  543 
skin  grafts,  I.  374 
Thigh,  amputations  through,  I.  862-866 

by  a  long  anterior  flap,  I.  864 
Thiosinamin  in  cheloid,  III.  1018 


Thirst  after  abdominal  operations,  II.  263 
in  cholera,  III.  426 
in  diabetes,  I.  417 

Thomas"  abduction  frame,  II.  1061,  1159 
caliper  splint,  I.  767 
(Guillard)  operation  for  fibro-adeuomata 

of  the  breast,  II.  956 
hip  splint,  I.  756,  765 
in    tuberculous    disease   of    hip-joint, 

I.  765 

•wrench  in  congenital  club-foot,  1. 955 
Thomson  (H.  Campbell),  hysteria,  II,  1008- 

1013 

Thomson  (J.  C.),  plague,  III.  401-409 
Thomson's  (St.  Clair)   post-nasal  forceps, 

III.  734 
Thoracic  aorta,  surgery  of,  in  aneurysm, 

I.  1303 

nerve,  posterior,  injuries  of,  II.  1112 
wall,  new  growths  of,  I.  1034 

osteomyelitis  of,  I.  1032 
Thoracopagus,    podalic    version    in,    IV. 

468 

Thoracoplasty  in  empyema,  I.  1107 
Thorax.     See  Chest. 
Thorburn  (William),  injuries  and  diseases 

of  the  spine,  I.  898-911 
Throat,  care  of,  in  scarlet  fever,  I.  284 
coughs   in  pulmonary   tuberculosis,    I. 

1145 
cut,  II.  164 

after-treatment  of,  II.  165 
complications  of,  II.  165 
sequelae  of,  ii.  166 
gouty  affections  of,  III.  77o 
rheumatic  affections  of,  III.  764 
sore,  complicating  influenza,  I.  239 

swabbing  of,  in  diphtheria,  I.  194 
ThromMc     obstruction     in     injuries     of 

arteries,  I.  1278 
Thrombosis  after  ovariotomy,  IV.  794 

and  phlebitis,  I.  1328-1338 
arterial,  I.  1337 
cerebral,  II.  1177-1180 
due    to  abnormal   blood   states,   II. 

1179 

circulatory  enfeeblement,  II.  1178 
obstruction  by  pressure  from  without, 

II. 1179 

senile  arterial  changes,  II.  1178 
syphilitic,  II.  1069 
vascular  disease  and,  II.  1177 
associated  with  renal  disease,   II. 

1178 

treatment  of,  11.1179 
chlorotic,  I.  1331 
complicating  abdominal  operations,  II. 

274 
femoral,     complicating    gynaecological 

surgery,  IV.  4!)4 
in  puerperal  sepsis,  IV.  321 
gangrene  due  to  sudden  obliteration  of 

arteries  by,  I.  215 
of  corpus  cavernosum,  I.  1331 
of  the  orbit,  III.  662 


116 


A    SYSTEM  OF  TREATMENT. 


Thrombosis 

of  portal  vein,  I.  1331  ;  II.  6G<i-«ir,7 

of  prostatic  veins,  I.  i:!31 

of  retinal  veins,  III.  (>  14 

of  sigmoid  sinus,  complicating 

of  the  ear,  III.  941-943 
of  the  veins  of   broad    ligaments,  IV. 

822-828 

prophylaxis  of,  after  abdominal  opera- 
tions, II.  271 

treatment    of,    after  abdominal    opera- 
tions, II.  274 
venous,    complicating    typhoid    fever, 

I.  360 
Thrombus  in  varicose  veins,  I.  1331  ;  IV. 

89 

Thrush,  II.  122-124  ;  III.  7!»2 
Thumb,  amputation  of,  I.  Sll 

congenital     lateral     deviation    of     the 

phalanges  of,  I.  938 
Thymol  in  typhoid  fever,  I.  355 

treatment  of  ankylostomiasis.  III.  490 
Thymus  extract  in  cancel1,  I.  l.~>0 
Thyro-glossal  cysts  of  neck,  II.  170 

fistula,  II.  167-170 
Thyro-hyoid  cyst  of  neck,  II.  K',s 

space,  injury  to  in  cut  throat,  II.  1<>4 
Thyroid  arteries,  ligature,  in  exophthalmic 

goitre.  II.  .V.i  "' 
i-ysts  of  neck,  II.  1  7o 
extract,  administration  of,  II.  49-50 

in  cancer,  I.  150 

in  eclampsia.  IV.  :>7 

in  goitre,  II.  62 

in  lipomatosis,  I.  108 

in  nocturnal  enuivsis,  II.  76 

in  obesity,  I.  473 

in  ostco-arthritis,  I.  402 

in  psoriasis,  III.  1114 
fistuhe  of  neck,  II.  167 
inland,  changes  in,  psychoses  associated 
with,  II.  1801-1302 

congestion  of,  II.  51 

diseases  of,  II.  49-74 

cnucleation  of,  in  goitre,  II.  64 

extirpation  of,  in  goitre,  II.  63 

hypertrophy  of,  1 1.  •">  I 

inflammation  of,  II.  51 

influence  on  obesity,  I.  473 
growths  of,  respiratory  obstruction  due 

to,  I.  142 

inadequacy,  II.  78 
inflammation  of,  acute,  II.  .VJ 

chronic,  II.  53 

surgical  treatment  of,  II.  5.'> 
malignant  disease  of,  IF.  73-71 

palliative  treatment  of,  II.  73 

radical  treatment  of,  II.  73 
Thyroidectomy   for   exophthalmic  goitre, 

1 1.  oil 

Thyroidism,  in  exophthalmic  goitre,  II.  59 
complicating  operation  for  goitre,   II. 

89 

Thyrotomy  in   malignant  growths  of  the 
larynx.  III.  854 


Tibia,  congenital  defects  of,  I.  950 

epiphysis.     lower     separation      of      in 

fracture,  I.  632 
upper  separation   of   in   fracture,   I. 

624 

extremity,  upper,  fracture  of,  I.  623 
fractures  of,  I.  (>22-632 

involving  the  ankle-joint,  I.  C>2S 
internal  malleolus  of,  fracture  of,  I.  (!28 
operations  on,  in  congenital  club-foot, 

1.958 

shaft  of,  fracture  of,  I.  624,  625,  (J26 
spine  of,  fracture  of,  I.  624 
torsion  or  spiral  fracture  of,  I.  l>.~>7 
tuberosities  of,  fracture  of,  I.  623 
Tic  douloureux,  II.  1116 
Tics,  II.  1047-1049 
convulsive,  II.  1047 
of  neck,  II.  1052 

Tilley's  tonsil  catch  forceps,  III.  7.",  I 
Tin,  salts  of,  acute  poisoning  by,  treat- 
ment of,  I.  529 
Tinea  cruris,  III.  478 
imbricate,  III.  480 
Tinned  foods,  poisoning  by,  I.  510 
Tinnitus  of  the  labyrinth,  III.  971-973 
Tobacco  and  arterio-sclerosis,  I.  12H2 
intoxication  by,  in  epilepsy.  II.  993 
poisoning  by,  I.  533 

chronic,  I.  534 
Tod  (Hunter;,  acute  inflammation  of  the 

middle  ear,  III.  894-!io3 
Tod's   (lap   in  operation  for    diseases  of 

mastoid  process,  III.  925 1 
Toes,  amputations  of,  I.  834%-836 
deformed  by  boots,  I.  57 
Faraboeuf's  method  of  amputation  of,  I. 

88B 

general  considerations  concerning  am- 
putations of,  I.  834 
Tolu,  syrup  of,  in  bronchitis,  I.  245 
Tongue,   acute   parenchymatous  glossitis 

in,  II.  133 

affections  of,  II.  132-140 
as  an  indication  of  disease,  I.  65 
cancer  of,  I.  124 

ligature  of,  arteries  in,  I.  136 
chancre  of,  II.  134 
drugs  in,  II.  134 
cysts  of,  II.  lir> 
epithelioma  of,  II.  138-144 

after-treatment  of  operations  for,  II. 

142 

choice  of  operation  for,  II.  139 
invading  floor  of  mouth,  II.  143 
operation  for,  II.  141 
X-rays  in,  II.  139,  144 
forceps  in  amesthetics,  III.  2 
geographical    (annulus     migrans),   II. 

126-12H 

leucomata  of,  II.  137 
leukoplakia  of,  II.  137 
na'vi  of,  II.  133 

operations  on,  and  anaesthetics,  III.  27 
lanula  cyst  of,  II.  145 


117 


A    SYSTEM   OF   TREATMENT. 


Tongue  (contd.~) — 
sarcoma  *of,  II.  144 

secondary  syphilitic  lesions  of,  II.  135 
sublingual  abscess  in,  II.  133 
syphilitic  affections  of,  II.  134-138 

inveterate  chronic  glossitis  in,  II.  136 
tie,  II.  132 

in  newborn  child,  IV.  358 
tuberculous  disease  of,  II.  133 
wounds  of,  II.  132 
Tonics  in  influenza,  I.  236 
premature  use  of.  I.  *>4 
Tonsil,  acute   tuberculous  ulceration    of, 

III.  757 
care  of  in  acute  rheumatism,  I.  271,  276 

in  scarlet  fever,  I.  284 
chronic  infections  of,  III.  750-759 

clinical  types,  III.  750 

galvano-cautery  in,  III.  751 

general  treatment,  III.  751 

morcellemeiit  and,  III.  751 

operative  treatment,  III.  751 

removal  by  guillotine,  III.  751 

tubercular  ulcer  of,  III.  757 
diseases  of,  III.  747-763 
embedded  in  relation  to  the  fauces,  III. 

750 

enlarged,  in  anaemia,  II.  14 
enucleation  of,  III.  752 
lingual,  benign  tumours  of,  III.  762 

chronic  abscess  of.  III.  762 

diseases  of,  III.  760-763 
lupus  of,  III.  757 

operations  of,  after-treatment,  III.  754 
pharyngeal,  hypertrophy  of,  III.    732- 
738 

anaesthetic  in,  III.  734 

instruments    in   operation    for,    III. 
735 

operation  for,  III.  735 
removal  of,  and  anaesthetics,  III.  28 
retained  secretion  within,  III.  755 
syphilis  of,  III.  756 
tonsilloliths  of,  III.  755 
tuberculosis  of,  III.  757 
•  tumours  of,  III.  758-759 

benign,  III.  758 

malignant,  III.  758 
Tonsillitis,  acute,  III.  747-749 

general  treatment  of,  III.  748 

lacunar,  III.  747 

lingual,  III.  760 

local  treatment,  III.  748 

parenchymatous,  III.  747 

prophylaxis  of,  III.  748 
chronic  lingual,  III.  761 
joint  affections  complicating,  I.  391 
ulcerative,  III.  747 
Tonsilloliths,  III.  755 
Tonsillotome,  lingual,  III.  761 
Tooth,  adjacent,  extraction  of,  III.  1188 
brush,  daily  use  of,  II.  127 
fracture  of,  in  extraction,  III.  1188 
haemorrhage  from  socket  of,  I.  l-_'7.". 
Tophi  of  the  auricle,  III.  880 


Torrens  (James),  coeliac  disease,  II.  426- 

427 
embolism  (excluding  cerebral  embolism), 

I.  1306-1308 
medical  treatment  of  aortic  aneurysm, 

I.  1297-1300 

myasthenia  gravis.  II.  1254 
pseudo-leukaemia,  II.  42 
treatment     of     fistulous      tracks      in 
empyema  by  the  injection  of  bismuth 
and  vaseline.  I.  1110-1111 
Torsion-clamp,  method   in    operation   for 

elephantiasis  scroti,  III.  509 
Torticollis,  II.  1050-1053 
mental,  II.  1052, 
neuralgic,  II.  1050 
paralytic,  II.  1051 
professional,  II.  1050 
rhythmic,  II.  1052 

scoliosis  and  deformities   of  the  shoul- 
ders, I.  972-988 
spasmodic,  true,  II.  1051 
wryneck  or,  I.  987 
Tourniquet,   control   of   haemorrhage,    I. 

798 

use  of,  in  haemorrhage,  I.  559 
Towels,  arrangement  of  before  operation, 

I.  85 

sterilisation  of,  I.  73 
Toxaemias,   subinvolution    of    uterus    in, 

IV.  720 

Toxic  psychoses,  II.  1303-1304 
Trachea,  cancer  of,  relief  of  obstruction 

in,  I.  142 
compression  of  from  without,  III.  801 

diseases  of,  III.  797 
fistula  of,  III.  799 
gummata  of,  III.  801 
inflammation  of,  in  influenza,  III.  798 
injuries  of,  III.  797 

in  cut  throat,  II.  165 
obstruction  of,  III.  800-802 
rupture  of.  III.  797 
scalds  of,  III.  797 
structure  of,  III.  801 
Tracheo-laryngostomy  in  stenosis  of  the 

larynx,  III.  866 
Tracheotomy,  high   and  low,   merits  of, 

I.  197 

in  aortic  aneurysm,  I.  1299 
in  cancer  of  larynx,  I.  142 
in  diphtheria,  I.  195 
in  foreign  bodies,  III.  820 
in   malignant    disease  of   the  thyroid, 

11.74 

Trachoma,  III.  557 
Transcondyloid  amputation  through  thigh, 

I.  862 

Transfusion  in  pernicious  anaemia,  II.  9 
in  tubal  pregnancy,  IV.  85 
of  human  blood  in  shock,  I.  102 
Traumatic  cases,  amputation  in,  I.  789 
cataract,  III.  638 
cyclitis,  III.  595 
gangrene,  I.  582 
118 


A    SYSTEM   OF   TREATMENT. 


Traumatic 

neuritis.  II.  1106 

of  the  uvula,  III.  7  IT. 

osteomyelitis.  L  889 

periostitis.  I.  7<>3 

pvopneumothorax,  I.  1114 

rhinitis,  III.  704 

Traumatism.  mineral  waters  and  baths  in, 
III.  145 

shock  caused  by,  I.  96 
Treatment,  based  on  aetiology,  I.  3-9 

clinical  indications  for,  I.  2<>-22 
symptomatic,  I.  15-20 

conservative  factors  in,  I.  11 

empirical,  I.  1 

indications  for,  I.  2 

methods  of  natural  resistance  indicating, 
I.  4 

of  acute  disease,  I.  20 

of  chronic  disease.  I.  20 

of  complications  and  sequela?,  I.  22 

of  specific  causes  of  disease,  I.  4-8 

palliative,  I.  18 

pathological  indications  for,  I.  10-15 

practice  and  management  of,  I.  22-25 

principles  of,  I.  1-25 

rational,  I.  1 

symptomatic,  I.  18 

Trendelenburg  position,  value  of,  I.  95 
Trephining  in  infective  lesions  of  skull, 
I.  889 

preparation  of  head  for,  I.  87 
Trichiasis  of  the  eyelids,  1 1  \.  580 
Trichinelliasis,  III.  524 

prophylaxis  of.  III.  524 
Trichini'asis,  IIL  524 

prophylaxis  of,  IIL  ~>'l  I 
Trichinosis.  III.  524 

prophylaxis  of,  III.  ."ii'l 
Trichlormethane  as  anaesthetic,  III.  13 
Trichocephaliasis,  III.  493,  496 
Trichorrhexis  nodosa,  III.  1145 
Trigeminal  neuralgia,  II.  1116 
Trigger  linger,  I.  '.Ml' 
Trigone,  exposure  and  division  of,  II.  935 
Trillat  autoclave,  fumigation  by,  I.  163 
Trinitin  in  high  blood  pressure,  I.  1283 
Trional,  poisoning  by,  I.  531 
Trismus  spasm,  II.  1048 
Trophic  diseases,  II.  122i', 
Tropical  anemia,  II.  15 

diseases,  HI.  :i7r,-.->n; 

fevers,  undefined,  III.  410 

liver.  II.  676-678 

phagedeiia,    II  I.    172 
general  treatment  of,  III.  472 
local  treatment  of,  HI.  473 
prophylaxis  of,  III.  472 

regions,     physiological    effect    of,    on 
Europeans,  III.  37.". 

skin  diseases,  lit.  47i>-|xr, 

ulcer,  III.  I7i> 

Tropics,  adaptation  of  habits  to  climate 
in,  III.  376 

diet  in.  III.  378 


Tropics  (contd.)  — 

diseases  disseminated  by  insects  in,  III. 

379 

'dress  in,  III.  377 
drink  in,  III.  378 

excretal  diseases  and  their  dissemina- 
tion in  the  tropics,  III.  383 
food  in,  III.  378 
general  hygiene  in,  III.  375 
housing  in,  III.  379 
insecticides  in,  III.  383 
malaria  in,  III.  380 
milk,  boiled  in,  III.  384 
personal  hygiene  in,  III.  375 
precautions  against   insanitary   condi- 
tions in,  IIL  383 

when  exposed  to  sun  in,  III.  :<77 
protection    from   insect-borne   diseases 

in,  III.  379 
rest  in,  III.  379 
ringworm  in,  III.  478 
sleep  in,  III.  379 
sleeping  sickness  in,  III.  383 
water  boiled  in,  III.  384 
yellow  fever  in.  III.  382 
Tropococaine,    injection     of,    for    spinal 

analgesia,  III.  37 

Trunk  exercises  in  gymnastics,  III.  226 
-raising  exercises  for  spinal  curvatures, 

III.  238 

-rolling  exercise  in  pulmonary  disease, 
III.  252 

for  scoliosis,  III.  242 
-rotation    exercise  in  defective  meta- 
bolism, III.  255 

for  lardosis,  III.  240 
varix  affecting,  I.  1320 
Truss,  child's  double,  for  inguinal  hernia, 

II.  527 

for  femoral  hernia,  II.  526 

for  inguinal  hernia,  II.  527 

for  irreducible  hernia,  II.  527 

for  movable  kidney,  II.  787 

in   palliative  treatment  of  hernia,  II. 

498 

umbilical,  II.  527 
Trypanosomiasis,  III.  417-422 
arsacetin  in,  III.  421 
arsenious  acid  in,  III.  42 JL 
arscnophenylglycin  in,  III.  419 
combined  therapy  of,  III.  421 
general    principles    of    chemotherapy, 

III.  419 

general  treatment  of,  III.  122 

tartar  emetic  in,  III.  421 
Trypsin  in  cancer,  I.  151 

in  treatment  of  cancer  of   alimentary 

system,  I.  140 
Tubercle  bacillus  in  salpingitis,  IV.  815 

fistula  of  anus  due  to,  II.  (509 
Tubercula  dolorosa,  I.  112 
Tuberculide,  papulo-squamous,  III.  11  .".2 
Tuberculides,  III.  1146-1152 
Tuberculin,    bacillary    emulsion      sensi- 
tized, III.  294 


119 


A    SYSTEM   OF   TREATMENT. 


Tuberculin  (contd.~) — 
Beraneck's,  III.  293 
Denys'  bouillon  filtre",  III.  293 
exercise    after    the  administration  of, 

I.  1139 

in  pulmonary  tuberculosis,  I.  1119 
in    tuberculous    lymphatic    glands,   I. 
1346 

meningitis,  I.  249 

peritonitis,  II.  646 
Koch's  new,  111.  293 
Koch's  old,  III.  293 
Perlsucht,  III.  293 
therapy,  dosage  in,  III.  295 

in  tuberculosis,  I.  323  ;  III.  291-298 

method  of  administration,  III.  294 

of  tuberculosis  of  the  kidney,  II.  820 

secondary  infections  in,  III.  297 

temperature  in,  I.  1141 
Tuberculosis,  acute,  I.  332-334 

without  localising  symptoms,  I.  332 
climate  for,  III.  100 
complicating  pregnancy,  IV.  50 
diet  in,  II.  203 

hyperplastic  of  the  colon,  II.  590 
miliary  or  generalised,  I.  332 
mineral  waters  and  baths  in,  III.  143 
of  bladder,  II.  820 
of  breast,  II.  981 
of  colon,  II.  590 
of  conjunctiva,  III.  560 
of  kidney,  II.  819-829 
of  larynx,  III.  870-875 
of  nares,  III.  687,  688 
of  naso-pharynx,  III.  742 
of  pharynx,  III.  793-794 
of  tonsil,  III.  757 
of  uvula,  III.  745 
of  vulva,  IV.  508 
prophylaxis  of,  I.  1126 
pulmonary,  I.  1117-1126 

after-treatment  of.  I.  1125 

anaemia  caused  by,  II.  13 

amemia  in,  I.  1149 

auto-inoculation,  regulation  of,  in,  I. 
1121 

climate  and,  IV.  1118 

complications  of,  I.  1155-1158 
by  albuminuria,  I.  1157 
by  cystitis,  I.  1156 
by  diabetes,  I.  1158 
by  empyema,  I.  1158 
by  epididymitis,  I.  1157 
by  ischio-rectal  abscess,  I.  1156 
by  pleurisy,  I.  1158 
by  pregnancy,  1. 1155 
by  syphilis,  I.  1156 

coughs  in,  various,  I.  1144 

creosote  vapour  bath  in,  I.  1149 

diet  in,  I.  1119 

dust  and, I. 1118 

dyspnoea  in,  I.  1138 

exercise  in,  I.  1123 

fresh  air  in,  I.  1118 

graduated  labour  in,  T.  1159-1163 


Tuberculosis,  pulmonary  (matd.') — 

guide  to  control  of   auto-inoculation 
in,  I.  1162 

haemoptysis  in,  I.  1150 
mild,  I.  1150 
moderate,  I.  1151 
severe,  I.  1154 

increase  of  patient's  resistance  to,  I. 
1118 

induction    of    an   artificial    pncumo- 
thorax  in  treatment  of,  1. 1164-1173 

inhalers,  dry,  in,  I.  1148 

injections,  intra-tracheal  in,  I.  1149 

injections,  secondary  in,  I.  1126 

insomnia  in,  I.  1149 

Kuhn's  mask  in,  I.  1148 

light  treatment  in,  III.  201 

massage  in,  I.  1139 

pneumothorax,  artificial  in,  I.  1164- 

1173 
completion  and  maintenance  of,  I. 

1168 

complications  of,  I.  1171 
difficulties  of,  I.  1167 
duration  of,  I.  1169 
dyspepsia  complicating,  I.  1170 
Forlanini's  method,  I.  1170 
modifications  of  method,  I.  1 1 70 
Murphy's  method,  I.  1170 
nitrogen  apparatus  for,  I.  1166 
pleurisy  complicating,  I.  1170 
Saugman's  needle  for,  I.  1107 

pulse  rate  in,  I.  1141 

rest  as  guide  to  control  of  auto-inocu- 
lation in,  I.  1162 

rest  in,  I.  1122 

sanatorium  treatment  of,  I.  1127-1158 
daily  notes  in,  I.  1132-1142 
exercise  stage  in,  I.  1129,  113.") 
exhaustion  in,  I.  1138 
lassitude  in,  I.  1138 
rest  stage  in,  I.  1128 
temperature  (body),   in,    I.   1131, 
1135 

secondary  infections  in,  I.  1126 

specific    measures    for,    reputed,    I. 
1126 

stomach  dilatation  in,  I.  1150 

sweating  in,  I.  1143 

temperature,  effect  of  the  mind  on, 

in,  I.  1141 

Castro-intestinal  in,  I.  1139 
increase  in,  I.  1140 
post-haemorrhagic  in,  I.  1141 

tuberculin  treatment  of,  1. 1119  ;  III. 

285-295 

exercise  in,  I.  1139 
temperature  in,  I.  1141 

weight,  loss  of,  in,  I.  1155 

wind  and,  I. 1118 

Tuberculous   abscess,   methods    of   treat- 
ment of,  I.  173-176 
adenitis,  III.  757 
bursitis,  II.  1335 
cystitis,  II.  861-863 


A    SYSTEM  OF  TREATMENT. 


Tuberculous  cystitis  (contd.} — 

complicating  pulmonary  tuberculosis, 

I.  1156 

disease  of  the  ankle  and  tarsus,  I.  772- 
776 

of  bones,  I.  7n4 

of  elbow,  I.  777-779 

of  Fallopian  tubes,  IV.  817-819 

of  hip-joint,  I.  752-705 

of  jaws,  II.  ln«.) 

of  joints,  I.  750-752 

of  knee- joint,  I.  765-772 

of  lymphatic  glands,  I.  1344-1347 

of    middle    ear     and    its    accessory 
cavities,  III.  935-9:56 

of  ribs,  rib  cartilages,  and  sternum, 
I.  1032 

of  sacro-iliac  joint,  I.  780 

of  shoulder,  I.  775-777 

of  testis,  II.  908-909 

of  tongue,  II.  133 

of  wrist,  I.  779 

spinal,  Pott's  disease,  I.  922-927 
empyema,  I.  1108 
cpididymitis    complicating    pulmonary 

tuberculosis,  I.  1157 
glands,  cheating,  in  the  mediastinum, 
I.  1177 

suiirical  treatment  of,  I.  1348 

X-rays  in,  III.  367 
iritis.  III.  589 

keratitis  of  the  cornea,  III.  569 
meningitis.  I.  2  is,  249 
onvchitis,  III.  10*2 
osteitis  of  the  skull,  I.  889 
pericardit  is.  I.  1 184 
peritonitis.  1 1.  t;i5-r,l7 
prostatitis,  II.  928-929 
psoriasis,  III.  1152 
pyopneumothorax,  I.  1114 
salpiiiL'itis,  IV.  817-819 
sinuses,  chronic,  I.  176 
synovitis,  I.  752 
tenosynovitis,  II.  1331 
ulcer,  chronic,  of  tonsil,  III.  757 
ulceration,  acute,  of  tonsil.  III.  7". 7 
Tufnell's  treatment  of  aortic  aneurysm,  I. 

1297 

Tumour  cells,  embolism  by,  I.  1306 
Tumours,  air  containing,  of  the  skull,  I. 

896 
cerebral,  in  children,  II.  1166 

-  ;-ic.  simple,  II.  400 
growing   from    the   bony  walls   of  the 

cranium,  I.  S'.i  1 
in  connection  with  tendon  sheaths,  II. 

1331 
innocent,  of  the  lips.  II.  (.i7 

of  the  vulva.  IV.  nil -.ML' 
intra-abdominal,    complicating     preg- 

nacy.  IV.  5  5 
intra-eranial,  coma  and,  II.  983 

headache  from,  II.  KCIt 

localised,  IT.  12<»2.  12n:; 
intra-liganic  nt;u  y.  IV.  7(18-770 


Tumours  (i-ontd.} — 

malignant,  Coley's  fluid,  III.  298-299 

degeneration  of,  I.  119 

of  the  lips,  II.  97 

of  the  prostate,  II.  932-938 
naso-pharyngeal,   and   Eustachian   ob- 
struction, III.  947 
of  bones,  I.  708 

of    brain,    medical  treatment    of,    II. 
120(1-1203 

surgical  treatment  of,  II.  1204-1207 
of  breast,  doubtful,  operative  diagnosis 
in,  II.  979-980 

operative  diagnosis  of.  II.  979 
of  ovary,  complicating  labour,  IV.  77:!- 
774 

complicating  puerperium,  IV.  774 

during  pregnancy,  IV.  771-772 

malignant,  IV.  786 
of  bile  ducta,  II.  713-715 
of  bladder,  II.  870-873 
of  broad  ligaments,  IV.  823 
of  gall  bladder,  II.  71O-712 
of  liver,  II.  679 
of  nerves,  II.  1142 
of  nose,  III.  692 
of  orbit,  III.  662 
of  prostate,  II.  930-949 
of  scalp,  I.  892-896 
of  skin,  III.  1057 
of  spinal  cord,  II.  1221-1225 
of  testis,  II.  910 

of  uterus,  inversion  due  to,  IV.  699 
of  vagina,  IV.  553-554 
of  umbilicus  due  to  vitelline  remains, 

II.  278 

pulmonary,  I.  1175 
simple  fibrous,  of  the  vulva.  IV.  511 
solid,  of  the  scalp,  I.  892 
surgical  treatment  of,  I.  106-156 
vascular,  of  the  scalp,  I.  893 

See  also  under  Organs  and  Regions. 
Tunbridge  Wells  spa,  III.  156 
Tunica  vaginal  is,  diseases  and  affections 

of,  II.  913-929 

Turkish,   baths  in  subacute  gout  contra- 
indicated,  I.  441 

Turner  (<J.  K.),  hernia,  II.  498-527 
Turner  (Philip),  fractures,  I.  568-633 
Turner   (William  Aldren),   epilepsy,   II. 

990-1007 
Tumour  (Meadows),  on  return  cases  of 

diphtheria,  I.  188 

Turpentine,  Chian,  in  cancer,  I.  148 
enema,  I.  32 

in  constipation  in  adults,  II.  454 
in  phosphorus  poisoning,  I.  525 
in  typhoid  fever,  I.  354 
liniment  in  whooping  cough,  I.  379 
oil  of,  in  haemophilia,  II.  34 
poisoning  by,  I.  532 
stupe,  I.  35 
Tweedy   (E.    Hastings),   management  of 

labour  in  special  presentations,    IV. 

128-156 


121 


A    SYSTEM   OF   TREATMENT. 


Tweedy  (E.  Hastings)  (eontd.*) — 

management  of  normal  labour,  IV.  91- 

127 

Twins,  locked,  forceps  in,  IV.  422 
poclalic  version  in,  IV.  467 
presentation  of,  in  labour,  IV.  1 55 
Tylosis,  III.  1153 
Tympanic  cavity,  mucous  membrane  of, 

III.  951 

membrane,  adhesions  of,  III.  892 
calcareous  deposits  in,  III.  892 
congenital  absence  of,  III.  891 

perforations  of,  III.  891 
diseases  of,  III.  891-893 
ecchymoses  of,  III.  891 
herpes  of.  III.  891 
inflammation  of,  III.  891 
injuries  of,  III.  893 
malformations  of,  III.  891 
massage  of,  III.  952 
myringitis  of,  III.  891-892 
perforations  of,  III.  892 

in   acute  inflammation  of  middle 

ear,  III.  896 
rupture  of,  III.  893 
ossicles,  massage  of,  III.  952 
Tympanitis  complicating  typhoid  fever,  I. 

358 

Typhoid  arthralgia,  I.  784 
fever,  I.  335-364 

albumin-water  in,  I.  342 
anti-pyretic  treatment  of,  I.  348 
antiseptic  treatment  of,  I.  352 
appendicitis  and,  II.  411 
arthritic'and  bone  complications  in, 

I.  363,  784 

bacteriology  of,  I.  345 
calomel  in,  I.  353 
cardiac  complications  in,  I.  364 
complicating  pregnancy,  IV.  48 
complications  and  sequelae  of,  I.  356- 

364 

cutaneous  complications  of,  I.  356 
delirium  in,  I.  362 
diarrhoea  in,  I.  358 
diet  in,  I.  340  ;  II.  202 
drugs  in,  I.  351 
epidermiology  of,  I.  335-337 
epistaxis  in,  I.  357 
gastric  complications  of,  I.  357 
general  remarks  on,  I.  344 
genito-urinary    complications    in,   I. 

361 

haemorrhage  in,  I.  359 
hepatic  complications  in,  I.  360 
hygiene    and     management     of    the 
patient  and  household  in,  I.  338 
of  mouth  and  nose  in,  I.  356 
intestinal  antiseptics  in,  I.  353-356 

complications  in,  I.  359 
lumbar  puncture  in,  I.  362 
meat  broths,  etc.,  in,  I.  342 
middle  ear,  disease  in,  III.  902 
milk  diet  in,  I.  341 
nervous  complications  in,  I.  362 


Typhoid  fever  (eont<l.~)— 

nursing  of,  I.  40 

origin  of  outbreaks,  I.  336 

perchloride  of  mercury  in,  I.  353 

peritonitis  in,  1. 359 

preventive  inoculation  of,  III.  299 

prophylactic  inoculation  in,  I.  348 

purgatives  in,  I.  :>.">."> 

respiratory  complications  in,  I.  361 

serum  therapy  of,  I.  347  ;  III.  300 

thrombosis  in,  I.  1331 

vaccine  therapy  of,  I.  345 ;  III.  293, 
SCO 

vascular  complications  in,  I.  360 

whey  in,  I.  341 

with  perforation,  II.  550 

Woodbridge  treatment  of,  I.  355 
Typhus  fever,  diet  in,  I.  366 
general  management  of,  I.  365 
remedial  treatment  of,  I.  366 
Tyrnauer's    electrical  hot-air  appliances, 
III.  320 


Ulcers,  anaemic,  I.  372 
callous,  I.  370 
chronic,  I.  369 

amputation  in,  I.  790 
dental,  in   tuberculous  disease  of   the 

tongue,  II.  133 
diabetic,  I.  373 
duodenal,  II.  391-394 

diet  in,  II.  211 
gastric.  II.  375-381 

perforation  of,  II.  389 

surgical  treatment  of,  II.  382-388 
healing,  I.  374 
horse  serum  in.  III.  262 
in  plague,  III.  406 
inflamed,  I.  368 
irritable,  I.  372 

of  leg,  antiseptic  treatment  of,  I.  83 
of  the  cornea,  III.  563 
phagedenic,  I.  369 
perforating,  I.  373 

complicating  diabetes  mellitus,  I.  426 
rodent,  III.  1132-1134 

ionic  medication  of,  III.  184 

of  the  auricle,  III.  879 

of  the  lips,  II.  97 

of  vulva,  IV.  508 

X-rays  in,  III.  347 
skin  grafting  in,  I.  373-375 
sub-lingual  in  whooping  cough,  I.  385 
syphilitic,  mercurial  treatment  of,   II. 

135 

tropical,  III.  472 
varicose,  I.  372 
Ulceration,  I.  368-375 

complicating  cystocele  of   the  vairina, 
IV.  547 

rectocele  of  the  vagina,  IV.  547 
control  of  in  inoperable  cancer,  I.  136 
of  the  pharynx,  III.  7!>.~> 
treatment  of,  I.  137 


A    SYSTEM  OF  TREATMENT. 


Ulna,  congenital  defects  ,,f.  I.  <.i:;r, 

dislocations  of,  1.  721 

shaft  of,  I'racliiiv  of,  I.  :,'.>>.).  Ctii).  i'.ol 

stvloid  process  of,  1'ract.un:  of,  I.  G03 
Ulnar  nerve,  dislocation  of.  II.  UK? 

injuries  of,  II.  1112 

neuritis  of,  at  elbow-joint,  IT.  1112 

paral  vsis  of.  1 1.  12f>7 
Umbilical  belt,  child's.  II.  :,27 

cord.  e.\|)ressioii    of,  in   podalic   version, 

iv.  4<;<; 

expression  of.  forceps  in,  IV.  421 
failure  of.  to  pull   up  with  uterus  in 

third  stage  of  labour.  IV.  12o 
lengthening    of,    in    third    stage    of 

labour,  IV.  11!) 
liirature  of,  in  third  stage  of  labour 

IV.  117 

pfolap>e  of,  forceps  in,  IV.  421 
lalxnir  in,  I  V.  117 
podalic  version  in.  IV.  Itii'i 
rupture    of,   in    newborn    child,   IV. 

366 

secondary    h;eniorrhage   of    in    new- 
born child,  IV.  370 
sepsis  of,  in  newborn  child,  IV.  37o 
shortness  of,  and  accidental  haemor- 
rhage. IV.  2!) 

grip  in  palpation  in  labour,  IV.  w 
Umbilicus,  acquired  affections  of,  II.  279- 

28] 
inflammatory  conditions  of  umbilicus 

as,  II.  27li 

urachal  cysts  as,  II.  27'.) 
acquired  fistula  of.  II.  2so 
affections  of,  II.  27H-2S1 
angioina  of.  in  newborn  child,  IV.  37(1 
antiseptic  treatment  of,  I.  !»1 
congenital  malformations  of,  II.  227 
and  urinary  fistula  in  infants,  If.  278 
persistence  of  urachal  remains  and, 

II.  278 

vitelline  remains  in,  II.  277 
vitello-intestinal  fistula  and,  II.  278 
inflammation  of,  II.  27!) 
primary  epithelioma  of,  II.  281 
sarcoma 'of,  II.  281 

'iidary  cancer  of,  II.  281 
tumours  of,  II.  280 

due  to  vitelline  remains,  II.  278 
urinary  fistula  at.  in  adults,  II.  279 

in  infants.  1 1.  27s 
Uncinariasis,  III.  Is: 
Undulant  fever.  III.  39!) 
Unna's  treatment  of  ulcers,  I.  371 
Urachus.  cysts  of,  in  acquired  affections 

of  the  umbilicus,  II.  27!> 
persistence  of  remains  of,  in  congenital 
malformations  of  the  umbilicus,   II. 
878 
Uraemia.  II.  s;i7-839 

headache  from,  II.  1034. 
Uraemic  coma,  II.!»S2 
Urea,  solution  of.  I.  l:!7 
Ureter,  diseases  of,  II.  730,  840-851 


Ureter  (nmtd.)— 

fistula  of,  II.  842-SI5 

results  of  uretero-cysto-ncostomy  in, 
II.  844 

treatment,  II.  843 

implantation  of  in  vesical  cancer,  1. 143 
malformations  of,  acquired,  II.  774 
obstruction  of,  in  cancer,  relief  of,  I. 

143 
operations  for  congenital  malformations 

of,  II.  77-1 
stone  in,  II.  846-851 

instrumental  treatment  of,  II.  847 

medicinal  treatment  of,  II.  847 

operative  treatment,  II.  848 

results  of  operative   treatment,    II. 

860 
wounds  of,  II.  840 

results  of  operative  treatment,  II.  841 
Ureteral  catheter  in  pyonephrosis,  II.  815 
Uretero-cysto-neostomy  in  fistula  of  the 

ureter,  II.  844 

Uretero-pyelo-neostomy,  II.  776 
Uretero- vaginal  fistulas,  IV.  534 
Urethra,  after  transverse  section  of,  II. 

934 

caruncle  of,  dyspareunia  in,  IV.  841 
diseases  and  affections  of,  II.  882-899 
female,  abscess  of,  IV.  870 

carcinoma  of,  IV.  872 

caruncle  of,  IV.  872 

dilatation  of,  IV.  869 

diseases  of,  IV.  868-874 

displacements  of,  IV.  868 

fibroma  of,  IV.  872 

haemorrhoids  of,  IV.  872 

mucous   membrane  of,   prolapse  of, 
IV.  869 

sacculus  of,  IV.  870 

sarcoma  of,  IV.  872 

stricture  of,  IV.  871 

tender  red  patches  in,  IV.  873 
fistuhe  of,  II.  894 
foreign  bodies  in,  II.  884 

operation  for,  II.  885 
hydronephrosis  due  to  obstruction  in, 

II.  772 
imperforate,     of    foetus,    complicating 

labour,   IV.    180 
injuries  of.  II.  882-885 

by  blow  on  the  perineum,  II.  882 

obstruction  due  to  cancer,  relief  of, 

I.  142 
piostatic,  gonorrhoeal   infection   of,  I. 

227 
stricture  of,  II.  886-892 

acute  retention  of  urine  in.  If.  890 

internal  urethrotomy  in,  II.  889 

uncomplicated,  II.  886 
Urethritis,  chronic  (gleet),  II.  877-87!) 
complicating  the  puerperium,  IV.  32!) 
gonorrhoeal,    complicating     the    puer- 
perium, I  V.  :<:.".) 

Urethro-cystitis  complicating  gonorrhoea, 
I.  22S 


123 


A    SYSTEM  OF   TREATMENT. 


Urethrotomy,  external,  in  acute  retention 
of  urine  complicating  stricture,  II. 
891 

internal,  in  stricture,  II.  889 
TJriage  spa,  III.  157 
Uric  acid,  diet  and,  II.  207 

in  gout  and  gouty  conditions,  I.  436 
solvents  of,  I.  436 
so  called,  I.  436 
Urinary  fistula?,  IV.  535 

organs,  cancer  of,  relief  of  obstruction 

in,  I.  141,  142 
diseases  of,  II.  730 
Urine,   acute  retention  of,   complicating 

stricture  of  urethra,  II.  890 
alkaline,  bicarbonate  of  soda,  produc- 
ing, I.  423 

production  of,  I.  410,  418 
Bence  Jones  protein  in,  II.  749 
diacetic  acid  in,  in  diabetes  mellitus,  I. 

409,  417 

diversion  of,  in  ectopia  vesicae,  II.  866 
effect  of  food  on,  II.  205 
examination  of,  in  infants,  I.  53 

in  poisoning,  I.  526,  529 
extravasation  of,  II.  893-894 
in  normal  puerperium,  IV.  258 
incontinence  of,  I.  53 
care  of  the  skin  in,  I.  31 
complicating  gynaecological  surgery, 

IV.  497 

nocturnal,  II.  75-77 
passage  of,  in  normal  puerperium,  IV. 

265 
reflex  incontinence  of,  injuries  of  the 

spine,  I.  909 

retention  of,  after  operation,  manage- 
ment of,  I.  29 
complicating  abdominal    operations, 

II.  272 

gynaecological  surgery,  IV.  496 
in  acute  prostatitis,  II.  921 
in  injuries  of  the  spine,  I.  909 
scanty  in  scarlet  fever,  I.  292 
sugar  in,  in  diabetes  mellitus,  I.  410 
suppression  of,  in  mercurial  poisoning, 

1.530 

in  yellow  fever,  III.  413 
typhoid  bacillus  in,  I.  346 
Urticaria,  III.  1154-1156 
complicating  pregnancy,  IV.  56 
pigmentosa,  III.  1154-1156 
Uterine  forceps  with  pledget  of  wool,  IV. 

625 

souffle  in  normal  labour,  IV.  104 
Uterus,  absence  of,  IV.  711 
adenomyoma  of,  IV.  663 
anteflexiou  of,  IV.  670-672 
acquired,  IV.  671 
acute,  subinvolution  in,  IV.  722 
congenital,  IV.  t;70 
juvenile,  IV.  ''.7" 
anteversion  of,  IV.  r.ii'.t 
application  of  strong  antiseptics  to,  in 
puerperal  sepsis,  IV.  310 


Uterus  (contd.) — 

atony  of,    after  removal    of  child,    in 

Ctesaiean  hysterectomy,  IV.  399 
retention  of  placenta  in,  IV.  229 

bicornal,  pregnancy  in,  IV.  712 

bi-manual  compression  of  post-partum 
haemorrhage,  IV.  220 

body  of,  leucorrhoea  from,  IV.  568 

broad    ligaments    of,    diseases  of*  IV. 
820-823 

cancer  of,  IV.  575-581 

abdominal  total  hysterectomv  in,  IV. 

579 

Caesarean  hysterectomy  in,  IV.  398 
curative  treatment,  IV.  576 
diagnosis  of,  IV.  576 
hystero-vaginectomy  in,  IV.  580 
limits  of  operations  in,  IV.  581 
operative  treatment,  IV.  578 
preventive  treatment,  IV.  575 
results  of  operations  for,  IV.  581 
salpingitis  complicating,  IV.  814 
vaccine  treatment  of,  I.  133 
vaginal  hysterectomy  in,  IV.  578 

cervical  canal  of,  malposition  of,  com- 
plicating labour,  IV.  157 

cervical  tear  of,  secondary  closure  of, 
IV.  190 

cervix.     See  Cervix  uteri. 

chorio-carcinoma  of,  IV.  618-619 

chorion  epithelioma  of,  IV.  618-U19 

cicatrix   of,  danger  of  giving  way  in 
Caesarean  section,  IV.  396 

condition  of  in  forceps,  IV.  424 

contraction     of,     tonic,     complicating 
labour,  IV.  248-249 

control  of.  in  third  stage  of  labour,  IV. 
118 

curettage  of,  in  puerperal  sepsis,  IV.  299 

decidua    of,    and    extra-uterine    preg- 
nancy, IV.  83 

deciduoma  malignum  of,  IV.  618-619 

degeneration  of,  Caesarean  hysterectomy 
in,  IV.  398 

development  of,  imperfect,  IV.  711 

diseases  of,  IV.  575 

dyspareunia  in,  IV.  841 

mineral  waters  and  baths  in,  III.  145 

displacements  of,  IV.  669-699 

double,  IV.  543 

douching  of,   in  puerperal   sepsis,  IV. 
310 

empty,  and  puerperal  sepsis.  IV.  290 

enlargement  of,  in  acute  hydramnios, 
IV.  44 

evacuation  of  in  puerperal  sepsis,  IV. 
297 

exhaustion  of,  complicating  labour,  IV. 
250-251 

exploration  of.  in  puerperal  sepsis,  IV. 
295 

fibro-myoma  of,  Cresarean  hysterectomy 
in,  IV.  398 

tibro-myoinata  of ,  Caesarean  section  in, 
IV.  384 


124 


A    SYSTEM  OF   TREATMENT. 


Uterus 
fibroids  of,  IV.  634-663 

complicating  extra-uterine  pregnancy, 

IV.  82 

polypus  of.  IV.  659 
fistula?  of,  IV.  664-668 
due  to  injury,  IV.  665 
from  malignant  growths,  IV.  668 
flexions  of,  IV.  66<J-t;!>:t 
t'undus  of,  complete  transverse  rupture 

of,  complicating  labour,  IV.  243 
compression      of      in      post-partum 

hsemorrlia.Lri',  I  V.  219 
rising  uf.  in  third  stage  of  labour,  IV. 

120 
haemorrhage  of,   accidental,   Csesarean 

hysterectomy  in,  IV.  398 
hour-glass     contraction     of,     retained 

placenta  in,  IV.  230,  231 
in  normal  puerperium.  IV.  257 
incision   of,   in   Cajsarean   section,  IV. 

888 
inert  ia  of,  complicating  labour,  IV.  252- 

•2:,:, 

drugs  in.  IV.  253 
primary,  forceps  to  assist  delivery  in, 

iv.  -ii-.i 

infantile,  IV.  711 

infective  processes  of,  fistulas  from,  IV. 

668 
inflammation     of,    chronic,    Cassarean 

hysterectomy  in.  IV.  398 
injuries  of,  IV.  575,  707-710 

by  operative  procedure,  criminal,  IV. 

708 
legitimate,  IV.  708 

incidental,  IV.  709 
inversion  of,  chronic,  IV.  697-699 

elastic  pressure  in.  IV.  698 

puerperal,  IV.  <>'.'7 

surgical  treatment  of,  IV.  698 

complete,  complicating  labour,  IV.  184 

complicating  labour,  IV.  182-187 

due  to  tumours,  IV.  699 
involution   of,   in  normal  puerperium, 

IV. 261 

leucorrhcea  of,  IV.  565 
malformations  of,  IV.  711-717 
maseulinus    in    hermaphroditism,    IV. 

86fi 
mobility  of,  in  third  stage  of  lalxmr,  IV. 

120 

mucous  polypus  of,  IV.  662 
muscular    wall   of,    overstretching    of, 

subinvolution  in,  IV.  722 
myoma  of.  X-rays  in,  III.  366 
obliquity  of,  abnormal,  forceps  in,  IV. 

120 

panliysteivctomv  of,  IV.  401 
plugging  of ,  in  meiioiThagia,  I  V.  7 57 

in  mi'trorrhagia.  I  V.  7.~>7 
pregnant,  prolapse  of,  I  V.  70 
prolapse  of,  IV.  688 

amputation  of  cervix  in,  IV.  t'.'.i:. 

anterior  colporrhaphy  in.  IV.  694 


Uterus,  prolapse  of  (contd.*)— 

posterior     colpo-perineorrhaphy    in, 

IV.  694 

preventive  treatment,  IV.  688 
reduction  in,  IV.  689 
results  of  operation,  IV.  697 
retention  by  pessaries,  IV.  690 
surgical  treatment,  IV.  692 
vaginal  hysterectomy  in,  IV.  693 
vesico-vaginal   interposition   in,    IV. 

696 

retroflexion  of,  IV.  674-688 
abdominal  fixation  in,  IV.  686 

operation,  IV.  687-688 
Alexander's    operation   in,   IV.   681, 
683 

difficulties,  IV.  683 
bimanual  manipulation  in,  IV.  676 
complicating  pregnancy,  IV.  74-75 
difficulties  in  reposition  of,  IV.  677 
mechanical  treatment  by   pessaries, 

IV.  678 
pessaries  in,  mode  of  action  of,  IV. 

680 
reposition  in,  IV.  676 

by  the  sound,  IV.  677 
sterility  in,  IV.  856 
subinvolution  in,  IV.  722 
surgical  treatment,  IV.  681 
vaginal  fixation  in,  IV.  684 
retroversion  of,  IV.  672-674 
douches  in,  IV.  673 
massage  in,  IV.  673 
reposition  by  the  volsella,  IV,  677 
wool  tampons  in,  IV.  674 
rudimentary,  IV.  711 
rupture  of,  Caesarean  hysterectomy  in, 

IV.  399 

complicating  labour,  IV.  238-247 
curative  treatment,  IV.  244 
in  puerperal  sepsis,  IV.  303 
incomplete,   involving  perineal  coat 

only,  complicating  labour,  IV.  242 
limited  to  lower  segment,  complicat- 
ing labour,  IV.  240 
lower  wall,  complicating  labour,  IV. 

241 

prophylaxis  of,  IV.  241 
sarcoma  of,  IV.  718-719 
septic,  Caesarein  hysterectomy  in,  IV. 

399 
shape  of,  in  third  stage  of  labour,  IV. 

120 
steaming  of,  in  menorrhagia,  IV.  760 

in  metrorrhagia,  IV.  760 
subinvolution  of,  IV.  720-724 
by  acute  fevers,  IV.  720 
by  deficiency   of  lime  salts   in   the 

blood,  IV.  721 
by  infective  processes  in  pelvis,  IV. 

'  7i':: 

by  retention  of  products  of  concep- 
tion, IV.  721 
by  toxaemias,  IV.  720 
due  to  general  causes,  IV.  720 


125 


A    SYSTEM   OF   TREATMENT. 


Uterus,  subinvolution  of 

local  causes,  IV.  721 
in  Caesarean  section.  IV.  391 

tumours  of,  inversion  in,  IV.  699 

wall  of.  growths  in,  subinvolution  by, 

IV.  722 
Uvula,  acute  inflammation  of,  III.  74."> 

benign  growths  of,  III.  746 

deformities  of,  III.  744 

diseases  of,  III.  744-746 

elongation  of,  III.  744 

infections  of,  III.  745 

malignant  diseases  of,  III.  746 

oedema  of,  III.  945 

traumatism  of.  III.  745 

tuberculosis  of,  III.  745 


Vaccination,  I.  311-314 
anti-choleraic,  III.  423 
diseases  ascribed  to.  I.  313 
in  small  capillary  naevi,  III.  1080 
methods  of,  I.  312 
protective  effect  of,  I.  311 
Vaccine  in  cholera,  III.  424 

therapy,   control  of  subsequent  tloses, 

III.  267 

doses,  summary  of,  III.  301 
general   principles   of,   III.  258-270. 

263 

in  acute  dysentery.  III.  430 
in  acute  tuberculosis,  I.  332 
in  cervical  endometritis,  IV.  630 
in  cystitis,  II.  860 
in  infective  endocarditis,  I.  206 
in  inoperable  cancer,  I.  133 
in  prophylaxis,  III.  262 
in  purulent  meningitis,  I.  251 
in  staphylococcus  infections,  III.  282- 

283 

initial  dose  in.  III.  265 
length  of,  IIL  264 

method  of  administration  of,  III.  265 
of  acne  vulgaris,  III.  989 
of  acute  arthritis,  I.  744 
bronchitis,  I.  1052 
gonorrhoea,  III.  274 
of  asthma,  I.  1041 
of  bacillus  coli  communis.  III.  271 
of  boils,  III.  1008 
of  cancer,  I.  152 
of  carbuncles,  III.  1013 
of  cellulitis,  I.  182 
of  cholera,  III.  273 
of  chronic  bronchitis,  I.  1056 
gonorrhoea,  III.  275 
rhinitis,  III.  7i".i 

of  corporeal  endometritis,  IV.  630 
of  dysentery,  III.  280 
of  gonorrhoea,  I.  225  ;  III.  274 
of  gonorrho?al  arthritis.  I.  7*2  :  III 

275 

vulvitis.  IV.  :,-27 

of  infective  pyelonephritis,  II.  808 
of  influenza,  I.  235,  238 


Vaccine  therapy  (cvntd.') — 

of  leucorrluea.  IV.  "'72 

of  lupus.  III.  IK." 

of  micrococcus  catarrhalis  infections, 
III.  i>77 

of  neonoformans.  III.  293 

of  pelvic  cellulitis.  IV.  837 

of  peritonitis,  II.  637 

of  pernicious  anemia,  II.  7 

of  plague,  III.  277 

of  pneumonia,  I.  263 

of  puerperal  sepsis,  IV.  309 

of  pyorrhoea  alveolaris,  III.  287 

of  Rigg's  disease,  III.  287 

of  scarlet  fever,  I.  288 

of  streptococcus  infections,  III.  289- 
291 

of  tuberculous  abscess,  I.  176 

of  typhoid  fever,  I.  345  ;  III.  300 

of  ulcerative  colitis,  II.  568 

of  whooping  cough,  I.  383 

pneumococcic.    in    diseases    of    the 
pericardium.  I.  1184 

results  of.  III.  269 
Vaccines,    sensitized,    in   serum   therapy, 

III.  260 

use  of,  I.  206.  L'"7 
Vacuum,  partial  for  hypenemic  treatment, 

III.  56 
Vagina,  absence  of  lower  portion  of,  IV. 

543 

atresia  of.  IV.  541 
cancer  of.  primary.  IV.  553 
congenital  malformations  of,  IV.  541 
cvstocele    of,   complicated    by  ulcera- 
tion,  IV.  547 

operative  treatment,  IV.  549 

palliative  treatment,  IV.  547 
cysts  of,  IV.  531-532 
discharge  from,  in  sterility,   IV.  845, 

852 

diseases  and  injuries  of,  IV.  531-.~7 1 
distension  of,  with   lotions  in  leucor- 

rhoea,  IV.  562.  563 
double,  IV.  c43 
douching  of,  I.  39 
drainage  of,  free,  in  puerperal  sepsis, 

IV.  290 

fistula?  of,  IV.  533-53»> 

fixation  of,  retroflexion  of  uterus   by, 

IV.  684 

foreign  bodies  in,  IV.  537 
haemorrhage  from,  in   newborn  child, 

IV.  371      - 
hysterectomy  by,  in  fibroids,  IV.  655- 

658 

in  normal  puerperium,  IV.  257 
incision  of,  for  drainage  of  pelvis   in 

puerperal  sepsis.  IV.  :^i~2 
infections  of,  IV.  538-539 
inflammations  of,  gonorrbceal,  IV.  .V,i 

in  pregnancy.  I  V.  .".•;  j 

puerperal,  IV.  562 

senile  leucorrhcea  in.  IV.  5t'..i 
iniuries  of,  IV.  540 


126 


A    SYSTEM   OF   TREATMENT. 


Vagina 

inversion  of.  complicating   labour,  IV. 
182 

laceration  of,  complicating  labour,  IV. 

201 

leucorrhtjL'a  of.  I  V.  Mil 
lithotomy  by,  IV.  S77 
lower  third,  laceration  of,  complicating 

labour.  IV.  2o  I 
malformations  of ,  IV.  .M 1-544 

IK'    [Ililcd.    I  V.    .".  1   1 

niyomata  of.  I  V.  .V)3 

operations   on,   preparation   of   patient 

in,  IV.  is  | 

ovariotomy  by,  IV.  ~'.»5 
pluming  of.  in  accidental  haemorrhage 

daring  pregnancy.  I  V.  -' I 
in  inenorrhagia.  IV.  757 
in  metrorrhagia.  I\'.  7~>7 
prolapse  of,  IV.  :>ir>-552,  688 
eoniplieating  pregnancy.  IV.  71 
preventive  treatment,  IV.  688 
rectocele  of,  complicated  by  ulceration, 

IV.  :,I7 

operative  treatment.  I  V.  .Vil 
palliative  treatment.  IV.  547 
>areomaof,  primary.  IN'.  .">.">:» 
tumours  of,  l\".  ."> .">-.">  I 

leueorrlnea  in,  IV.  .V<7 
Vaginal  douches,  directions  as  to,  I.  :;;i 
examination,  in  normal  labour,  l\'.  lul 

in  pregnancy.  I  V.  ."> 
injections  in  vulvitis,  IV.  529 
Vaginismus,  IV.  860-864 
glass  dilators  in,  IV.  863 
operative  treatment  of,  IV.  863 
palliative  treatment  of.  IV.  862 
Valerian  in  diabetes  insipidus.  I.  •(:.",» 
Valsspa,  III.  157 

Valsalva  on  aortic  aneurysm,  I.  1297 
Valsalva's    experiment    in    patency    of 

Kustachian  tube.  III.  '.MS 
Van  Horn's  catgut,  sterilisation  of,  I.  72 
Vapour,    anaesthetic,     inhalation     of,    in 

labour.  IV.  376 
baths,  I.  38  ;  III.  129 
Vapours  in  asthma,  I.  1039 

medicated,   in    patency   of   Eustachian 

tube,  III.  951 
Varicocele.  I.  1323-1327 

diminution  in  size  of.  I.  1327 
operation  available  for,  I.  1  :>!>."> 
operative  treatment  of,  I.  1324 
spontaneous  disappearance  of,  I.  1327 
Varicose  Ivmphatic  glands,  III.  516 
ulcers,  f.  :?7i' 
veins.  I.  i:;o!>-1322 

complicating  pregnancy.  IV.  89-90 
ha-matoma    in,    complicating     preg- 
nancy. I  V.  '.in 
haemorrhage  from.  I.  lL'7»i 
of  lower  extremities,  I.  1311-1319 
hygienic  treatment  in,  I.  1311 
massage  in.  I.  i:<li>. 
mechanical  supports  for,  I.  1313 


Varicose     veins     of    lower     extremities 

((•until. ) 

non-operative,  I.  1311 
operative  treatment  of,  I.  1315 
of  upper  extremities,  I.  1320 
of  vulva,  IV.  522 
pain  in,  complicating  pregnancy,  IV. 

89 
phlebitis  in.  complicating  pregnancy, 

IV.  89 
recurrence   in  cases  of,  after  onera- 

tion,  I.  1322 
rupture  of,  complicating  pregnancy, 

I  V.  89 

shrinking  of,  I.  1321 
spontaneous  disappearance  of,  1. 1321 
thrombosis    in,    complicating    preg- 
nancy, IV.  89 
thrombus  in,  I.  1331 
Varix  affecting  the  trunk,  I.  1320 

congenital,  I.  1310 
Varus  at  the  elbow  joint,  I.  938 
Vasa,  division    of,   in  carcinoma  of  the 

prostate,  II.  936 

Vascular   degeneration,   cerebral   throm- 
bosis due  to,  II.  1177 
disease  associated  with   renal   disease, 
cerebral    thrombosis    due    to,    II. 
1178 

cerebral  thrombosis  due  to,  II.  1 177 
syphilitic,  cerebral  thrombosis  due  to, 

11.1177 
Vaseline,  injection  of,  in  fistulous  tracks 

in  empyema,  I.  1110 
Vaso-constriction,  local,   in   haemophilia, 

II.  33 

Vasomotor  centres,  shock  caused  by  ex- 
haustion of,  I.  93 
diseases,  II.  1226 
neuroses,  II.  1242-1243 

drugs  in,  II.  1242 

Veal,  chemical  composition  of,  II.  193 
Vegetable  food,  II.  195 
in  gout,  I.  452 
poisoning,  I.  506 
irritants,  poisoning  by.  I.  533 
preparations  for  cancer,  I.  148 
purgatives,   in  constipation   in  adults, 

II.  447,  454 

Vegetables  and  salads  in  obesity,  I.  472 
chemical  composition  of,  II.  195 
in  children's  dietary,  directions  for,  I.  59 
Vegetarian  treatment  of  oljesity,  I.  471 
Veins,  diseases  of,  I.  1309-1338 
hepatic,  obstruction  of,  II.  667 
methods  of  infusion  into,  I.  100 
of  the  broad  ligaments,  thrombosis  of, 

IV.  822-823 
pelvic,  ligature  of  in  puerperal  sepsis, 

IV.  304 

portal,  thrombosis  of,  II.  666-667 
retinal,  thrombosis  of,  III.  644 
sub-inflammatory  conditions  of,  mineral 

baths  in,  III.  138 
varicose,  I.  1309-1322 


127 


A   SYSTEM  OF   TREATMENT. 


Veldt  sore,  III.  475 

Venesection  in  aortic  aneurysm,  I.  1299 
in  chronic  congestion  of  the  lungs,  I. 

1078 

in  diseases  of  the  heart,  I.  1211 
in  eclampsia,  IV.  36 
in  high  blood  pressure,  I.  1283 
in  intra-cerebral  haemorrhage,  II.  1172 
Venous  haemorrhage,  I.  1271 
infusion    in  post-partum   hemorrhage, 

IV.  222 

Ventilation  in  typhus  fever,  I.  365 
of  nurseries,  methods  of,  I.  45 
of  sick  room,  I.  157 
Ver  du  Cayor  in  myiasis,  III.  483 
Ver  macaque  in  myiasis,  III.  483 
Veratrine,  poisoning  by,  I.  533 
Veratrum  viride  in  eclampsia,  IV.  37 
Vernet-les-Bains  spa,  III.  157 
Vernon-Harcourt  inhaler  for  anaesthetics, 

III.  14 

Veronal  in  diseases  of  the  heart,  I.  1225 
in  insomnia,  II.  990,  1022 
poisoning  by,  I.  531 
Verrucae,  warts,  III.  1157-1159 
Verruga  Peruviana,  III.  459-460 

prognosis  in,  III.  459 
Version,  anaesthetic  in,  IV.  463 

cephalic,  bi-polar,  IV.  464,  467,  468 
difficulties  in,  IV.  465,  469 
position  of  mother  in,  IV.  465 
steps  of  operation  in,  IV.  465 
time  for  operating  in,  IV.  465 
when  head  is  presenting.  IV.  469 
when  shoulder  is  presenting,  IV. 

469 

difficulties  of,'IV.  464 
external,  IV.  463 
indications  for,  IV.  463 
position  of  patient  in,  IV.  463 
steps  of  operation  for,  IV.  463 
centra-indications  in,  IV.  462 
dangers  of,  IV.  461 
difficulties  of,  IV.  461 
in  craniotomy,  IV.  411 
in  labour,  IV.  461-473 
indications  for,  IV.  4G1 
methods  of,  IV.  461 
.   podalic,  IV.  465 

accouchement  force  in,  IV.  466 

expression  of  cord  in,  IV.  466 

in  ante-partum  haemorrhage,  IV.  466 

in  cancer  of  cervix,  IV.  468 

in  double  monsters,  IV.  467 

in  flattened  pelvis,  IV.  466 

in  locked  twins,  IV.  467 

in  prolapse  of  cord,  IV.  466 

indications  in,  IV.  465 

internal,  IV.  470 

asphyxia  neonatorum  in,  IV.  473 
dangers  of,  IV.  473 
difficulties  of,  IV.  472 
position  of  mother  in,  IV.  470 
position  of  operator  in,  IV.  470 
steps  of  operation,  IV.  470 


Version,  podalic,  internal  (contd.~) — 
time  for  operating  in,  IV.  470 
when  shoulder  is  presenting,  IV. 

472 

mal-presentations  of  child  in,  IV.  1C5 
position  of  child  in,  IV.  462 
preliminary  treatment  for  all  methods 

in,  IV.  462 

relative  advantages  of,  IV.  432 
varieties  of,  IV.  461 
Vertebrae,   cervical,    unilateral    luxations 

of,  I.  903 
fractures  of  the  lamina?  of,  I.  904 

of  spinous  processes  of,  I.  904 
Vertebral  hook  in  craniotomy,  IV.  411 
Vertex,    occipito-posterior    positions     of 

forceps  in,  IV.  430 
Vertigo,   aural,  indications  for  operation 

in,  III.  974 

in  disseminated  sclerosis,  II.  1075 
laryngeal,  III.  841 
of  labyrinth,  paroxysmal,  and  middle 

ear  suppuration,  III.  960-961 
of  vasomotor  origin,  III.  958-961  . 
with  destruction  of  one  labyrinth, 

III.  961 

Vesico-cervical  fistula,  IV.  880 
Vesico-urethral      anastomosis,     diagram 

showing  plan  of,  II.  937 
Vesico-vaginal  fistulae,  IV.  533,  878-881 
interposition  in  prolapse  of  uterus,  IV. 

696 

Vesicular  mole,  IV.  59 
Vestibulotomy,  double,    in  labyrinthitis. 

III.  962 
inferior  operation  of,  in  labyrinthitis, 

III.  962-963 

Vibration  massage,  III.  204 
mechanical,  III.  213-221 
application  of,  III.  215 

in  abnormal  secretion,  III.  220 
in  aphonia,  III.  219 
in  asthma,  III.  216 
in  enlarged  glands,  III.  218 
in  goitre,  III.  216 
in  insomnia,  III.  221 
in  neuritis.  III.  221 
in  spinal  curvature,  III.  22n 
to  abdominal  organs,  III.  220 
to  ear,  III.  215 
to  eye,  III.  215 
to  face,  III.  220 
to  the  extremities,  III.  220 
to  vocal  cords,  III.  218 
Vibrator,  Sanitas  Electrical  Co.'s,  III.  214 
Vibratory    massage    in    constipation    in 

adults,  II.  463 
Vicarious  action,  I.  16 
Vichy  spa,  III.  157 
Vienna  paste  in  lupus,  III.  1150 
Vinadis  spa,  III.  157 
Vincent's  angina,  III.  771 
Violet  leaves  in  cancer,  I.  149 
Viscera,  actinomycosis  of,  I.  177 
displacement  of,  I.  430,  431 


128 


A    SYSTEM  OF  TREATMENT. 


Viscera  (rowfr/.) — 

neuralgias  of,  II.  1122 

perversion  of  functions  of  in  epilepsy, 

II.  1018 

prolapse  of,    in   wounds  of  abdominal 

wall,  II.  245 
taeniasis  of,  III.  521 

Vitality  of  children  lowered  by  "  harden- 
in^''  system,  I.  4<i.  5o 

Vitelline  remains  in  congenital  malforma- 
tions of  the  umbilicus,  II.  277 

Vitiligo,  III.  ll.V.t 

Vitreous    opacities    in    inflammation    of 
ciliarv  bo.ly,  111.  .V.)3 

Vittel  spa,  III.  157 

Vocal  cords,  application  of  vibration  to, 

III.  218 
ataxia  of,  III.  841 

internal  tensors  of,  paralysis   of,   III. 
843 

paralysis  of,  complete  recurrent,  III.  844 
Voeux  (H.  A.  des),  chicken  pox,  1.  18.") 

influenza,  I.  233-242 

mumps,  I.  256-257 
Voice  production.  III.  331-340 
Voisin's  method  of  hypnotism,  III.  165 
Volkmann's  contraction.  I.  ."73 
or  ischiemic  paralysis,  1.  940 

perforating  tuberculosis,  I.  889 
Volsellum.  Fenton's,  IV.  476 

for  lacerations  of  cervix.  IV.  190 

reposition    by,  in    retroflexion   of    the 

uterus,  IV.  677 
Volvulus  of  the  colon.  II.  591 

of  the  stomach.  II.  400 
Vomit,   examination   of,   in   poisoning,  I. 

526-586 
Vomiting,  after  ovariotomy,  IV.  791 

and    modifications    of    diet   in   simple 
diLre>tive  d Borders,  II.  230 

anesthetic,  after  abdominal  operations. 

II.  L'<;:< 

complicating     acute     endocarditis,     I. 
1193 

gynecological  surgery,  IV.  489 

ulcer  of  the  stomach,  II.  380 
drugs  in.  I.  507,  509,  :>12 
following  amesthesia,  III.  35 
in  acute  gastritis,  II.  347 
in  cancer  of  the  stomach,  II.  299 
in  disordered  digestion  in  the  stomach, 

II.  373 

in  food  fever,  II.  234 
in  heart  failure,  complicating  diphtheria, 

I.  200 

in  pyloric  spasm,  II.  337 
in  relapsing  fevers,  I.  267 
in  \vhooping  cough,  I.  383 
irritative,   complicating    gynecological 

Miv-ery,  IV.  489 
mixture  for,  I.  507,  509 
neurotic,    complicating    gynecological 

Miruery,  IV.  489 
pernicious,    complicating,     pregnancy, 

IV.  62-64 

S.T. 


Vomiting  (cuiitil. ) 

persistent,      complicating      abdominal 

operations,  II.  26i> 
post-aiiffisthetic,  prevention  of,  I.  84 
treatment  of,  in  abdominal  case,  I.  29 
Vulva,    acuminate,    condylomata  of,  IV. 

511 

atresia,  superficial  of,  IV.  513 
cancer  of,  relief  of  obstruction  in,  1.14? 
cleansing  of,  in  normal  puerperium,  IV. 

260 

clitoris,  hypertrophied,  and,  IV.  514 
cysts  of,  IV.  511 
dermatitis  of,  IV.  523 
diphtheria  of,  IV.  523 
diseases,  affections  and  injuries  of,  IV. 

505-530 

eczema  of,  ointments  for,  IV.  530 
effect   of    irritative  discharges   to,  IV. 

506 
elephantiasis  of,  III.  515 

arabum  of,  IV.  511 
epithelioma  of,  IV.  515 
erysipelas  of,  IV.  524 
esthiomene  of,  IV.  508 
hasmatoma  of,  IV.  522 
hydrocele  of  the  canal  of  nuck  of,  IV. 

512 
inflammation  of,  IV.  523-529 

appendix  of  formulae  for,  IV.  529 

dusting  powders  for,  IV.  529 

gonorrnceal,  IV.  524 

chronic,  IV.  561 

in  children,  IV.  560 

in  women,  IV.  560 

lotions  for,  IV.  530 

mild  in  women,  IV.  560 

non-venereal,  IV.  523 

vaginal  injections  in,  IV.  529 
injuries  of,  IV.  509-510 
kraurosis  of,  IV.  508 
laceration  of,  complicating  labour,  IV. 

204 

leucoplakia  of,  preceding  cancer,  I.  119 
leucorrhoea  of,  IV.  559 
lipomata  of,  IV.  511 
lupus  of,  IV.  508 
malformations  of,  IV.  513-514 
malignant  disease  of,  IV.  515-516 
noma  of,  IV.  508 

pad  in  third  stage  of  labour,  IV.  125 
pruritus  of,  III.  1106-1108  ;  IV.  517-519 

complicating  pregnancy,  IV.  72-73 

drugs  in,  IV.  517 

local  treatment.  IV.  518 
rodent  ulcer  of,  IV.  508 
sarcoma  of,  IV.  516 
syphilitic  affections  of,  IV.  520-521 

Ehrlich's  "606"  in,  IV.  .VJI 

mercury  in,  IV.  520 
tuberculosis  of,  IV.  508 
tumours  of,  innocent,  IV.  511-512 

simple  fibrous,  IV.  511 
varix  of,  IV.  522 
Vulvo-vaginitis  in  children,  IV.  528,  560 

129  9 


A    SYSTEM   OF   TREATMENT. 


Waggett  (E.  B.),  injuries  and  malforma- 
tions of  the  nasal  septum,  III.  678-686 
Walcher's  position  for  forceps,  IV.  424 
Walker  (J.   W.   Thomson),  affections  of 

the  ureter,  II.  840-851 
aneurysm  of  the  renal  artery,  II.  752 
calculus,  II.  753-766 
hydronephrosis,  II.  770-779 
injury  to  the  kidney  without  external 

injury,  II.  780-782 
movable  kidney,  II.  785-791 
perinephritic  abscess,  II.  801-802 
pyelitis,  II.  803-806 
pyelonephritis  infective,  II.  807-813 
pyonephrosis,  II.  814-818 
renal  and  peri-renal  fistulas,  II.  767-769  | 
surgical  treatment  of  non-suppurative 

nephritis,  II.  798-800 
tuberculosis  of  the  kidney,  II.  819-829 
tumours  of  the  kidney  in  adults,  II.  830- 

835 
tumours  of  the  kidney  in  children,  II. 

836 

Walker's  balance  for  anaesthetics,  III.  14 
pliable  ureteral  scoop,  II.  849 
stone  forceps  for  calculus,  II.  760 
Walking  of  infants,  risks  of  too  early,  I.  51 
on  the  dorsum  exercise  for  flat  foot,  III. 

235 

Wall  (Walker),  on  purin-free  food,  I.  452 
Wallis   (Sir  F.  C.),  diseases  of  the  ano- 

rectal  area,  II.  593-612 
haemorrhoids,  II.  615-620 
malformations  of  the  anus,  II.  613 
malignant  growths  of  the  rectum,  II. 

625 
prolapse  and  procidenta  of  the  rectum, 

II.  621-623 
rectal  neuroses  and  obscure  rectal  pain, 

II.  614 

simple  tumours  of  the  rectum,  II.  624 
Walls  of  nursery,  covering  of,  I.  44 
Walther  (Otto)  on  pulmonary  tuberculosis, 

I.  1121 

Warburg's  tincture  in  malaria,  III.  398 
Warm  climates,  diseases  of,  III.  375-516 
Warming  for  nursery,  methods  of,  I.  44 
Warmth  necessary  during  operations  I 

96,  97 

in  shock,  I.  97 
Warts,  anatomical,  III.  1152 
common,  X-rays  in,  III.  347 
excision  of,  importance  of,  I.  118 
gonorrhaeal,  1.  226 
ionic  medication  of,  III.  184 
of  the  scalp,  I.  892 
post-mortem,  III.  1152 
senile,  III.  1159 

solid  carbon  dioxide  in,  III.  1157 
verrucas,  III.  1157-1159 
Washing,  disinfection  by  means  of,  I.  163 

of  infants  and  children,  I.  47 
Wassermann  reaction  in  syphilis,  I.  325 
Water,  allowance  of  in  nephritis,  II.  206 
as  cause  of  goitre,  II.  62 


Water  (c"#fr7.) — 

boiled,  in  the  tropics,  III.  384 

borne  typhoid,  I.  337 

cold,  drinking,  in  fevers,  necessity  of, 

I.  158 

enemas  of  in  typhoid  fever,  I.  355 
drinking,   for  young  children,  reasons 

for,  I.  53 
in  gout,  I.  434 
in  typhoid  fever,  I.  343 
itch,  III.  486 
medicinal  use  of,  III.  Ill 

nomenclature  of,  III.  Ill 
pillows,  use  of,  I.  3 1 
point  of  thermal  indifference  for,  III. 

113 

sterile,  for  use  at  operations,  I.  28 
Waterbrash  in  disordered  digestion  in  the 

stomach,  II.  374 

Waterhouse  (Herbert  F.),  Bier's  treatment 
by  means  of  induced  hyperremia,  III. 
40-68 
Waters,  alkaline,  III.  119 

in  chronic  gastritis,  II.  351 
arsenical,  III.  122 

in  pernicious  anaemia,  II.  5 
calcareous,  III.  120 
chalybeate,  III.  1'2'2 
diuretic,  III.  120 
hypertonic  salt,  III.  119 
natural     aperient,    in    constipation    in 

adults,  II.  466 
radio-activity  of,  III.  115 
salt  muriated,  III.  118,  129 
sulphated  purgative,  III.  121 
sulphur,  III.  117 
Watson  (C.  Gordon),  surgical  diseases  of 

joints,  I.  741-788 
Watson- Williams     (P.),      anaemia      and 

hyperaemia  of  the  larynx,  III.  822 
haemorrhage  from  the  larynx,  III.  824 
laryngitis,  III.. 831-837 
neuroses  of  the  larynx,  III.  840-845 
oedema  of  the  larynx,  III.  858-860 
Weaning  of  infants,  II.  218 
Wearing  apparel,  disinfection  of,  I.  162 
Weather,  suitable  for  young  children,  I.  52 
Webbed  fingers  or  syndactyly,  I.  943 
Wedge,  wooden,   for  separating  clenched 

teeth,  III.  1 

Weichselbaum's  meningococcus,  I.  254 
Weight  and  pulley  for  elbow  exercises,  I. 

778 

(body)  influence  in  osteo-arthritis,  I.  400 
extension  in  sprains,  I.  739 

in   tuberculous   disease  of  the   knee- 
joint,  I.  767 
in  tuberculous  joints,  I.  764 

synovitis,  I.  752 
loss  of,  in  cancer  of  alimentary  system, 

1.139 

in  pulmonary  tuberculosis,  I.  1155 
Weilbach  spa,  III.  157 
Weir-Mitchell  treatment  in  coccyerodynia, 
I.  921 


130 


A    SYSTEM   OF   TREATMENT, 


Weir-Mitchell  (V»/«/V/.>- 

in  hysterical  joint  disease,  I.  788 

of  neurasthenia.  II.  1()4<> 
Weisbaden  spa,  III.  157 
Welch  and   Schamberg  on  treatment  of 

small-pox  eruption,  I.  306 
Wells  (A.  Primrose),  mechanical  vibration, 
III.  213-221 

treatment    by  various   forms  of   light, 

III.  186-302 

Wells  (Russell)  on  cocaine  in  whooping 

cough. I. 381 
Wertheim's   operation,   complications   of, 

IV.  (505 

dangers  of,  IV.  605 
difficulties  of,  IV.  <;i>5 

dividing  para-vaginal  tissue  in,  IV.  606 

vagina  in,  IV.  607 
hasmorrhage  in,  IV.  607 
identifying  the  ureter  in,  IV.  603 
immediate  results  of,  IV.  608 
in  cancer  of  cervix.  I  V.  ('.01 
isolating  the  ureter  in,  IV.  605,  606 
ligature  of  uterine  artery  in,  IV.  604 
limits  of,  IV.  610 
percentage  of,  IV.  609 
removing  iliac  glands  in,  IV.  608 
shock  in,  IV.  607 

standpoint  of  pathology  of,  IV.  (501 
technique  of  operation,  IV.  602 
ultimate  results  of,  IV.  609 
West  (C.  Ernest),  acute  diseases  and  sup- 
puration of  the  labyrinth,  III.  958-966 
West  Africa,  rqalaria  and,  III.  381 
Westmacott  (F.  H.),  diseases  and  affec- 
tions  of   the  accessory  sinuses   of  the 
nose.  III.  716-731 
Wet-nursing.  JI.  219 
Wet-pack.  u>e  of.  in  typhoid  fever,  I.  350 
Wethered    (Frank    J.),    atelectasis    and 

collapse  of  the  lungs,  I.  1063-1065 
emphysema  and  its  varieties,  I.  1082- 

1089 
Wetterstrand's  method  of  hypnotism,  III. 

164 

Whey  in  infant  feeding,  II.  227 
in  marasmus,  I.  465 
in  typhoid  fever,  I.  341 
Whistler's  laryngeal  forceps,  III.  848 
White  (W.  Hale),  colitis,  II.  .V.2-569 
empya-ma.  I.  1099-1100 
exophthalmic  goitre,  II.  54-57 
pneumonia.  I.  25S-263 
Whitehead  (A.  L.),  intra-cranial  and  intra- 
venous complications  of  ear  disease,  III. 
937-948 

White-leg  in  puerperal  sepsis,  IV.  321 
Whitlow  (Sir  W.),  on  food  and  diet,  1.341 
Whitlow,  cause  and  treatment  of,  I.  168- 

170 

sub-cutaneous,  I.  169 
sub-cuticular,  I.  1  <'>'.' 
sub-periosteal,  I.  169 
thecal,  I.  Ki'.i 
Whooping-cough,  I.  37(5-385 


Whooping-cough  (rontd.) — 

associated  with  measles,  I.  243 

diet  in,  I.  379 

.  external  applications  to  chest  in,  I.  379 

general  treatment  of,  I.  377 

incubation  period  of,  I.  :'.77 

local  applications  in,  I.  379 

medicinal  treatment  of,  I.  380 

prevention  of,  I.  876 

treatment  during  convalescence,  I.  384 
of  paroxysm,  1. 379 

vaccine  therapy  of,  I.  383 
Widal's  test  in  typhoid,  I.  337,  347 
Wildbad  spa,  III.  157 
Wilde's  incision  in  acute  inflammation  of 

middle  ear,  III.  897 
Wildungen  spa,  III.  157 
Wilkinson  (G.),  foreign  bodies,  maggots, 
and  rhinoliths,  III.  667-669 

influenzal  tracheitis,  III.  798 

injuries  of  the  trachea,  III.  797 

tracheal  fistuhe,  III.  799 

obstruct  ion,  III.  800-802 
Willcox  (W.  H.),  asthma,  I.  1035-1042 

food  poisoning,  I.  506-511 

poisons  and  antidotes,  I.  526-535 
Williams    (Leonard),    administration    of 
thyroid  extract,  II.  49-50 

blood  pressure,  I.  1281-1286 

congestion    and    inflammation   of    the 
thyroid  gland,  II.  51-52 

infantilism,  II.  71 

myxeedema  and  cretinism,  II.  72 

nocturnal  enuresis,  II.  75-77 

obesity,  I.  468-474 

thyroid  inadequacy,  II.  78 
Williams  (Whitridge),  on  pubiotomy,  IV. 

449 

Wilson     (S.    A.    Kinnier),     amyotrophic 
lateral  sclerosis,  II.  1054 

bulbar  palsy,  II.  1061 

facial  hemiatrophy,  II.  1232 

herpes  zoster,  II.  1096-1097 

hydrocephalus,  II.  1191-1192 

intermittent  claudication,  II.  1234-1236 

Landry's  paralysis,  II.  1080 

paramyoelonus  multiplex,  II.  1255-1256 

paraplegia,  II.  1195-1199 

progressive  muscular  atrophy.  II.  1081- 
1082 

torticollis,  II.  1050-1053 

vasomotor  neuroses,  II.  1242-1243 
Wilson  (Thomas),  flexions  and  displace- 
ments of  the  uterus,  IV.  669-699 
Wind  and  pulmonary  tuberculosis,  I.  1118 

cold,  protection  of  young  children  from, 

I.  52 
Windows,   arrangement  of,  in  nurseries, 

I.  45 
Wine,  avoidance  of  in  gout,  I.  448 

egg,  preparation  of,  I.  43 

in  gouty  conditions,  I.  t.~>7 

iron,  in  chlorosis,  II.  25. 
Witch  hazel  in  haemorrhage,  I.  1261 
Withering  on  digitalis,  I.  1218 


131 


A    SYSTEM  OF  TREATMENT. 


Witzel's  method  for  malignant  stricture 

of  the  oesophagus,  II.  182 
Woillez.  maladie  de,  I.  1076 
Wolffs  law  in  deformities,  I.  934 
Woodbridge  treatment  of  typhoid  fever, 

T.  355 

Woodhall  spa,  III.  157 
Woods  (John  F.),  hypnotism   and  treat- 
ment by  suggestion,  III.  159-179 
Woods'  method  of  hypnotism,  III.  166 
Wool  for  surgical  dressings,  I.  74-78 
Woollen  clothing  for  rheumatism,  I.  485 

underclothing  for  children,  I.  50 
Wool-sorters'  disease,  I.  179 
Word-deafness,   restoration   in    by   func- 
tional compensation,  II.  1146-1149 
Workmen's  Compensation  Act  and  electric 

shock,  I.  548 
Worth's  amblyoscope  in  strabismus,  III.  j 

652 
Wounds.  I.  550-556 

antiseptic  treatment  of.  I.  85 

bursting    of,    complicating    gynaecolo- 

.  gical  surgery,  IV.  496 

cellulitis  following,  I.  181 

cleansing  of,  I.  550 

closure  of,  I.  551 

complication  of,  I.  555 

concentrated  arc  light  in,  III.  200 

drainage  of,  I.  551 

dressings  in,  I.  554 

examination  of,  I.  550 

gangrene  from,  I.  214 

general,  I.  540-544 

treatment  of,  I.  555 
granulation  in,  I.  554 
gunshot,  I.  557-567 

abdominal  injuries  in,  I.  565 
amputation  in,  I.  562 
cardiac  injuries  in,  I.  565 
cranial  fractures  in,  I.  562 
facial  injuries  in,  I.  563 
fractures  in,  I.  561 
haemorrhage  in,  I.  559 
injuries  of  nerves  in,  I.  560 
joint  injuries  in,  I.  562 
lodged  missiles  in,  I.  558 
neck  injuries  in,  I.  564 
of  liver,  II.  251 
of  the  abdomen,  II.  248 
of  the  eyeball,  III.  657 
of  the  skull,  I.  877 
of  the  spine,  I.  902 
of  the  stomach,  II.  283 
penetrating  of  chest,  I.  564 
prevention  of  infection  in,  I.  557 
septic,  I.  558 
shock  in,  I.  558 
spinal  injuries  in,  I.  563 
traumatic  aneurysms  in,  I.  560 
implantation  cysts,  due  to,  I.  Ill 
in  tetanus,  local  treatment  of,  I.  329 
incised,  of  abdominal  wall,  II.  249 
injuries  of,   with  external  wound,  II. 
783-784 


Wounds  (contd.} — 

local  treatment  of.  I.  55n 
nerve  injury  in,  II.  1099 
non-penetrating,  of  abdominal  wall,  II. 

246 

Of  brachial  plexus,  II.  1110 
of  diaphragm,  II.  253 
of  facial  nerve,  II.  1108 
of  irie,  III.  591 
of  lips,  II.  96 
of  muscles,  II.  1321 
of  nerves,  II.  1098-1105 
of  special  blood-vessels,  I.  1274 
of  special  nerves,  II.  1108-1113 
of  tongue,  II.  132 
of  uterus,  IV.  575 
subcutaneous,  to  nerves,  II.  1100 
sutures  in,  I.  553 

in  amputations,  I.  802 
vicious  contraction  in.  I.  555 
Wright    (Sir    Almroth)^    on    pulmonary 

tuberculosis,  I.  1121 
on  vaccine  treatment  of  cancer,  I.  152 
Wright's  extension  in  tuberculous  disease 

of  the  hip-joint,  I.  754 
salt  and  citron  lotion,  I.  168,  176 
Wringer  for  fomentations,  I.  35 
Wrist,  congenital  contraction  of,  I.  937 

dislocation  of,  I.  723,  937 
dropped,  in  paralytic  deformities  of  the 
upper  limb,  I.  990 

paralytic,  prognosis  in,  I.  992 
paralysis  of,  in  lead  poisoning,  I.  513 
spontaneous  subluxation  of,  I.  939 
tuberculous  disease  of,  I.  779-780 

operative  treatment,  I.  780 
Wrist-joint,  disarticulation  at,  I.  813-816 
by  circular  incision,  I.  815 
by  elliptical  incision,  I.  813 
fracture    in    the   neighbourhood  of,  I. 

602-603 
Writer's  cramp,  II.  1264 

hypnotism  in  case  of,  III.  174,  175 
Xussbaum's  bracelet  in,  II.  1265 
Wryneck  or  torticollis,  I.  987 
physical  exercise  for,  III.  233 
spasmodic,   physical   exercises   in,  III. 

257. 
Wyatt    (James),    abnormalities    of    the 

maternal  soft  parts  affecting  labour, 

IV.  157-160 
deformities  and  diseases  of  the  foetus 

causing  obstruction   to    labour,   IV. 

176-181 


Xanthelasma  of  the  eyelids,  III.  582 
Xanthoma,  III.  1160 

diabeticorum,  III.  1160 
Xeroderma,  III.  1053 

pigmentosum,  III.  1057 
Xerosis  of  the  conjunctiva,  III.  561 
Xerostomia  (dry  mouth),  II.  130 

in  inflammation  of  parotid  glands,  II. 
163 


A    SYSTEM  OF  TREATMENT. 


X-rays,    application    of,    for    ringworm, 

head  in  position  during,  III.  356 
in  leukaemia,  II.  39 
position  of  nails,  during,  III.  351 
box  shield,  with  lead-glass  localiser,  III. 

342 
dermatitis,   preceding    cancer,    I.  117 ; 

III.  1030 
examination  in  calculus  of  the  bladder, 

II.  853 

for  comedones,  III.  1023 
in  acne  rosacea,  III.  350 
in  acne  vulgaris.  III.  349,  987 
in  cancer,  I.  154 

in  chronic  affections  of  the  nails,  III. 
351 

eczema,  III.  351 

lichen  planus,  III.  351 

localised  inflammations,  III.  349 
in  common  warts,  III.  347 
in  disease,  cardinal  points  in,  III.  362 
in  disseminated  sclerosis,  II.  1074 
in  elephantiasis.  III.  353 
in  epithelioma  of  tongue,  II.  139,  144, 

III.  348 

in  Hodgkin's  disease,  I.  1342 

in  hyperidrosis,  III.  359 

in  hypertrichosis,  III.  1046 

inkerion,III.  1129 

in  lichenification,  III.  1060 

in  lupus,  crusted  and  ulcerated.  III.  353 
verrucosus,  III.  352 
vulgaris.  11J.  352,  353,  1148 

in  malignant  disease,  III.  362 

in  mycosis  fungoides,  III.  1076 

in  pruritus,  III.  359 

in  psoriasis,  III.  351,  1122 

in  pyonephrosis,  II.  814 

in  ringworm,  III.  354,  1125 

in  rodent  ulcer,  I.  115  :  III.  347,  1133 

in  scrofuloderma,  III.  352 

in  seborrhcea,  III.  359 

in  skin  diseases,  earlier  methods  of,  III. 

341 

present  methods,  III.  342 
protection  of  patient  in,  III.  345 

in  spleno-medullary  leukaemia,  III.  363 

in  sycosis,  III.  350 

in  syringomyelia,  II.  1219 

in  treatment  of  cancer,  I.  129 
of  skin  diseases,  III.  340-359 


X-rays  (contd.')— 

in  tuberculosis  of  the  skin,  III.  353 
in  tuberculous    disease    of    lymphatic 

glands,  I.  1344 
'  modification  of  skin  functions  by,  III. 

353 
treatment  of  diseases  other  than   skin 

diseases,  III.  360-368 
use  of,  protection  of  the  operator  during, 
•   III.  343 


Yaws  (Framboesia  tropica),  III.  461 
Yeast  in  acne  vulgaris,  III.  988 

in  boils,  III.  1008 

in  leucorrhcea,  IV.  572 

in  rabies.  III.  288 

powder  in  leucorrhoea,  IV.  572 
Yellow  fever  in  the  tropics,  III.  382 

prophylaxis  of,  III.  412 

symptomatic  treatment  of,  III.  412 
Yew,  poisoning  by,  I.  533 
Young  (E.  A.),  congestion  and  oedema  of 

the  lungs,  I.  1076-1081 
Yverdon  spa,  III.  158 


Zambelleti's    subcutaneous  injections  of 

iron  and  arsenic,  II.  294 
Zander  Institutes,  use  of,  in  obesity,  I.  470 
Zander  treatment,  III.  369-374 

in  disorders  of  the  circulation,  III.  371 

in  disorders  of  the  digestive  system, 
III.  372 

in   functional  derangements  of  joint", 
III.  373 

in  scoliosis,  III.  372 

of  fractures,  III.  374 
Zeroni's  hook,  III.  915 
Ziegler's  sickle  knife,  III.  637 
Zinc  astringent  solutions  in  gonorrhoea,  I. 
224 

dressings  in  burns  and  scalds,  I.  541 

percentage  of  in  cyanide  gauze,  I.  76 

salts  of,  acute  poisoning  by,  I.  529 

in  epilepsy,  II.  998 

Zittmann  treatment  of  syphilis,  I.  323 
Zyzygium  jambulanuin  in  diabetes  melli- 

tus,  I.  424 


S.T. 


BKADBURY,   AGSEW,    &   CO.    LD.,    PRINTERS,    LON'DOS   ASD   TOXBRIDGE. 

133 


10 


Date  Due 


PRINTED  IN   U.S.*.  CAT.     NO.     24      161 


2AA 


WB300 
L352s 


Latham.  v.2 

A  system  of  treatment 


WB300 
L352s 


Latharr.  v*2 

A  system  of  treatment 


CALIFORNIA  COLLEGE  OF  MEDICINE  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

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